MCN Finals Notes

FIRST SEMESTER A.Y.
2021-2022
MATERNAL AND CHILD NURSING
LESSON ONE - MCH nurses educate, through this we are

FRAMEWORK FOR MATERNAL AND promoting at the same time
CHILD HEALTH NURSING independence
- As nurses we protect patients rights, to
Primary Goal of MCHN acknowledge one's decisions with
- Promotion and maintenance of optimal regards to the client’s health
family health - Double-check for errors, nurses should
Rooted on the primary goal of nursing catch, stop, and fix errors and flag
which is health promotion and disease conflicting orders, information, or
prevention. oversights by physicians and others
- In here, we focus on the family as a whole caring for the patient
and our client. We cater to the needs of all - Connect patients to resources, help
members of the family extending from patients find resources inside or outside
preconception to menopause or from the hospital to support their wellbeing, be
womb to womb. aware of resources in the community that
you can share with the patients such as
Philosophy of MCHN financial assistance and transportation
1. Family-centered and considers the needs
of all members of the family, looks not MCHN Goals and Standards
only into the needs of the pregnant client Millenium Health Goals
but also of the other family members Goal 4: Reduce child mortality
2. Cares for clients beyond the hospital - Target 4A: Reduce by two-thirds, between
setting but extends to families in a 1990 and 2015, the under-five mortality
community setting rate
3. The consensus, explicit, and judicious use Goal 5: Improve maternal health
of current best evidence in - Target 5A: Reduce by three-quarters,
decision-making in caring for the patient. between 1990 and 2015, the maternal
Through evidence-based practice, critical mortality ratio
knowledge emerges. All our actions justify Promoting maternal health directly leads to
the studies and researches which promoting child health thus reducing mortality
provides us the confidence to care for our rate
clients
4. A maternal and child health nurse serves WHO’s 17 Developmental Goals
as an advocate to protect the rights of all - Goals #3 Good health and well-being for
family members through: people.
- Ensuring safety in the setting (anywhere in “Ensure healthy lives and promote well
the community) being for all at all ages”
- We give patients a voice especially when Entails increasing life expectancy and reducing
they are vulnerable, to make sure they are some of the common killers associated with child
able to communicate and understand well and maternal mortality. This goal aims to achieve
things concerning their health interpersonal health coverage including access to
essential medicines and vaccines which
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proposes to end or prevent the death of more comfortable with her
newborns and children under 5? (not sure). To decision-making and mothering
end epidemics such as AIDS, Tuberculosis, skills
Malaria, and water-born diseases. 4. Achievement of maternal identity.
Formally known as the Personal stage
Theory Application of MCHN ● The final stage which typically
Mercer’s Theory of Maternal Role Attainment occurs at about 4 months after
- Motherhood is a developmental and birth is the point in which the new
interactional process through which the mother has successfully integrated
mother and child bond over time prior learning with personal
Motherhood as a process of mother and child experience. She feels confident,
bond divided into steps: competent, and accomplished in
1. Commitment, attachment and her role and begins to experience
preparation. Formally the Anticipatory the joy of motherhood and secure
stage attachment to the child
● The mother-to-be begins to adjust
to the anticipated realities of her Scope of MCHN
new role - Deals with preconception healthcare soon
● Includes learning the social after a couple gets married and plans to
expectations associated with have their own offspring, it is ideal for the
motherhood, adapting to the couple to submit for screening for any
physical and physiological possible problems they may have when
changes of pregnancy, fantasizing trying to conceive
about motherhood and dealing - As an MCH nurse we ensure that the
with health concerns including couple is well educated and serve as
prenatal care and preparations for advocates for the couple.Once the couple
childbirth can successfully conceive, we now take
2. Acquaintance, learning, and physical care of the pregnant woman for the whole
restoration. Formally known as the Formal trimester of gestation or pregnancy up
stage until ___ or immediately after child
● The stage immediately after delivery. The nurse now takes care of the
childbirth, adoption, or bringing a mother and growing fetus and makes sure
new child into the home the father is of his role during this time
● The stage during which the new - After delivery, the client is now the
mother adapts to her role by newborn, this is one of the vulnerable
modelling her behaviors and populations to take care of. We make sure
confirming closely to social and we attend to the needs of the newborn,
family norms especially while the mother is past (?)
3. Moving towards the new normal. Formally recovered. We assist the family in
known as the Informal stage welcoming a new member.
● The period in which the mother - As a child grows we cover its growth and
begins to develop her own development from infancy up to
maternal identity and becomes adolescence
by Amistoso, Bacalso, Go, Kangleon, Muñeses, Serbise, Villegas, Yap, SN (VLZ BSN Batch 2024)
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- There are different considerations in to call a family. This change affects the
promoting the well-being, disease current ___ clients, of course clients also
prevention,and handling clients from adopt to the ___
different age groups 2. Changes in the settings of maternity and
- Since our philosophy is to take care of childcare
the community setting to ensure the Before home birth has become rampant
continuity of care from hospital up to the for delivering ___, mothers choose to
homes. It is ideal that community health submit themselves to the obstetric
nurses look into the condition of the complex of tertiary hospitals for
mother and child at home especially the convenience and safety assurance.
adaptation of the mother to the new Moreover,clients have increased in
normal world number catching up with the increase of
population
Roles and Responsibilities of an MCN 3. More involvement of technology
1. Considers family as a whole Different machineries get involved in the
2. Advocate for family including the fetus care (ultrasound machines etc.)
3. Teaches and counsels as an independent 4. Government policies
nursing function - Expanded Maternity Leave Act
4. Promotes health and prevents diseases (main ● Increases number of days of a
goal) postpartum mother can stay out of
5. Resources for families especially during work
childbearing and childrearing period ● Goal is directed towards mother
(Resource managers ensuring they are well and child bonding
provided by the community especially the ● 105 days of maternity leave
basic needs of the growing child) ● 14 days of paternity leave
6. Encourages developmental stimulation
7. Assess families (to guide us in our nursing Ethical Considerations
action) 1. Documentation
8. Encourage family bonding, early hospital ● Ensure accurate documentation
discharge, and reaching out to the community 2. Informed Consent
● Ensure that the client understands
all the undertakings
MCHN as a Changing Discipline 3. Conception
Evolves in so many aspects as 4. Pregnancy termination
technology, research, government ___, 5. Stem cell research
new treatment modalities. We nurses 6. Invasive procedure on children
adapt to these growing changes in our
field as well: LECTURE TWO
1. Trends in the MCHN population, changes EVIDENCE BASED PRACTICE IN
in lifestyle and social structure MATERNAL AND CHILD HEALTH
Family structures have evolved as well,
there are different kinds of families or so What is new in maternal and child-nursing, we
called groups of people we may consider should keep ourselves updated thus we should
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look into the different sources that show
Evidence-based practice Maternal and child
health nursing
LECTURE THREE A
REPRODUCTIVE AND SEXUAL
HEALTH: FEMALE AND MALE
REPRODUCTIVE SYSTEM
Male Reproductive System

The Internal Structures Of The Male
Reproductive System
1. Scrotum
- Houses testes
2. Testes
- Responsible for producing
testosterone (primary male sex
hormone) and sperm
3. Epididymis
The External Structures Of The Male - Above the testes
Reproductive System - Brings sperm to maturity since the
1. Penis ones that come from the testes are
- divided into the: immature and incapable of
a) Root fertilization
b) Body/shaft ➔ From the epididymis, sperm travels up
c) Glans through the Vas Deferens
○ In the glans you can see the 4. Vas Deferens
prepuce/foreskin which is incised - From the Vas Deferens, sperm
during circumcision meets with the fluid produced by
○ You can also see the external the seminal vesicles
urethral meatus which is the 5. Seminal Vesicles
opening from the urethra (the - The fluid from the seminal vesicles
innermost portion of the body compose 65% of the total semen
where the urine and semen travel produced. This fluid is sugar-rich
through coming out of the penis and produces fructose for sperm
○ Surrounded by erectile tissue energy and motility. From this
called corpus cavernosa and portion, the fluid now fuses with
inside which is the corpus the ejaculatory duct, wherein it
spongiosum combines with the fluid produced
○ In the roots, you will see the by the prostate gland
accumulation/bundle of nerves 6. Prostate Gland
and blood vessels that support the - Sperm will then meet with the fluid
penis produced by the cowper’s gland
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7. Cowper’s/Bulbourethral Gland - Spermatogenesis occurs in the testes →
- Produces a fluid that lessens the Goes up the epididymis → Travels
acidity of the urethra (Sperm through the vas deferens → Meets with
passes through the urethra but the fluid from the seminal vesicle → Then
cannot survive in acidic the fluid from the prostate → Then the
environments). fluid from the bulbourethral gland →
Moves to the ejaculatory duct → Empties
Physiology towards the urethra → Out of the urethral
○ Spermatogenesis meatus
■ Sperm
● Travels from testes to Female Reproductive System
epididymis for 12 - 20 days
● Matures within 65 - 75
days
● In every ejaculation
seminal fluid contains < 20
million sperms/mL
○ Endocrine Gland
■ Affects the system through
Hormonal influence
■ Pubertal development
1. Increase in height and
weight
The External Structures of the Female
2. Enlargement of testes and
Reproductive System
scrotum
1. Mons Pubis
3. Appearance of body hair
- Upon the appearance of
4. Penile growth and
secondary sex characteristics, the
enlargement
pubic hair initially appears on the
5. Nocturnal emissions
mons pubis
(signifies spermatogenesis)
➔ Ejaculate or the Semen 2.5-5mL; sticky
2. Labia Majora
- The outer sides with pubic hair
3. Labia Minora
- Inner sides without pubic hair
4. Clitoris
- Meets with the labia minora on the
superior portion beneath the mons
pubis
5. Urethral Orifice
- Beneath the clitoris
- Opening for the urethra
- Where urine comes out
Flow Wrap-up
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-Important landmark for need to make an incision or it may
catheterization naturally tear down
○ Inserted in urethral orifice ● May go down to the anus
○ Do not insert at vaginal 2. Perineal Body
orifice 3. Hymen
6. Vaginal Orifice ● Thin piece of mucosal tissue that
- Opening from the vaginal canal surrounds or partially covers the external
- Where the head of the baby vaginal opening
comes out first ● Most of the time, it is perforated through
7. Perineal Body and Anus mechanical means
- Below the vaginal orifice ● In cases where the hymen cannot be
perforated
○ Hematocolpometra may occur
■ Accumulation of blood in
the vagina and uterus,
especially during
menstruation
○ Surgical intervention or the
incision of hymen must be done
■ Called Hymenectomy
Parts of the Perineum

- Knowing the parts of the perineum will
help you get acquainted with the affecting
labor and delivery
- Plays an important roles in functions such
as micturition, defecation, sexual
intercourse, and childbirth
1. Fourchette
● Posterior structure where the labia minora
meets.
The Internal Structures of the Female
● Important landmark
Reproductive System
○ Tears apart during vaginal delivery
1. Vaginal Canal
○ Where the doctors perform
- Port of entry from the external
Episiotomy
structures to the internal
■ Surgical incision to
- Passes through the cervix
increase the passageway
2. Cervix
of the fetus
- Divided into 2 parts the external os
■ May extend down
and internal os
depending on the size of
- Important in keeping pregnancy
the baby
intact all throughout 9 months of
● If the baby’s head is too large for
gestation
the vaginal orifice, the doctor may
3. Uterus
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● Above the cervix ● This ciliated
● Comprises most parts of the structure is called
system Fimbriae
● Divided into 3 walls: 6. Ovary
a) Endometrium - Where oogenesis occurs
● Inner portion (production of egg cells)
● Sheds off down the 7. Ligaments Maintaining the Uterus:
cervical canal of the vagina a) Round Ligament
during menstruation ● Is a remnant of the
b) Myometrium gubernaculum that extends
● Underneath the from the uterine horns to
endometrium the labia majora via the
● Responsible for inguinal canal
contractions during labor ● It goes at the back of the
and delivery ovary down to the labia
c) Perimetrium majora
● Outer layer ● *One side attaches from
4. Fundus the superior and lateral
- Important landmark during side of the uterus to labia
pregnancy majora*
- Gives information on fetal growth
- Locate the fundus during
assessment of pregnant clients
○ You will know it because it is Firm
Upon Touch
5. Fallopian Tube
- Located on both sides of the
uterus
- Divided into 3 sections:
a) Isthmus
● Narrow part
b) Ampulla
● Where fertilization
occurs b) Broad Ligament
● Where sperm and ● Double layer of peritoneum
egg meets for attaching the sides of the
fertilization uterus to the pelvis
c) Infundibulum ● Acts as mesentery of the
● Holds the ciliated or uterus and contributes in
finger-like maintaining its position
projections which
capture the ovum
from the ovary
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e) Uterosacral Ligament
● Extends from the cervix to
the sacrum
● Provides support to the
uterus as well
c) Ovarian Ligament
● Holds the ovary
d) Cardinal Ligament
The Ovarian Cycle (Video Trans)
- Located at the base of the
1. Primordial Follicles
broad ligament
● Start at Day 0
- Extends from the cervix to
● 15 - 20 primordial follicles begin
the lateral pelvic walls
maturation making their way to
- Contains the uterine artery
maturation
and vein in addition to
● Not all will reach maturation
providing support to the
● Only 1 oocyte will be ovulated
uterus
● Others will degenerate in a
- *Not seen in picture but
process called Atresia
should be around the
○ Turns them into Atretic
encircled area*
Follicles
2. Early Primary Follicles
- Those that survive are called early
primary follicles
■ We see a transformation of
the follicular cell
■ Change from squamous to
cuboidal cells
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■ The stromal cells
3. Late Primary Follicle begin to organize
● As the cycle continues, the follicle themselves around
cells grow larger and larger and the follicle and form
experience changes which will be a layer called the
the following: Theca Folliculi
a) Follicular cells proliferate “theca = case”
and form a few rows of ➔ All these changes are
cells called Granulosa characteristic of Late Primary
Cells Follicles
● The entire structure 4. Secondary Follicles
is called Stratum - Granulosa cells continue to
Granulosum proliferate and enlarge the follicle
b) Then the granulosa cells ■ They also begin to secrete
and the oocyte begin to fluids into these space
secrete certain between them and form a
glycoproteins that form a vesicle called Antrum
layer between them - When the antrum appears, the
● This layer is called follicle is considered a secondary
Zona Pellucida follicle
● “Transparent zone” ■ A new feature also arises
● Separates the which is a little mound of
primary oocyte from granulosa cells squished
its surrounding into the antrum called
granulosa cells Cumulus Oophorus (Aka
● Makes it difficult for Heap of Eggs)
the oocyte to - The theca folliculi also
receive nutrients differentiates into 2 separate layers
● To solve that called:
problem, the ➢ Theca Interna
granulosa cells ● Important layer
send fingerlike ● Highly vascularized
processes through ● Supplies follicles
the zona pellucida with nutrients
to reach and feed ● Has a role in
the oocyte hormone secretion
c) Change in the cells ➢ Theca Externa
surrounding the follicle ○ Has ability to
■ These cells are part contract
of the connective ■ Important
tissue of the ovary for ovulation
and are called ➔ At the end of this stage, the
Stromal Cells oocyte finally wakes up from its
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arrested state, completes Meiosis 6. Ovulation
I, enters Meiosis II, and arrested in - Day 14 in a 28-day cycle
Metaphase II - The follicle ruptures and allows the
➔ The oocyte is now known as the oocyte to be ejected from the
secondary oocyte ovary
➔ We still have only 1 oocyte - In order to help with oocyte
● During cell division, ejection, the ovary as well as the
1 cell gets almost theca externa contract and give it
all the cytoplasm a little push
(Secondary - Once the oocyte is out of the
Oocyte), the other ovary with the help of the
gets practically tentacle-like structures called
nothing and fimbriae, it enters the fallopian
becomes this tiny tube where it can be fertilized
cell called a Polar - If the cycle is shorter or longer
Body than 28-days, ovulation will occur
● The polar body 14 days before the end of the
serves no function cycle
and will eventually 7. Corpus Luteum
degenerate and - The granulosa cells and theca
disappear interna cells of the ruptured follicle
5. Graafian Follicles differentiate and turn into Lutein
- Dominant Follicle Cells
- Granulosa cells continue to - These lutein cells form a structure
secrete fluids causing the antrum called Corpus Luteum (Yellow
to grow Body)
- The follicle after Meiosis I and - Essential for maintenance of the
before ovulation growing embryo and the uterus
- This is where the ovulated oocyte - Its future depends on the event of
will originate fertilization
- The follicle will be pushed against ○ Fertilized and Implanted Oocyte
the surface of the ovary into the Uterus
- Last step before ovulation ■ Corpus Luteum persists
- The secondary oocyte, together and grow bigger and
with the cumulus oophorus and bigger to support the
the rest of the surrounding embryo
granulosa cells, detach from the ○ No fertilization = Corpus Luteum
follicle and float inside the antrum degenerates and turns into
- The structure of cells that now Corpus Albicans (White Body)
surrounds the floating oocyte is which has no function and will
called the Corona Radiata disappear over time
- Soon after the detachment, ○ DAY 28 and the end of the cycle
ovulation happens
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Uterine Blood Supply

- Uterus is a highly vascularized organ
Ovarian Cycle Lecturer’s Discussion - If the mother continues to bleed after
- Oogenesis is a process of formation of delivery, it could be fatal
female gametes which begins inside the - 3 major blood vessels that supply the
fetus before birth uterus and ovary:
- The steps in Oogenesis up to the 1. Hypogastric Artery/ Iliac Artery
production of primary oocytes occur 2. Uterine Artery
before birth 3. Ovarian Artery
- Primary oocytes do not divide further but
rather they either become secondary
oocytes or they degenerate
- The Corpus Luteum produces and
regulates the production of progesterone
- In case the mature ovum has been
fertilized, it goes towards the uterus and
implants itself on the lining of the uterus
- The corpus luteum continues the
production of progesterone to hasten and
nurture the developing embryo
- During non fertilization, the corpus luteum
turns into corpus albicans and the mature
ovum will just shed off along with the
inner lining of the uterus in the process
called menstruation
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Ensure strengthening of this
○
muscle to prevent pulling down of
the organs once the muscle
weakens due to pregnancy or
hormonal changes
○ Multigravid women may have
weak pelvic muscle and can cause
Cystocele
➢ Cystocele
- Protrusion of the bladder out of
the vagina
- Caused by weak pelvic muscle
➢ Rectocele
- The rectum protrudes out of the
vagina
➢ Oogenesis
○ Process of formation of female
gametes
➢ Endocrine gland
Lateral View of the Female Reproductive System ○ Its hormonal control
- The uterus is found on top of the bladder ■ Reproduction control is
which is why pregnant women manifest more complex in females
frequent urinations and suffer from than male
constipation ■ The anterior pituitary
○ The growing fetus compresses the hormone cause the release
bladder towards the symphysis of the hormones FSH and
pubis and compresses the rectum LH
backwards ■ In addition to that, for
- The pelvic muscle is an important muscle females, estrogen and
of pregnant women progesterone are released
from the developing follicle
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● Estrogen is a
reproductive
hormone in females
■ Estrogen assists in
endometrial growth,
ovulation, and calcium
absorption and is
responsible for the
secondary sex
characteristic of females
○ Pubertal development
■ Growth spurt
■ Breast budding
■ Increase in size of pelvis
■ Appearance of body hair
■ Menstruation then
ovulation
Variations of the Uterus
- Greatly affected by congenital uterine Variations of the Uterus based on its Position
malformations on the Pelvic Cavity
1. Normal ➢ Version
- Ample space for embryonic - Where the uterus lean towards
growth - Can lean towards the front,
2. Bicornuate uterus symphysis pubis, or the sacrum of
- May appear normal the woman
- However, a semi-junction or a part ➢ Flexion
of a septum that may disrupt the ● Bending of the uterus on itself
growth of the fetus ➔ Version or flexion does not
3. Septum-dividing uterus necessarily impose problems on
- Most complicated case women unless the women is in her
- Presence of a septum that will late pregnancy stage
disrupt or halt the growth of the ➢ Retroverted
fetus - In case the woman is retroverted
- Can cause termination of the uterus leans towards the
pregnancy sacrum
4. Double uterus ○ It can compress the nerves
- Also double vaginal canals of the sacrum which can
- Each uterus has its own cervix and cause back pain
vaginal canals ➢ Anteverted
- Very rare congenital malformation - If anteverted, it can aggravatedly
compress the bladder
➢ Retroverted and Retroflexed
- Leans to the sacrum and flexed
backward
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➢ Anteverted and anteflexed 2. Oocyte Ovulation
- Leans forward and flexes on its - Use LH
own 3. Corpus Luteum
Breasts Formation
● The breasts is an important part of the - Use LH
reproductive system ➢ Uterine cycle
● Similar hormones affect its function 1. Uterine Growth as it
● Important for lactation and breastfeeding prepares for implantation
● Tissue overlying the chest or the pectoral - Hormones involved:
muscles 1. Follicle Stimulating Hormone
● Women’s breast are made of a specialized (FSH)
tissue that produces milk and fatty tissue - Stimulates follicle maturation
● The amount of fat determines breast size 2. Luteinizing Hormone (LH)
● The milk producing part of the breast is - 2 main roles:
organized into 15 - 20 sections called a) Trigger oocyte ovulation
Lobes b) Forms and maintains the
● Within each lobe are smaller structures corpus luteum
called Lobules 3. Estradiol and Progesterone
○ Where milk is produced - Prepare the uterus for embryo
● Milk travels through a network of tiny implantation
tubes called Ducts 4. Gonadotropin Releasing
● The ducts connect and come together Hormone (GnRH)
into large ducts which eventually exit the - Controls the menstrual cycle
skin through the nipple - Main regulator and initiator of the
● The dark area of the skin surrounding the cycle
nipple is called the Areola
Ovaries Uterus
Main Follicle Oocyte Corpus Uterus

Maturation Ovulation Luteum
Events Formation Growth
Hormones FSH LH LH Estradiol

involved in Progeste
the events rone
GNRH- MAIN REGULATOR AND INITIATOR
Menstrual Cycle - Hormonal Regulation (Video)

- Uterine Cycle + Ovarian Cycle =
Menstrual Cycle
- Main Events that Occur:
➢ Ovarian Cycle
1. Follicle Ovulation
- Use FSH
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Menstrual Cycle ➢ Pre-ovulatory Phase
- Regular activity of changes between the ● Ovaries during the
ovary and the endometrium preovulatory phase is
- Endometrium consists of: called the Follicular Phase
1. Functional Layer ● On the other hand, in the
- Subject to hormonal endometrium it is called
changes the Menstrual And
- Shed during menstruation Proliferative Phase
2. Thin Basal Layer ➢ Post-ovulatory Phase
- Feeds the functional layer ● Ovaries during the
- Consists of 2 synchronized cycles: postovulatory phase is
a) Ovarian cycle called the Luteal Phase
b) Uterine cycle ● On the other hand, in the
endometrium it is called
Menarche the Secretory Phase
- Onset of 1st menstrual period
- Occurs during early adolescence as part Follicular phase
of puberty ● Starts on the 1st day of menstruation
- Following menarche, the menstrual cycle ● Weeks 1 and 2 of the 4-week cycle
occurs monthly, pausing only at ● The whole menstrual cycle is controlled
pregnancy until a person reaches by the Hypothalamus and the Pituitary
Menopause gland
➔ Menopause is when ovarian ● Hypothalamus releases GnRH
function declines and period stops ● GnRH causes the anterior pituitary gland
- Monthly menstrual cycle can vary in to release FSH and LH
duration from 20 - 35 days with an ● Before puberty GnRH is released at a
average of 28 days steady rate
- Each cycle begins on the first day of ● After puberty GnRH is released in pulses
menstruation (bleeding) sometimes more sometimes less
○ Day 1 ○ Frequency and magnitude of these
- Ovulation occurs 14 days before the first pulse determine how much FSH
day of menstruation or 14 days before the and LH are produced
next cycle begins ● Pituitary hormones control ovarian follicle
○ In a 28-day cycle, there are 14 maturation
days leading up to ovulation ● Over the course of this phase, these
(Pre-ovulatory Phase) and 14 oocyte containing groups of follicles grow
days following ovulation and compete for a chance of ovulation
(Post-ovulatory Phase) ● During the 1st 10 days, theca cells
○ During these 2 phases, the ovaries develop receptors and bind LH, and in
and the endometrium undergo response secretes large amounts of the
separate but related changes hormone Androstenedione, an androgen
hormone
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○ Similarly, granulosa cells develop the rupture of the ovarian
receptors and bind FSH, and follicle and the release of
produce the enzyme Aromatase the oocyte
in response ● Most of the follicular phase, the
■ Converts androstenedione pituitary saves it energy, but once
to 17beta-estradiol it sense the dominant follicle is
● During days 10 - 14 granulosa ready for release, it uses all of its
cells also begin to develop LH energy to release FSH and LH to
receptors induce ovulation
○ As the follicles grow and ● While the ovaries are busy preparing an
estrogen is released into egg for ovulation, the uterus is preparing
the bloodstream, increased the endometrium for implantation and
estrogen levels act as a maintenance of pregnancy. This begins at
negative feedback signal, the Menstrual Phase.
telling the pituitary gland to
secrete less FSH Menstrual and Proliferative Phase
○ This causes some ● Old endometrial lining/ functional layer is
developing follicles to stop shed and bled out of the vagina,
growing, regress, and die producing the bleeding pattern known as
off the Menstrual Period
○ Follicles with the most FSH ● Lasts an average of 5 days
receptors continue to grow ○ After that follows the Proliferative
becoming the Dominant Phase
Follicle which continues to ■ High estrogen levels
secrete estrogen stimulate thickening of the
○ Rising estrogen levels endometrium, growth of
make the pituitary gland to endometrial glands, and
be more responsive to the emergence of spiral
pulses-style action of arteries from the basal
GnRH layer to feed the functional
○ As blood estrogen levels layer
grow higher and higher, the ■ Rising estrogen levels also
estrogen from the help change the
dominant follicle now consistency of the cervical
becomes a positive mucus, making it more
feedback signal, making hospitable to incoming
the pituitary gland secrete sperm
more FSH and LH in ■ The combined effects this
response to GnRH spike of estrogen on the
○ This surge of FSH and LH uterus and cervix help
usually happens 1 - 2 days optimize the chance for
before ovulation and is fertilization
responsible for stimulating
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● Highest in Day 11 - Secretory Phase
Day 15 in a 28-day ● Under the influence of progesterone, the
cycle uterus enters the secretory phase of
endometrial cycle
Luteal phase ● Spiral arteries continue to grow
● Following ovulation, the remnant of the ● Uterine glands secrete more mucus
ovarian follicle becomes the corpus ● After Day 15 of the cycle, the optimal
luteum, which is made up of luteinized window for fertilization starts to close
theca and granulosa cells ● Cervical mucus starts to thicken and
○ These cells have been exposed to become less hospitable for the sperm
high LH levels ● Over time, the corpus luteum degenerates
● Luteinized theca cells keeps secreting into the non-functional corpus albicans
androstenedione ○ Doesn’t make hormones so
● Luteinized granulosa cells keep estrogen and progesterone levels
converting it to 17beta-estradiol slowly decrease
● However, luteinized granulosa cells also ● When progesterone reaches its lowest
respond to low LH levels that occur after level, the spiral arteries begin to collapse
ovulation by increasing the active of and the functional layer sloughs off in the
cholesterol side-chain cleavage enzyme form of menstruation
(P450scc) ● Shedding marks the beginning of a new
● This enzyme converts more cholesterol menstrual cycle
into Pregnenolone a progesterone
precursor Menstrual Cycle Lecture Discussion
● So luteinized granulosa cells secrete more Menstruation
progesterone than estrogen during the ● Menarche occurs at the age of 9 - 17 yrs
luteal phase old
● Progesterone has a negative feedback ● Each cycle lasts for avg 28 days
signal on the pituitary gland decreasing ● Menstrual phase may last for 4 - 6 days
LH and FSH release ○ May expel 30 - 80 mL/ period
● At the same time, luteinized granulosa ○ Discharges may include blood,
cells begin secreting inhibin which vaginal secretions, and
similarly inhibit the pituitary gland from endometrial cells
making FSH ○ Dark-red in color
● Both result in decline of estrogen levels, ○ Marigold odor
making progesterone the dominant
hormone during this phase
● Decrease in estrogen and increase in
progesterone signals that ovulation has
occurred, and makes the endometrium
receptive to implantation of a fertilized
gamete
18
Estrogen Progesterone
2. Follicular Phase/ Proliferative Phase
Estrogen refers to a Progesterone refers to - Reformation of the endometrium
steroid hormone that a steroid hormone - High estrogen
is important in the that prepares the - Thickens uterus
reproductive uterus for pregnancy
- Low progesterone
development in
females 3. Luteal Phase/ Secretory Phase
- Increased LH producing corpus
Estrogen is produced Progesterone is luteum (yellow body) which lives
by the growing produced by the for 10-14 days
Graafian follicle corpus luteum
■ Produces progesterone
Estrogen is secreted Progesterone is which readies uterus for
by ovaries prior to secreted by the possible implantation
ovulation. It is also ovaries after the 4. Ischemic Phase
produced by the ovulation. It is also - Corpus albicans for 10 - 14 days
placenta during produced by the - Low estrogen and progesterone
pregnancy placenta during
- Depletion of both hormones,
pregnancy
starting the new menstrual cycle
The secretion of The secretion of
estrogen is regulated progesterone is Menstruation
by FSH regulated by LH ➔ Ovulation
Estrogen is involved in Progesterone is ○ Usually at the middle of the cycle
the formation and involved in the ○ Depends on the length of the
maintenance of formation and follicular phase, varies for
secondary sex maintenance of everyone person
characteristics. It is endometrium and ○ 14 days prior the next cycle for
also important in bone uterus.
Luteal phase
resorption.
○ S/S upon ovulation
Estrogen is involved in Progesterone is 1. Breast tenderness
the enlargement of involved in the 2. Increased basal body
the uterus and breasts reduction of temp (BBT)
during pregnancy contractility of the - May rise up to 1°C
uterus and stimulates
higher than normal
the growth of
mammary glands. - Caused by increase
in progesterone
3. (+) Spinnbarkeit test
Menstrual Cycle Summary
- Under estrogen
1. Menstrual Phase/ Bleeding Phase
influence, cervical
- 1 - 4 days
mucus becomes
- Terminal phase
abundant, clear,
- 1st bleeding day is day 1 of the
stretchable, and
whole cycle
somewhat like egg
- Inner glandular layer of the
whites
endometrium sloughs off
19
- Stretchability is
described by its
spinnbarkeit
- Variation in Length, Flow, and Discharge

4. Mittelschmerz in Normal Menstrual Period
- One sided or Lower 1. Dysmenorrhea
abdominal pain ● 2 kinds which are Primary
associated with and Secondary
ovulation ● Primary dysmenorrhea
- Pain on one side occurs in the absence of
means the ovary of any underlying anatomic
that side released abnormality
the egg for ○ Normal because of
ovulation the high
5. (+) Ferning test prostaglandin
- Cervical mucus produced by the
forms a fern-like endometrium or
structure due to the psychological
crystallization of factors
NaCl on mucus ○ Nursing
fibers responsibilities
- Only detected include rest, heat
under a microscope application,
disruption, or
analgesics
● Secondary dysmenorrhea
occurs when there are
underlying structural
abnormality of the cervix,
uterus, pelvic inflammatory
disease, and such
2. Amenorrhea
● Absence of menstruation
● Primary amenorrhea
20
○ Menarche never Nursing Responsibilities
occurred - How to Manage Menstrual Problems
○ May be related to Especially Dysmenorrhea
hormonal 1. Exercise
alterations - Kegel yoga, aerobic
● Secondary amenorrhea exercises, or leg-lifts are
○ Cessation of believed to alleviate pain
menstruation for during menstruation
more than 3 - Best done prior to
months after regular menstruation
menstrual cycles 2. Diet
have been - Restrict food rich in sugar,
established salt, and stimulates
○ Common reasons: - Increase intake of complex
■ Pregnancy carbohydrates and proteins
■ Other 3. Activities of Daily Living
conditions - Modify activities that does
3. Oligomenorrhea not worsen the pain
- Infrequent menstruation 4. Nutrition
4. Polymenorrhagia 5. Pain Relief
- Frequent menstruation 6. Rest
5. Hypomenorrhea 7. Psychological support
- Abnormally short menstrual - Encourage verbalization of
cycle fears, anxieties, problems,
6. Hypermenorrhea and related concerns
- Abnormally long menstrual - Provide and protect privacy
cycles
7. Metrorrhagia
- Abnormal bleeding LECTURE THREE B
between menses or REPRODUCTIVE AND SEXUAL
intracyclic bleeding related HEALTH: HUMAN SEXUALITY
to cancer or gynecologic
problems According to Dr. Dailey human sexuality is the
8. Menorrhagia totality of our physical, emotional, and spiritual
- Excessive profuse responses,thoughts, and feelings. It is more on
menstrual flow caused by who we are than what we do.
hormonal imbalance,
infection, or uterine tumors Human Sexuality
9. Menopause 1. Sexuality
- Transitional phase marking - Feelings, attitude, and actions
the end of reproductive Regardless if a person is physically male,
abilities his sexuality is determined by the nature
21
actions, behavior, or how he expresses 4. Gender dysphoria
himself - Clinically significant distress
2. Biologic Gender caused when a persons assigned
- Chromosomal sex birth gender is not the same as the
- Refers to the innate sex one with which they identify
determination, either based on the - According to the American
chromosome (XX or XY), Psychiatric Association diagnostic
reproductive organs (ovaries or and Statistical Manual of Mental
testes), hormones (estrogen or Disorders, the term replaces
testosterone) gender identity disorder. It is
3. Gender Identity intended to better characterize the
- Inner sense of being experiences of affected children,
- One’s innermost concept of self as adolescents, and adults
male, female, blend of both or 5. Gender Role
neither. How individuals perceive - Behavioral expression
themselves and what they call - How we are expected to act,
themselves, ones gender or speak, dress, groom, conduct
identity can be different from the ourselves based upon our
ones they are assigned with at assigned sex (girls and women are
birth generally expected to dress in
a. Transgender feminine ways and be polite,
● An umbrella term for accomodating, and nurturing while
people whose gender Men are generally expected to be
identity and/or expression strong, aggressive, and bold)
is different from cultural
expectations based on the Sexual Orientation
sex they were assigned at - Enduring pattern of romantic or sexual
birth. Being transgender attraction to persons of the opposite sex
does not imply any specific or gender, the same sex or gender, or to
sexual orientation, both sexes or more than one gender
therefore transgender ➢ Heterosexuality
people may identify as ○ Refers to an enduring pattern of
straight, gay, lesbian, or romantic or sexual attraction or a
bisexual etc. combination of these to persons of
b. Cisgender the opposite sex or gender, the
● The opposite of same sex or gender, or to both the
transgender, a term for sexes or more than one gender
people whose gender ➢ Homosexuality
identity matches their sex ○ MSM, WSW
assigned at birth (identify ○ Romantic or sexual attraction or
as woman and assigned sexual behavior between members
female at birth) of the same sex or gender
22
➢ Bisexuality 2. Plateau phase
○ Romantic and sexual attraction or ● Changes during the first phase are
sexual behavior towards both male intensified.
and female individuals ● The vagina and penis swells from
➢ Asexual increased blood flow and the
○ Lack of sexual attraction to others vaginal wall turns dark purple.
or low or absent interest or desire ● Breathing, heart rate, and blood
for sexual activity pressure continue to rise
● Muscle spasm may begin in the
Human Sexual Response feet, face, and hand.
- The sequence of physical and emotional ● Tension in the muscles also
changes that occur as a person becomes increases
sexually aroused and participates in ● In Women:
sexually stimulating activities including ○ The woman’s clitoris
intercourse and masturbation becomes highly sensitive
Phases: and retracts under the
1. Excitement phase clitoral hood to avoid direct
● General characteristics: stimulation from the penis.
○ Muscle tension increases ● In Men:
○ Heart rate quickens ○ The man’s testicles are
○ Breathing is accelerated withdrawn up into the
○ Skin may become flushed scrotum.
○ Nipples harden or become 3. Orgasm phase
erect ● The climax of the sexual response
○ Blood flow to the genitals cycle.
increases resulting in ● It is the shortest of the phases and
swelling of the woman's generally lasts only a few seconds.
clitoris and labia minora ● Involuntary muscle contraction
and erection of the man's happens.
penis. ● Blood pressure, heart rate, and
● In Women: breathing are at their highest rate
○ Vaginal lubrication begins with a rapid intake of oxygen.
○ The woman's breast ● Muscles in the feet spasm, there is
becomes fuller a sudden forceful release of sexual
○ Vaginal walls begin to tension.
swell. ● In Women:
● In Men: ○ the muscles of the vagina
○ The man’s testicles swell contract
○ The scrotum tightens ○ The uterus also undergoes
○ He begins secreting a rhythmic contraction.
lubricating liquid ● In Men:
○ Rhythmic contraction of
the muscles at the base of
23
the penis results in the Care of the Mother and the Fetus During
ejaculation of semen. Perinatal Period
○ A rash or “sex flush” may The perinatal period commences at 22
appear all over the body completed weeks or 154 days of gestation and at
4. Resolution phase seven completed days after birth. This topic is
● During this phase the body slowly divided into weeks and divided into three periods
returns to its normal level of of transition: prenatal (during pregnancy or before
functioning and swelled and erect birth), intrapartal (labor and delivery), postpartum
body parts turn to their previous (period after delivery)
size and color Prenatal Care: Care of the Fetus
● This phase is marked by a general Fetal Formation
sense of wellbeing and often ➢ Fertilization
fatigue. This has been mentioned in the previous
● Some women are capable of a topics where fertilization can occur once a
rapid return to the orgasm phase mature egg cell unites with the sperm cell
with further sexual stimulation and at the ampulla.
may experience multiple orgasms. ○ Other terms of fertilization:
➔ Refractory period Conception, fecundation,
Men need recovery time after impregnation
orgasms which is called the ○ The union of mature egg cell and
refractory period, during which sperm cell at the ampulla of the
they cannot reach orgasm again. fallopian tube shortly after
The duration of the refractory ejaculation (often only within 5
period varies among men and minutes with an average of 46
changes with age hours which seems more
reasonable)
All the phases are experienced by both sexes ○ Formation of zygote with
although the timing is usually different, for combination of genetic mtrl
example it is unlikely that both partners will reach ○ Sperm: lives for 72 hours (48 hours
orgasm at the same time. In addition the intensity prior ovulation and 24 hours after);
of the response and the time spent in each phase 5 minutes to travel
varies from person to person ○ Ova: 24-48 hours only
Sperms must be in the genital
tract 4-6 hours before they are
LECTURE FOUR A able to fertilize an egg.
CARE OF THE MOTHER AND THE ○ Hyaluronidase
FETUS DURING THE PERINATAL It is during this time when the
PERIOD: PRENATAL CARE enzyme needed to dissolve the
semen substance hyaluronic acid
Perinatal → Refers to the period surrounding the that holds together the cells
pregnancy until the delivery covering the ovum it activated.
This enzyme is called
Hyaluronidase.
24
○ Factors affecting fertilization penetrate the
1. Equal maturation of ovum).
sperm and ovum
Sperm must be able to do
two processes: Sperm
Capacitation and
Acrosomal Reaction.
2. Ability of sperm to reach

ovum (Sperm
Capacitation)
➔ Sperm Capacitation: - As soon as the sperm penetrates
Process by which the the zona pellucida, it makes
sperm becomes contact with the vitelline
hypermobile and there is a membrane of the ovum.
breakdown of plasma - A cellular change occurs in the
membrane which exposes ovum that inhibits the other
the acrosomal membrane sperms to penetrate.
of the sperm head, - The other sperms can't penetrate
allowing the sperm to bind anymore since there is already a
to the zona pellucida of the single sperm that is able to reach
ovum. or penetrate the vitelline
3. Ability of sperm to membrane.
penetrate the zona - This cellular membrane is
pellucida and cell mediated by the release of
membrane (Acrosomal material from the cortical granules,
Reaction) organelles found just below the
- Reaction that egg surface.
follows capacitation
- Sperm head
contains
hyaluronidase
- As millions of
sperms surround
the ovum, they
deposit minute
amounts of
hyaluronidase in the
corona radiata (the
outer layer of the
ovum which allows
the sperm head to
25
- When fertilization occurs, the male - It is a fluid-filled cavity that
pronucleus unites with the female reaches the uterine cavity.
pronucleus, thus the chromosome - Over the next 3-4 days of
deployed number 46 is restored on development, a differentiation of
a new cell. cells as their specific potencies
- The zygote is created with a new occur, the reorganization of the
combination of genetic material morula follows forming a
which creates a unique individual blastocyst.
from the parents and anyone else. - The morula is a jam-packed cell
- As seen in the picture, it is a set of of divided differentiated cells.
chromosomes. - Once this cell accumulates in one
- The ovum releases or gives up 23 area forming a cavity or the
of its chromosomes while the blastocyst cavity, the cell is now
sperm gives up another 23 of its called a blastocyst.
chromosomes. - This is the stage where there is
- It then unites, forming 23 pairs of already a cavity in the morula
chromosomes for a total of 46. called the blastocoel and when it
- The 22 pairs is called the enters the uterine cavity, the cavity
autosomes while the last pair of enlarges and pushes morula cells
chromosomes refers to the sex into an outer layer of cells called
chromosomes which determines the trophoblast.
the sex or gender of the fetus. - This trophoblast is a very
- If the female gives off an X and the important part of the cell because
male gives off an X, then the fetus this is the portion which attaches
will be a female. If the ovum itself to the endometrium of the
produces an X and the sperm uterus.
releases a Y chromosome, then - Along with this is the inner cell
the fetus will be male. mass attached to one side of the
blastocyst, the divisions or the
(Youtube Video Crash Course) reorganization have already
consumed energy stores available
in the zygote.
- Such that, it becomes necessary
for the blastocyst to embed or
implant in the uterine wall.
- This is necessary for it to obtain
nourishment for its further
development.
- An important part of embryonic

development is the blastocyst.
26
➢ Implantation amniotic cavity, the
○ Aka Nidation amniotic fluid, and
○ 8-10 days after fertilization; at the fetus.
fundal portion ■ Langerhans layer
- Happens in the fundal - Layer of the
portion or the upper ⅓ of placenta that
the uterus. It can be prevents the
anterior or posterior. penetration of
- Abnormal implantation viruses in the early
sites are fallopian tubes stage of pregnancy.
which lead to ectopic
pregnancy and the lower
uterine segment which
causes placenta previa.
- At the time of implantation,
the blastocyst completely
buries itself in the
endometrium.
○ Trophoblast
- Its outermost layer or the
trophoblast is responsible
for attaching itself to the
maternal side.
- The embryo then impulses
itself in the amniotic sac Ectopic Pregnancy
filled with fluid (amniotic
fluid).
- It is a thin but tough
transparent pair of
membranes that hold a
developing embryo.
➔ Forms a hair-like structure
which is the chorionic villi.
■ Chorion
- The outer
membrane contains
the amnion and is - In cases like this, it could be fatal if it is
part of the placenta. detected late because the fallopian tubes
■ Amnion may burst due to the growing embryo.
- The inner of these - Supposedly, the embryo should enlarge in
fetal membranes is the uterus, however it is implanted in the
the amnion, it fallopian tube.
encloses the
27
- Once the fetus grows or the embryo
grows, it may cause the rupture of the
fallopian tube
- Another abnormality is the low-lying

implantation of the uterus (Placenta - As the embryo implants itself in the
Previa) wherein it can obstruct the cervix endometrium of the uterus, the
or the passageway of the baby. endometrial lining thickens and is called
- Once the baby is born, ideally it should be the Decidua.
head first, placenta soon after the fetus. - This layer supported by the Hcg hormone
- But in cases like placenta previa, it can be which is an essential hormone that helps
difficult for the baby to be delivered maintain pregnancy
naturally due to the blockage of placenta - Decidua is approx 5 - 10 mm thick.
in the cervix. - The decidua basalis refers to the portion
- Usually complications may occur late in meaning the site of implantation.
the pregnancy or once in later. - Decidua capsularis is a portion overlying
- This is usually detected late or the the developing fetus.
problems may occur in late pregnancy. - Decidua parietalis or decidua vera, lies
- Supposedly, the placenta should grow on the remainder of the uterus.
the upper part of the fundus, but in - The trophoblast, the portion of the
placenta previa it grows on the lower part blastocyst that attaches to the
of the uterus, blocking the cervix. endometrium, forms a hairlike structure
called the chorionic villi.
Placenta - The chorionic villi together with the
- 400-600 grams decidua basalis forms the placenta
- Union of chorionic villi and decidua (Chorionic Villi + Decidua Basalis =
- Loses function beyond 42 weeks Placenta).
- Decidua: Supported by Hcg (Human - The placenta is an organ that develops in
Chorionic Gonadotropin) the uterus during pregnancy which
provides oxygen and nutrients for the
baby and removes waste products from
the baby’s blood.
28
- It attaches to the wall of the uterus and
the fetal umbilical cord who arises from it
and has a discoid shape.
- It matures when it reaches 12 weeks and
it is in its utmost effectiveness when it
reaches 40 - 42 weeks AOG (Age of
Gestation = Age of Pregnancy).
- Beyond 42 weeks AOG, the placenta will
lose its function.
Functions of the Placenta

● Transport of nutrients and fluid
○ Mother takes in nutrients and
fluids to nourish the growing fetus
○ It is rare for the fetus to bring back
to its mother except for AFP or
alpha fetoprotein
● Excretion of amniotic fluid
○ Clear, straw fluid produced by the
fetus and mother which help
nourish the fetus
● Respiratory organ
○ Respiratory organ all throughout
- Placenta has 2 sides.
the pregnancy
- The Maternal side is called Duncan, and
○ Size of the placenta affects the
the Fetal side is called Schultz.
amount of blood exchanged
- Duncan is considered the dirty side
● Protective barrier
because of the ruggaeted part which
○ It acts as a protective barrier
looks like a beefy structure of the
against some substances and
placenta called the Cotyledon.
organisms like heparin and
- The Schultz is the side where the fetus
bacteria
lies and where you will see the
○ It is ineffective against viruses,
attachment of the cord of the placenta.
alcohol, nicotine, antibiotics,
- It is shiny and clean.
depressants, and stimulants
- Upon placental delivery part of the
○ This barrier is called the Placental
nursing responsibility is to take note of the
Barrier
cotyledons.
● Secretes hormones
- Any missing cotyledons should be
○ Hormones such as estrogen,
noted and informed to the doctor
progesterone, hCG, hPL (Human
immediately as it can indicate
Placental Lactogen) or hCS
retained placental fragments which
(Human Chorionic
can cause postpartum bleeding to
Somatomammotropin)
the mother.
29
Dirty → Duncan
Shiny → Schultz Fetal Formation
Placental Hormones
1. Human Chorionic Gonadotropin (HCG)
- Secreted as early as 8 - 10 days
after fertilization
- Detected in the serum as early as
the time of implantation by the
most sensitive pregnancy test
- Present in urine and blood after
missed menstruation up to 1-2
weeks postpartum
- Why women immediately
- The orange mass is how the H mole looks
test themselves for
like.
pregnancy if they miss their
- It is a rare complication of pregnancy
menstruation
characterized by abnormal trophoblast
- Pregnancy test kits detect
growth.
the presence of HCG
- These cells normally develop into the
- Suppress rejection of placenta,
placenta.
prolongs the life of corpus luteum
- Women may think they are pregnant
which produces progesterone in
because their abdomen may grow large
the first few weeks
because of the mass.
- Responsible for nausea and
- This may appear as cancer as well and is
vomiting of pregnant women
treated similarly.
- Not all women with increased
HCG is pregnant
Placental Hormones (continuation)
- HCG may also be produced in
- After the first 2 months of gestation,
other situations such as H mole or
estrogen and progesterone is now
Hydatidiform mole which follows
produced by the placenta
the symptoms of pregnancy
2. Progesterone
■ May make women think they are
- Maintain pregnancy and prevent
pregnant
uterine contraction
- N=400,000 IU/24 hours
3. Estrogen
- Mammary gland and uterine
development
4. Human Chorionic
Somatomammotropin
- Promotes lactation
- HCS or HPL is secreted by the 3rd
week after ovulation
30
- Influences somatic cellular growth ■ Meconium is fetal stool
of the fetus expelled intrauterine
- Resembles growth hormone especially if the gestational
- Principal diabetogenic factor as it age goes beyond normal
is a major insulin antagonist or a span
glucose-sparing hormone ○ Golden-colored amniotic fluid
- Prepares breast of the mother for ■ May indicate haemolytic
lactation disease or the breakdown
of RBCs in a faster rate
Amniotic Fluid ■ Causes the release of high
● Clear, straw-colored fluid; slightly alkaline bilirubin which causes
(pH 7.2) yellow color
● Where the fetus floats ● Purpose:
● Originates both from the fetus and mother ○ Shock absorber
● 800mL-1200mL ■ Separates fetus from the
● Source: membrane allowing
○ Amniotic membrane symmetrical growth and
○ Fetal urine free movement of the fetus
■ In the 10th week of fetal ○ Medium of excretion
life, the fetal urine ○ Serves as a fetal drink
contributes to the fluid ○ Specimen
■ Oligohydramnios ■ To determine fetal
● Amniotic fluid index wellbeing or its absence
< 500 mL ○ Fetal temperature
● May imply kidney ○ Equalizes uterine pressure and
problem prevents marked interference with
■ Polyhydramnios placental circulation during labor
● Amniotic fluid index
> 2000 mL Umbilical Cord
● May indicate ● Conduit between developing
esophageal atresia embryo/fetus and the placenta
(Atresia means ● Approximately 55 cm in length and an
blocked esophagus inch across the fetus reaches term
● Esophageal atresia ● A bundle of one umbilical vein which
may mean that the carries oxygenated blood to the fetus and
fetus is unable to 2 umbilical arteries which carry
ingest amniotic fluid deoxygenated blood from the fetus to the
causing the placenta
excessive amount ● AVA (determinant for heart and kidney
● Variations: diseases)
○ Green-colored amniotic fluid ○ Artery vein and artery
■ Meconium-stained
31
● Covered by Wharton’s jelly (gelatinous affected at all and
mucopolysaccharide) continues to grow
○ Prevents the cord from normally
compression 2. Embryonic (3-8 weeks after fertilization;
● The blood volume in the cord also period of organogenesis)
prevents cord compression - Period of organ differentiation
● The cord extends from the fetal surface of - Most dangerous period of
the placenta to the umbilicus of the fetus development
● Transports oxygen and nutrients to the - Teratogen introduced at this stage
fetus and return metabolic wastes may cause severe organ
including CO2 from the fetus to the malformation or dysfunction which
placenta can result to congenital defects
➢ Nuchal cord 3. Fetal (8 weeks up to birth)
○ Umbilical cord wraps around the - Age of viability: At least 20-24
neck of the fetus weeks and more than 500 grams
○ Common and may occur during - Period of post differentiation
pregnancy, labor and delivery - Teratogen exposure at this time
causes minimal malformation
(least likely)
- If there is an effect, the effect is
most likely alteration in size or
function
- Fetus is viable or can survive
outside the uterus after birth,
natural or induced when
supported by up to date medicine,
if it reaches at least 20 weeks AOG
Stages of Intrauterine/Fetal Development
and greater than 500 grams
1. Pre-embryonic stage (First 2 weeks after
- Terminated fetus less than these
fertilization)
values is considered an Abortus
- Ovum → Zygote
or a product of abortion
- Fertilized ovum implants itself into
the uterus and becomes a zygote
Embryonic Germ Layers
- At this time pre-differentiation of
- Cephalocaudal
organs occur
- When the ovum exposed to a
teratogen or any harmful
substance to the fetus
- This is where the “All or
None Law” applies
- The ovum is
damaged and it is
out in spontaneous
abortion or is not
32
- Germ layer is a group of cells in an
embryo that interact with each other as
the embryo develops and contributes to
the formation of all organs and tissues.
- The development of organs happens in a
Cephalocaudal fashion.
- Ectoderm is responsible for the formation
Image of Fetal Doppler and Fetoscope connected
of the nervous system, hair, nails, skin,
to a Stethoscope
epidermis, sebaceous glands, sweat
glands, salivary glands, oral mucous
Cardiovascular System (Mesoderm)
membrane, epithelium of naso-oral
passages
- Mesoderm is the middle layer and
develop into dermis, cardiovascular
system, reproductive system,
musculoskeletal system, and urogenital
system except for the bladder
- The Endoderm/Ectoderm is the inner layer
which forms the lining of the GI tract from
pharynx to rectum, liver, pancreas,
thyroid, parathyroid, respiratory tract,
bladder, and thymus - The fetal circulation system uses 3 shunts
which are small passages that direct
Systems of the Fetus blood that needs to be oxygenated.
➢ Cardiovascular System (Mesoderm) - The purpose of these shunts are to
○ Starts at 16th Day of life bypass the lungs and the liver because
○ Fetal Heart Tone (FHT) is audible these organs do not develop and work
via Fetal Doppler at 10 - 12 weeks fully until after birth.
AOG - The shunt that bypasses the lungs is
■ Via fetoscope at 16 weeks called the Foramen Ovale which moves
AOG blood from the right atrium of the heart to
■ Via stethoscope at 20 the left atrium which is abnormal in adults.
weeks AOG
○ Fetal Heart Rate (FHR) = 110 - 150
bpm starting 28 weeks AOG
■ Irregular in the first few
weeks .
○ Hemoconcentrated Image of Foramen Ovale
■ High RBC concentrations
- Another shunt is the Ductus Arteriosus
which moves blood from the pulmonary
artery to the aorta.
33
- Oxygen and nutrients from the mother’s
blood are sent across the placenta to the
fetus.
- The enriched blood flows through the
umbilical cord to the liver and splits into 3
branches.
- The blood then reaches the inferior vena
cava which is a major vein connected to
the heart.
Image of Ductus Arteriosus (in red) and Foramen

Ovale (in purple)
Image of Ductus Arteriosus

- Most of the blood is sent through the Youtube Video on Fetal Circulation and Transition
Ductus Venosus coming from the to Postnatal Circulation after Birth
placenta directly to the inferior vena cava.
- This is a shunt that lets highly oxygenated Specific structures involved include
blood bypass the liver to the inferior vena 1. Placenta
cava and then to the right atrium of the 2. Umbilical vein
heart for pumping. 3. Ductus venosus
- A small amount of this blood is pumped 4. Foramen ovale
straight to the liver to give it the oxygen 5. Ductus arteriosus
and nutrients it needs, 6. Umbilical arteries
- Waste products from the fetal blood are ● Blood rich in nutrient and oxygen supplied
transferred across the placenta to the by the Placenta flows through the
mother’s blood Umbilical Vein to the Ductus Venosus.
● Blood flows there to the inferior vena cava
to the right atrium.
● This blood mixes with blood returning to
the heart from the upper body by the
superior vena cava and from the lower
body by the inferior vena cava
Image of Ductus Venosus ● Once in the right atrium, some of the
blood flows to the right ventricle, and
some of the blood flows to the Foramen
Ovale, to the left atrium and into the left
ventricle where it is then pumped out into
the aorta to the body
● Blood that flows into the right ventricle is
then pumped into the pulmonary artery.
34
● Because the lungs are fluid-filled instead pulmonary vascular resistance decreases
of air-filled, the vessels in the lungs are to normal
narrow, creating a higher resistance of
blood flow into the lungs
● Due to this high resistance to blood flow
in the pulmonary circulation and a low
resistance to blood flow in the systemic
circulation, blood pumped into the
pulmonary artery by the right ventricle is
more likely to flow into the Ductus
Arteriosus and into the aorta.
● Due to the high blood flow from the
superior and inferior vena cava up to the
right atrium, pressures in the right atrium ● In the postnatal circulation, blood no
are higher than the left atrium. longer flows through the foramen ovale or
○ This promotes blood flow to the the ductus arteriosus. The increase in left
foramen ovale in the atrial level atrial pressure after breath forces the
● Only 8% of right ventricular output flows septum primum against the septum
into the lungs, providing nutrients to the secundum functionally closing the
developing lung tissues foramen ovale.
● Most of the blood passes through the ● Within 3 months, the foramen ovale
ductus arteriosus into the aorta and out to permanently closes as fibrin deposits fuse
the body the layers of septal wall together
● The Umbilical Arteries allow blood to ○ 15 - 25% of adults have a pro
flow from the body to the placenta to be pain foramen ovale that has never
enriched with oxygen and nutrients closed. The shunt via the PFO via
● Once the baby is born and takes a breath, birth is usually small
the umbilical cord is clamped and the ● The ductus arteriosus begins to close
placenta is removed from the systemic shortly after birth once the infant breaths
circulation ○ Normally ductus closes completely
● Transition from fetal to postnatal in 4 - 10 days
circulation begins. With the removal of the ● The ductus venosus is open at the time of
placenta from the circulation, systemic birth, making central venous access
vascular resistance begins to rise possible through the umbilical vein. As
● With each breath, alveoli in the lungs fibrin infiltrates the ductus venosus, it
begin to expand and the vessels usually closes in 3 - 7 days
surrounding them dilate in response to the ○ After it closes, the remnant is
presence of oxygen called Ligamentum Venosum
● Pulmonary pressures begin to decrease, ● Within a week after birth, the umbilical
although pulmonary pressures are lower vein and arteries are infiltrated with fibrin
than systemic pressure within minutes and become ligaments
after breath, it is 6 - 8 weeks before
35
Respiratory System (Endoderm) ● But helps the
● Not functional as a whole until the birth of newborn
new born
● Develops from a hollow tube of
esophagus and trachea until 4th week
AOG
● 1 hollow tube for esophagus and trachea
until 4th week
● Respiratory movement at 3rd months
rotation
○ Lecithin: Sphingomyelin
○ Surfactant: at 24th week
■ Phospholipid substance
which decreases alveolar
surface tension on
expiration preventing
alveolar collapse and
improving the infant’s
ability to maintain
respirations Nervous System (Ectoderm)
■ Basis of determining fetus ● Develops intrauterine from ectoderm
viability ● Neural plate
■ Lack of surfactant means ○ Thickened portion of the ectoderm
the newborn won’t be able ○ Apparent at 3rd week AOG
to breath on its own in the ○ Top portion differentiates into the
extrauterine life neural tube which will form the
● Betamethasone CNS
○ In cases where the mother goes ● Neural crest
into labor, they are immediately ○ Will develop the PNS
given IM doses of steroids or ● Brain growth until 6 years old
Betamethasone or ○ All parts of the brain form in the
Dexamethasone. This steroid is uterus although none are
believed to stimulate synthesis completely mature at birth
and release of the surfactants ○ Growth precedes rapidly in the
○ In cases where the newborn is still first year and continues at high
preterm, they are given through levels until 5 - 6 yo
endotracheal tube or through a ● Folic acid
tube inserted directly into the ○ Spinal cord disorders such as
lungs, they are given the artificial meningocele may occur because
surfactants of lack of folic acid in green leafy
■ Commonly Survanta vegetables and pregnancy
● Costly vitamins
36
Digestive System (Endoderm) ○ Meconium
● GI tract of the fetus is STERILE ■ First stool
● Vitamin K is synthesized by the action of ■ Composed of ingested
bacteria in the intestine material during fetal
○ Low Vit K levels in newborns development such as
● Sterile intestine intestinal epithelial cells,
● Common congenital GI defects lanugo, mucos, amniotic
○ Atresia/Stenosis fluid, bile, and water
■ Atresia ■ Viscous and sticky like tar
● Orifice is ■ Very dark olive green color
abnormally closed ■ Almost odorless
or absent ■ Important To Note If Baby
● Stenosis Has Passed Its
● Narrowing of GI Meconium
tract ● Rules out stricture
■ Failure to differentiate of or non canalization
the initial 1 hollow tube will of the anus
result in atresia or stenosis
which may pose feeding
problems in the
extrauterine life
○ Omphalocele
■ If abdomen fails to close
anteriorly, it may result in ○ Fetal liver
omphalocele ■ The liver is active through
■ Birth defect in which the gestation functioning as a
the abdominal organs are filter between the incoming
outside of the body blood and the fetal
because of a hole in the circulation, and as a
navel area deposit site for fetal stores
■ Intestines are covered only such as iron and glycogen
by a thin layer of tissue ■ Still immature at birth
and can be seen easily
37
■ Can lead to hypoglycemia ○ Excreted into the amniotic fluid at
and hyperbilirubinemia 16 weeks
● Serious problems at ● At term, fetal urine is excreted 500
first 24 hours after mL/day
birth ● An amount of amniotic fluid that is less
■ Liver does not prevent than normal (Oligohydramnios) suggests
recreational drugs or that fetal kidneys are not secreting
alcohol ingested by the adequate urine
mother from entering fetal ● Integumentary System
circulation ○ Skin of a fetus appears thin and
translucent until subcutaneous fat
Reproductive System (Mesoderm) begins to be deposited at 36
● A child’s sex is determined at the moment weeks
of conception via spermatozoon carrying ● Lanugo
an X or Y chromosome ○ Skin is covered by fine, soft downy
● Ascertained as early as 8 weeks of hair
chromosomal analysis ○ Serves as insulation in utero
● Gonads develop at 6 weeks AOG ○ Develops at 16 weeks AOG
● If testes forms, testosterone is secreted, ○ Diminishes at the end of 36 weeks
influencing the sexual neutral gentle duct
to form other male organs
● In the absence of testosterone secretion,
female organs will form
● Testes first forms in the abdominal cavity
and do not descend into the scrotal sac
until the 34th to the 38th week
○ Because of this, many preterm
male infants are born with ● Vernix caseosa
undescended testes ○ Cream, cheese like substance
■ Need follow up care to ○ Important for lubrication and
make sure that the testes prevent maceration in utero
descend when they reach ○ Forms by the end of 20 weeks
the 34th - 38th week
■ Testicular descent does not
occur easily in extrauterine
life
Urinary System
● Kidney presence is not essential before
birth
○ Placenta clears the fetus of waste
products
● Urine formation at 12 weeks
38
Immune system Musculoskeletal System

➢ IgG ● First 2 weeks AOG
○ Crosses placental barrier at 20 ○ Cartilage prototypes provide
weeks position and support to the fetus
○ Certain at 24 weeks AOG to give ○ Ossification of this cartilage in the
fetus temporary passive immunity bone begins at about the 12th
against diseases for which the week and continues all throughout
mother has antibodies fetal life and into adulthood
○ The level of acquired immunity ● Carpals, tarsals, and sternal bones
peaks at birth and then decreases generally do not ossify until birth is
over the next 8 months as the imminent
infant builds up his/her own stores ● Fetal movement at ultrasonography at
of IgG as well as IgA and IgM 11th week
○ Because passive immunity has ● Quickening at 16 - 20 weeks AOG
declined by 2 months, basic ● Usually felt earlier in multigravida women
immunization is then started
○ A fetus is capable of active Fetal Formation
antibody production late in - 267 - 280 days, 9 calendar mos, 40
pregnancy weeks, 3 trimester, 10 lunar mos.
➢ IgA and IgM
○ IgA and IgM cannot be passed
from the mother to the fetus
○ Presence indicates the newborn is
exposed to a disease
○ Produced after infection
Endocrine System Fetal Development month by month

● Function begins along nervous system ➢ Month 1
development ○ A primitive face will take form with
● Fetal pancreas produces insulin needed large dark circles for eyes. The
by the fetus mouth, lower jaw, and throat are
○ Insulin is one of the few developing.
substances that does not cross ○ Blood cells are taking shape, and
placenta from the mother to the circulation will begin.
fetus ○ The tiny “heart” tube will beat 65
● Thyroid and parathyroid glands play vital times a minute by the end of the
roles in fetal metabolic function and fourth week.
calcium balance ○ By the end of the first month, your
● Fetal adrenal glands supply a precursor baby is about 1/4 inch long -
necessary for estrogen synthesis by the smaller than a grain of rice
placenta
39
➢ Month 3
○ Your baby’s arms, hands, fingers,
feet, and toes are fully formed.
○ Your baby can open and close its
fists and mouth.
○ Fingernails & toenails are
beginning to develop and the
external ears are formed.
➢ Month 2 ○ The beginnings of teeth are
○ Your baby’s facial features forming.
continue to develop. ○ Your baby’s reproductive organs
○ Each ear begins as a little fold of also develop, but the baby’s
skin at the side of the head. gender is difficult to distinguish on
○ Tiny buds that eventually grow into ultrasound
arms and legs are forming. ○ By the end of the third month, your
○ Fingers, toes & eyes are also baby is fully formed.
forming ○ All the organs and extremities are
○ The Neural tube (Brain, spinal present and will continue to
cord and other neural tissue of the mature in order to become
central nervous system) is well functional
formed. ○ The circulatory and urinary
○ The digestive tract and sensory systems are working and the liver
organs begin to develop. Bone produces bile.
starts to replace cartilage ○ At the end of the third month, your
○ The head is large in proportion to baby is about 4 inches and weighs
the rest of the baby’s body. about 1 ounce
○ By the end of the second month, ○ Since your baby’s most critical
your baby is about 1 inch long and development has taken place,
weighs about 1/30 of an ounce. your chance of miscarriage drops
○ At about 6 weeks, your baby’s considerably after three months.
heart can usually be detected
○ After the 8th week, your baby is
called a fetus instead of an
embryo
➢ Month 4
○ Your baby’s heartbeat may now be
audible through an instrument
called a doppler.
40
○ The fingers and toes are well - ○ The baby’s skin is covered with a
defined. whitish coating called vernix
○ Eyelids, eyebrows, eyelashes, caseosa.
nails, and hair are formed. ■ This “cheesy” substance is
○ Teeth and bones become denser. thought to protect baby’s
○ Your baby can even suck his or skin from the long
her thumb, yawn, stretch, and exposure to the amniotic
make faces fluid. This coating is shed
○ The nervous system is starting to just before birth.
function. ○ By the end of the fifth month, your
○ The reproductive organs and baby is about 10 inches long and
genitalia are now fully developed, weighs from ½ to 1 pound
and your doctor can see on
ultrasound if you are having a boy
or a girl.
○ By the end of the fourth month,
your baby is about 6 inches long
and weighs about 4 ounces.
➢ Month 6
○ Your baby’s skin is reddish in
color, wrinkled, and veins are
visible through the baby’s
translucent skin.
○ Baby’s finger and toe prints are
visible. The eyelids begin to part
➢ Month 5
and the eyes open
○ You may begin to feel your baby
○ Baby responds to sounds by
move, since he or she is
moving or increasing the pulse.
developing muscles and exercising
○ You may notice jerking motions if
them.
baby hiccups
■ This first movement is
○ If born prematurely, your baby
called quickening.
may survive after the 23rd week
○ Hair begins to grow on the baby's
with intensive care.
head.
○ By the end of the sixth month,
○ Your baby’s shoulders, back, and
your baby is about 12 inches long
temples are covered by a soft fine
and weighs about 2 pounds
hair called lanugo.
■ This hair protects your
baby and is usually shed at
the end of the baby’s first
week of life
41
○ Most internal systems are well
developed, but the lungs may still
be immature.
○ Your baby is about 18 inches long
and weighs as much as 5 pounds.
➢ Month 7
○ Your baby will continue to mature
and develop reserves of body fat.
○ Your baby’s hearing is fully
developed. ➢ Month 9
○ He or She changes position ○ Your baby continues to grow and
frequently and responds to stimuli, mature: the lungs are nearly fully
including sound, pain, and light developed.
○ The amniotic fluid begins to ○ Your baby’s reflexes are
diminish. coordinated so he or she can
○ At the end of the 7th month, your blink, close the eyes, turn the
baby is about 14 inches long and head, grasp firmly and respond to
weighs from 2-4 pounds. sounds, light, and touch.
○ If born prematurely, your baby ○ Baby is definitely ready to enter
would be likely to survive after 7th the world!
month ○ You may notice that your baby
moves less due to tight space.
○ Your baby’s position changes to
prepare itself for labor and
delivery.
○ The baby drops down in your
pelvis.
○ Usually the baby’s head is down
toward the birth canal. Your baby
is about 18 to 20 inches long and
➢ Month 8
weighs about 7 pounds.
○ Your baby will continue to mature
and develop reserves of body fat.
Fetal Formation
○ You may notice that your baby is
➢ Fetal Milestone
kicking more.
○ 1st Trimester
○ Baby’s brain is developing rapidly
■ Period of rapid
at this time, and your baby can
organogenesis
see and hear.
■ Susceptible to teratogens
(such as alcohol, drugs,
42
virus, and radiation are Assessment of Fetal Growth
highly damaging) 1. History taking
○ 2nd Trimester - Fetal growth and development can
■ Most comfortable period be compromised if a fetus has a
■ Pregnant women find this metabolic or a chromosomal
the most comfortable disorder that interferes with normal
period since the initial growth.
signs of pregnancy - If the supporting structures
stabilizes during this time such as the placenta or
and the fetus keeps cord do not form normally
growing or if environmental
○ 3rd Trimester influences such as
■ Rapid fetal growth cigarette smoking, alcohol
● As there would be consumption interfere with
rapid deposition of fetal growth.
fats, iron and - Like all assessments, fetal
calcium assessment begins with a health
history of the mother.
Estimated Date of Birth - Ask specifically about nutritional
○ 38 - 42 weeks intake because if a woman is not
○ Naegele’s Rule (The method’s name) eating a well balanced diet she
○ LMP - 3 months + 7 days = EDB (LMP may not be taking sufficient
refers to the first day of the last nutrients for fetal growth.
menstruation) - Be certain also to ask about
It is a nursing’s responsibility to determine personal habits such as smoking
the date of birth, it is call the expected or recreational drug use and
due date) exercise because all of this
Example: influences glucose or insulin
LMP= july 4, 2020 balance and fetal growth.
7 4 2020 - Most women actively protect a
-3____+7_(Naegele's’ Rule) fetus growing inside them
4 11 2021 - Asking if a woman has had any
(April 11, 2021) accident or experienced intimate
- Convert the LMP date to numbers it partner abuse would help
would be 7, 4, 2020. determine whether the fetus could
- Then following the naegele's rule have suffered trauma.
we subtract 3 month and add 7
days the result would be 4, 11,
2021 since we will be jumping
another year we add 1 to the year
so it is april 11, 2021
43
2. Fundus a. Bartholomew’s Rule of Fours
- Aside from the subjective factors

you also need to determine the
- Utilizing two methods, we will be
fetal growth objectively
able to estimate the fetal size
- For laboring women, the fundus (a
following the age of gestation.
muscle) is the location to feel the
- This method estimates the age of
contraction
gestation relative to the height of
➔ Steps: How to Locate the
the fundus of the uterus above
Fundus
the symphysis pubis.
1. Gently palpate the lower
➔ It follows the four landmarks:
end of the sternum or the
● At 12 weeks the fundus is
typhoid process
slightly palpated above the
2. Continue to palpate down
symphysis pubis
until you feel a firm area
○ If you can feel the
where there is a firm
firm fundus, it
muscle beneath the
means the woman
typhoid process and above
is 12 weeks
the fetus
pregnant.
● In 16 weeks, it is between
the symphysis pubis and
the umbilicus
● By 20 weeks, the fundus is
palpable at the level of the
umbilicus
● On the 9th lunar month or
when it’s full term, you can
feel the fundus at the level
of the xiphoid process
44
growing more in weight than in
b. Mcdonalds’ Rule height during this time.
- Until then, a fundal height much
greater than this standard
suggests:
1. Multiple pregnancy
2. A miscalculated due date
3. A large per gestational age
infant or the baby is just
too large based on the
normal or the standard size
- The Mcdonald's Rule follows a
4. Hydramnios
symphysis fundal height
5. Polyhydramnios
measurement, determining during
6. H mole
needed pregnancy that a fetus is
- A fundal measurement much less
growing in utero.
than this suggests that the fetus is
- Typically, the distance from the
failing to thrive intrauterine growth
uterine fundus to the symphysis
restriction, the pregnancy length is
pubis in cm is equal to the week of
miscalculated, or an anomaly such
gestation between the 20th and
as anencephaly or no brain fetus
31st weeks of pregnancy.
has developed.
➔ Steps:
c. Johnson’s rule
1. Make a measurement from
FH(cm) - n x 155 = FW(grams)
the notch of the
n = 11 if unengaged
symphysis pubis to over
12 if engaged
the top of the uterine
● We will be able to have an
fundus as the woman lays
approximate data or information
supine.
on how the baby weights or how
○ Use a tape measure
heavy the baby is.
in cm and measure
● This rule is applicable vertically or
the length of the
head towards the pelvis of the
symphysis pubis up
mother only. It's not applicable in
to where you can
other positions.
palpate the firm
➔ Steps:
fundus.
1. Having a empty bladder,
● Example: you are able to
measure the fundal height
measure from the
■ Every time you measure or
symphysis pubis to the
any assessment on the
umbilicus its 20cm then the
pregnant client it is best to
mother is probably in her
have them void first before
20th week age of gestation
doing anything.
- This rule becomes inaccurate
■ This is to avoid disturbance
during the third trimester of
during the assessment and
pregnancy because the fetus is
45
also for the comfort of the to feel the proceeded fetal
mother movements in the uterus.
■ Make sure when you touch ○ It occurs in 18 to 20 weeks and
the mother’s abdomen peaks at 28 to 38 weeks.
make sure your hands are ● Basically a fetus moves at least 10 times
warm and not cold. This per day. In contrast, a fetus does not
can cause alteration or receive enough nutrients because of
this can cause the placental inseffucitany, which has
abdomen to contract. greatly decreased movement
■ Determine fetal height or ● Based on this, asking a woman to
the fundal height in cm observe and record the number of
2. Minus n (refers to 11 if it is movements the fetus is making, offers a
unengaged and 12 if it is grasp assessment of fetal well-being so
engaged) we teach mothers the Sadovsky method.
■ Engaged: Fetus is already ➢ Sadovsky Method
down the ischial spine of ○ We ask the woman to lay on a left
the symphysis of your succumbed position after a meal
pelvis and to record how many fetal
● Engaged fetus movements she feels over the next
usually happens on hour.
the late days of ● Now it is important to notice that every
pregnancy already after meal the baby or the fetus is active
■ Unengaged: the fetus or that is why it is the best time to check for
the head of the fetus is still fetal movement
above the ischial spine ○ A fetus normally moves twice
3. Then multiply it by 155 (constant every 10 mins or an average of
value) 10 to 12 times an hour if less
4. The result is the approximate or than 10 kicks an hour, the woman
estimated fetus weight in grams. repeats the test for the next hour
○ So we need a total of two hours
Assessment of Fetal Well - Being for this test.
1. Fetal Heart Rate - 110 - 160bpm at ○ She should call her health provider
28wks ) if she feels fewer than 10
2. Fetal movement (quickening) - 10 movements or half the normal
kick/hr (2 in 10mins) number during the chosen 2 hours
● Mothers are taught how to do this at (remember this should be done
home so this will give them an idea or as after meals)
a sense of urgency when to see their
doctor, pregnant woman should
determine quickening,
➢ Quickening
○ It is a movement in pregnancy
when the pregnant woman starts I see you
46
3. Rhythm strip testing - Remember its either:
- The term Rhythm strip testing means ● None
assessment of the fetal heart rate, ○ Meaning no
whether a good baseline rate in a degree changes in the
of variability is present baseline
a. Baseline ● Minimal
- It refers to the average rate of the ○ Having small
fetal heart beat per min fluctuations
b. Variability ● Moderate
- Refers to the small changes in rate ○ From 6 to 25 beats
that occur if the fetal per min
parasympathetic and sympathetic ● Mark
nervous system are receiving ○ Above 25 beats per
adequate oxygen and nutrients min
- When the fetus is stressed or if c. Acceleration
they have depletion in oxygen they - Acceleration refers to the increase
tend to be fussy inside the uterus of FHR related to the uterine
causing an acceleration of the contraction or intrauterine stress.
heart rate d. Deceleration
- However if they are too weak to - Refers to the drop of FHR all
compensate, the heart rate could caused by stress
decrease. So variability is
categorized as absent (or not
apparent) minimal, meaning
extremely small fluctuation
● So from the base line you
just have a small
fluctuation. It is either an
increase or decrease of the
heart rate
- Moderate meaning the amplitude
range is 6 to 25 beats per min so
● Example: your basic
baseline fetal heart rate is image of a Fetal Doppler
110 having an increase of
116 to 120 would mean a
moderate variability
● If it marks greater than 125
beats per min a change of
the baseline above 25
beats per min this is what
we call Marked Variability
47
Fetal Formation 4. Cardiff Count to Ten Movement Method
-This is another protocol when counting

the number of movements a fetus makes
- This chart is used which is similar to the
Sadovsky Method however we use this
When assisting a client during Rhythm strip chart
testing or in any procedures or test we assist - Usually this occurs 16 mins make sure to
them in this position or what we call lap side a sure the woman the fetal movements do
lying position and better in semi-fowler's vary especially in relation to the sleep
position then turn them to their left shoulder cycle of the fetus her activity and the time
● So we can have this in a comfortable she last ate otherwise she can become
lounge chair or on a examining table or untruly worried her fetus maybe in
bed with elevated back rest, jeopardy when this fetus is just having an
○ This is to prevent her uterus from inactive time
compressing the vena cava and - So one thing we can do if the mother
causing supine hypotension notes the varies decrease in fetal
syndrome or vena cava movement is to let the mother eat
syndrome. - Another way is we can just jar the
○ If you let the woman lay towards abdomen of the mother as we are
the left this will release pressure awakening the fetus or we can ring
occluding the inferior vena cava. a bell or play a sound to the fetus
● Rhythm strip testing requires the woman to stay awake, and we can
to remain a fairly fixed position for 20 monitor the fetal movement
mins keep her well informed about the 5. Nonstress Testing (CardioTocogram)
purpose of the test how it is interpreted - It measures the response of the fetal heart
and the meaning of the results after the rate to the fetal movement
test - Position the woman and attach both fetal
○ The more she understands about heart rate and the uterine contraction
the process the better she can monitor
cooperate to make it successful - We instruct a woman to push the button
attached to the monitor it is like a call bell
- Whenever she feels the fetus move this
will create a dark mark on the paper
tracing at this time.
48
- When the fetus moves the fetal heart contractions so we induce
range will increase by 15 beats per min contraction by administering
and remain elevated for 15 seconds, it oxytocin
should decrease average rate again as the i. Oxytocin Challenge Test
fetus quiets. - We have the
- If knowing this beats per min are medication oxytocin
noticeable in fetal movement, poor or artificial hormone
oxygen perfusion of the fetus is which includes
suggested contraction to the
- A non-stress test is usually done for 10 to uterus other than
20 minutes. the oxytocin we can
- The test is said to be reactive if two use nipple
accelerations of fetal heart rate by 15 stimulation
beats or more lasting for more than 15 ii. Nipple Stimulation Test
sec occur after movement within the - Rolling the nipple
chosen time period. The test is non between the fingers
reactive if no acceleration occur per fetal induces the release
movement, the results can be interpreted of natural oxytocin
as non reactive as no fetal movement which causes the
occur when there are short term fetal uterus to contract
heart rate variability meaning less than 6 or induce stress to
beats per min throughout the testing the fetus and at this
period if a 20 min period passes with fetal time we monitor the
movement it may mean only the fetus is relation of the fetal
sleeping. Other reasons for less variability heart rate with the
are maternal smoking, drug use or contraction of the
hypoglycemia. If you give the woman an uterus.
oral carbohydrate snack such as oranges 1. “Negative” (normal)
it can cause a revived glucose level - Shows no
enough to cause fetal movement. The deceleration
fetus may also be stimulated by loud on 3
sounds to cause movement because contractions
both rhythm strip testing are noninvasive 2. “Positive”
procedures and cause no risk for the (abnormal)
mother or the fetus; they can be used for - CTG with 3
all pregnancy. They can be done at home contractions
daily as part of home monitoring program and with
for the women who is having a deceleration
complication of pregnancy
● Contraction Stress Testing
- The fetal heart rate is analyzed
similar to non stress testing but
this we use it conjunction with
49
- Basically it is used in conjunction
with stress testing or non stress
testing.
- Reduced sound for us to awaken
the baby and monitor accurately
the fetal movement
7. Ultrasonography
- We use a machine called
- It is a much more used tool in
“Cardiotocogram” Cardio
modern obstetrics, it can diagnose
meaning heart, toco meaning
pregnancy as early as 6 weeks
contraction so it monitors both.
stresstation confirm the presence
- This is how a CTG paper looks like
of the size and location of the
[the one above]
placental and amniotic fluid
- It shows the relation between the
- We can also establish the fetus is
FHR and the uterine contraction,
growing and has no gross
so the upper graph is the FHR and
anomalies such as hydrocephalus
the bottom is the contraction
and a non cyphali or spinal cord,
- You will see the intensity, how
heart, kidney and bladder defects.
strong it is, how frequent it is and
- Through ultrasound we can
how close one contraction is to
determine the sex if a penis is
the other.
reveleaed, establish the
- You will also see small boxes [
presentation and the position of
between the graphs] that refer to
the fetus predict maturity by
the time or the point in time during
mearument of biparietal diameter
the testing when the fetus moved
of the head,
- So you can see how the baby
- Before aa ultrasound examination
reacts to every movement and to
be sure the woman has received a
every contraction.
good explanation of what will
- The baseline is the average heart
happen and reassurance that the
rate of the fetus within a 10 min
process does not involve x rays.
window so one box is one min.
- This means it is also safe for the
- The blue shaded area refers to the
father of the child to remain in the
normal rate of the fetus.
room during the test.
- If it goes beyond it is a variability
- For the sound waves to reflect
you need to determine is it none or
best if the uterus is held stable, it
moderate or is it marked variability
is helpful if the woman has a full
6. Vibroacoustic Stimulation
bladder t the time of the procedure
- It is applied to the mother’s
- To ensure this have a drink a full
abdomen this is to produce a
glass of water for every 15 mins
sharp sound of approximately 80
beginning 90 mins before the
decibels at 80 hertz startingling
procedure or 1 and a half hour and
and waking the fetus.
not void not until after the
procedure
50
- Have the woman hop on to a
examining table drape her for
modesty but her abdomen
exposed to prevent supine
hypotension syndrome or vena
cava syndrome
- We place a towel under their right
bottom to tip her body slightly so
that the uterus will roll away from
the vena cava then a gel is applied
on to her abdomen to improve the
contact of the transducer
- Be certain the gel is at room temp.
or even slightly warmer because it
can cause uncomfortable uterine
cramping.
- The doppler ultrasound
velocimetry uses ultra sound but
focuses on the velocity at which
red blood cells at the uterine fetal
vessels travel
(Doppler ultrasound velocimetry)
8. Biophysical Profile
- It is a prenatal test used to check
babies' well-being. The test
combines fetal heart rate,
monitoring or the non stress test
and fetal ultrasound. All of this
uses fetal ultrasound except the
non stress testing
iii. Fetal Breathing
iv. Fetal Movement
v. Fetal Tone
vi. Amniotic Fluid Volume -
12-15cm
1. Oligohydramnios
2. Polyhydramnios
vii. FHR - NST
51
because fecal lungs can mature up to 38
Biophysical Profile weeks.
Variables Normal Score = 2 Abnormal score = 0 ● Maternal Serum
- If the fetus has a open body defect there
Fetal breathing ≥1 episode in Absent or no
movements 30min each lasting episode ≥30se in will be an increase level of AFP produced
30 sec ≥30 sec 30 min by the fetal liver and it will be present in
Gross body Three or more Less than 3 Amniotic Fluid because of the leakage of
movements discrete body or episodes of body AFP to the fluid which can be detected in
limb movements in or limb movements
30 min ( episodes in 30 mins the maternal serum
of active
continuous
- The level will decrease in case the fetus
movement = a has a chromosomal defect such as down
single movement)
syndrome
Fetal Tone ≥1 episodes of Slow extension w/ - Remember increase or up refers to
active extension return to flexion,
with return to movement of limb congenital defects and decrease or down
flexion of fetal in full extension, or refers to down syndrome or chromosomal
limb(s) or trunk; fetal movement
opening and absent defect.
closing of hand is
considered normal
- It is best taken after 11 weeks AOG
tone a. Alpha-fetoprotein (AFP)
Reactive fetal heart ≥2 episodes of < 2 episodes of
rate acceleration (≥15 accelerations or ● Amniocentesis
beats/min) in 20 acceleration of <
min, each ≥ 15 sec 15 beats/min in 20 - It is a procedure that involves entering the
and associated min amniotic sac guided by ultrasound in
with fetal
movement imaging the aspirate amniotic fluid for a
variety of diagnostic exams to detect fetal
Qualitative amniotic ≥1 pockets of fluid Pockets absent o
fluid volume measuring > 1cm pocket < 1cm in 2 well being or lack thereof.
in 2 perpendicular Perpendicular
planes places
- Major risk include trauma, infection,
abortion, and preterm labor
Score Notes
- Since this is an invasive procedure,
Normal 8-10 (If amniotic CNS is functional & informed consent is a must
fluid index is fetus is not
adequate) hypoxemic
- It is done at 18 weeks AOG and up to
Equivocal 6 30ml of amniotic fluid is obtained.
Abnormal <4 Along
w/oligohydramnios - In preparation we need to ask the woman
-> labor induction to void to reduce the size of the bladder
- Each variable consist 2 points each in the and to prevent inadvertent puncture.
total score of the BP
● Modified Biophysical Profile
a. Amniotic Fluid Index (AFI)
b. NST (Non stress testing)
● Placental Grading
- Placenta can be graded by ultrasound as
0 meaning the placenta is within 12 to 24
weeks, 1 meaning within 30 to 32 weeks,
2 with 36 weeks, 3 within 38 weeks
52
- We place the client in a supine position on - When it comes to radiation not any or all
a examining table and drape her radiation is harmful for pregnant clients
appropriately exposing her abdomen, this refers to large amounts of radiation
place a folded towel under her right that is being exposed to the mother
buttocks to tip her body slightly to the left ● Environmental Chemicals
and move the uterus from the vena cava, ● Occupational Hazards
always avoid vena cava syndrome and ● Infectious Agents/ Viruses e.g T-O-R-C-H
also supine hypotension syndrome - For torch or the viruses, TORCH means
a. AFP Toxoplasmosis, Other diseases, Rubella
b. Acetylcholinesterase or German measles, Citomegalovirus,
c. Bilirubin Herpes simplex type 1 & 2. People who
d. Genetic Analysis are infected with these illnesses or theses
e. Color agent should be kept away from pregnant
f. Fibronectin women
g. Inborn Errors of Metabolism
h. Lecithin/SPhingomyelin Ratio (2:1)
● Percutaneous Umbilical Blood Sampling
- This is done during the second or
third trimester and uses ultrasound
to locate the umbilical cord, cord
blood is aspirated and then tested
i. Cordocentesis
ii. Via UTZ Teratogens
● Fetoscopy - at 16-17weeks ● Any factor, chemical or physical that
- In which the fetus is visualized by adversely affects the fertilized ovum,
inspection through a fetoscope, embryo or fetus.
- This is an extremely narrow ● The typical manifestation of
hollow tube inserted by an teratogenesis is restricted growth or
amniocentesis technique it death of a fetus, carcinogenesis or
can be helpful to assess malformation defined as defects of organ
fetal well being and it is structure or function.
done at 16 to 17 weeks ● This is not only risky for the mother, there
AOG is also a possibility of paternal exposure.
○ This happens when substances
Maternal Lifestyle and Environmental Hazards alter the quality, size, shape,
to the Fetus performance, production of the
● Smoking sperm and may put the fetus at
● Recreational Drugs risk
● Medically Prescribed Drugs
● Alcohol
● Caffeine
● Radiation
53
Category Description periods, 14 days must be
subtracted from the first day she
A Controlled studies of
started her period (MLP)
pregnant women show no
risk in first trimester 2. Life span:
- The sperm can last around 5 days
B Animal Studies show no
risk, or animals show risk - Ovum can last for 1 day
unconfirmed in humans 3. The most fertile days to be considered, or
the fertile window is counted 5 days
C Animals studies show risk,
caution is advised, benefits before the ovulation (sperm life) and
may outweigh risks one day after the ovulation (a leeway for
D Evidence of risk to human the ovum to survive for 24 hours).
fetus, benefits may 4. Thelarche (add-on point to the
outweigh risks in serious
conditions
development of non-sexual organs)
- Referring to the development of
X Risk outweighs benefits the breast for females
- Part of the secondary sex
- This is the US food and drugs characteristics is the development
administration or FDA table of categories of the breasts.
of safety drugs
- Always look for the drugs category before 5. When prenatal assessment is done (not
administration to pregnant women and all specifically for the fetal development but
medication indicates or category for the mother as well), it is to promote
according to this table, and also when we comfort.
give or administer medications when it's ● Utmost priority is the safety and
prescribed comfort of the client.
- We always check it and we advise women ● Make sure to always have warm
not to take over the counter medication hands when palpating the client’s
especially when they are pregnant. abdomen ( when palpating fundus,
- Most of the medication taken by pregnant fundal height, etc.)
women belong to Category A because ● Always ask for permission when
this refers to the medication that are lifting the top garments of the
controlled studies for pregnant women mother.
and show no risk in the first trimester. ● Properly drape by placing a
- The rest poses harmful effects to the blanket below the abdomen and
mother and to the fetus then lifting the upper garment up
to the lower part of the breasts.
Questions After Class ● Make sure the stethoscope is
Important Points to Remember: also warm when auscultating fetal
1. “Ovulation happens in the middle of the sounds.
menstrual cycle” But it is important to ○ Coldness can cause the
note that it is not always in the middle. contraction of the mother’s
- Regardless of patient having abdominal muscles
irregular periods or regular
54
● Before positioning the mother on hypertension, blood
the bed, make sure to let her flow towards the
void first. (When calculating fetus may be
fundal height, a full bladder can depleted.
alter the measurements) - All the nutrients and
○ Upon palpation, a full oxygenation
bladder can increase the depends on the
urge to void. maternal circulation.
6. Familiarize the important stages in fetal - Maternal circulation is important
development when quickening occurs as this will also provide circulation
➢ Quickening for the fetus.
○ Movement of fetus inside 10. Upon fetal assessment, the rhythm strip is
which usually occurs within taken from the CTG (cardiotocogram)
16 to 20 weeks age of machine
gestation - Monitors two things:
➢ Gestation a) Cardio: Heart rate of the
○ Age of pregnancy fetus
7. The first trimester is where from the start b) Toco: Contraction of the
of ovulation and after it becomes a zygote Uterus
and then it is implanted (First 8 weeks)
● When Organogenesis occurs 11. Best source of reference for contraction is
rapidly in the fundus.
○ Development of the organs - To determine if the contraction is
○ Thus, smoking, drugs, mild, moderate, or strong, always
caffeine, etc., are advised look for the fundus and then
to be avoided by the palpate the area.
mother during the first
trimester.
8. Naegele’s Rule (Memorize formulas)
- Determination of the estimated
date of birth
12.
- Also called EDC (Estimated Date
- Top graph monitors the fetal heart
of Confinement) and EDD
rate.
(Estimated Date of Delivery)
- Lower graph indicates the
9. It is important to position the mother on
contraction.
her left side.
➔ This is to determine what is the
- This is because the increased
effect of the contraction to the
weight of the gravid uterus can
fetal wellbeing.
impede or put pressure/weight into
➔ Contraction of the uterus serves as
the inferior vena cava
a stressor (stimulates fetus)
- Causes hypertension.
- When the heart rate of the fetus is
- When a mother is
high during contraction, it means
experiencing
that the fetus is responsive.
55
➢ Fetal distress are now widely accepted compared to
◆ Fetus’s heart drops when being taboos in the past
there is a strong ● The typical delivery room setting is that it
contraction is only the mother who can go inside and
13. Mother is attached to a CTG machine the delivery room nurse will be assisting
every 4 hours while she is in the labor the mother all throughout the delivery
room until she delivers her newborn and process
it is taken for at least 10 minutes. ● However, we already have amenities in
14. The langerhans layer is a protective some tertiary hospitals that offer the labor
element of the chorionic villi that protects in the delivery room suite in which the
the fetus from viruses. mother or the husband can support the
- Serves as a protective barrier for mother in the labor until delivery
the fetus to avoid contracting the 2. Cultural Influence
virus ● A pregnant woman’s culture and beliefs
- Only effective within the first 20 may also greatly affect the course of her
weeks and diminishes its function pregnancy
for the rest of gestation. ● It is important for us to assess if the
woman and her partner have particular
beliefs that might affect the way they take
LECTURE FOUR A care of the pregnancy so we can integrate
CARE OF THE MOTHER AND THE them in the plan of care
FETUS DURING THE PERINATAL ● Despite the modern ages, there are still
PERIOD: PRENATAL CARE groups who firmly believe in their cultures
explanations about birth complications
Prenatal Care of Mother and the healthcare providers must respect
- A mother undergoes several this
Psychological Changes which are ● There are some mothers that upon
affected by different influences admission, they hand out a copy of their
1. Social Influences birth plan/wishes which may include
● In the past, a pregnant woman is isolated ○ Having their husband along their
from her family starting from visiting for side during labor and delivery
prenatal consultation until the day of birth ○ Having no medications/pain
● She is isolated from her family and the relievers during labor
baby a week after birth ○ Natural birth
● Today, having a support system for ● Myths that surround pregnancy should be
pregnant women is highly encouraged like respected but the couple should be
bringing along someone to accompany educated properly regarding what could
her during prenatal visits and allowing the be dangerous for the fetus’ health
husband to be with the wife during 3. Family Influence
delivery if he chooses to ● The environment where the woman grew,
● Opinions on teenage pregnancy, late influences the way she would perceive
pregancy, and having same sex parents pregnancy
56
● Family culture and beliefs also affect a ● A woman who feels that the pregnancy
woman’s perception of pregnancy may rob her freedom, promotion, or youth
● If she is loved as a child, she would have would need a strong support system so
an easy time accepting her pregnancy she could express her feelings and
compared to women who were neglected unburden her chest
by their family during childhood ● A father’s acceptance of the pregnancy
● A woman who has been told of disturbing also influences the woman’s ability to
stories of pregnancy and giving birth accept marriage
would view her own in a negative light ● Utmost support from her husband would
while those who grew hearing beautiful be very meaningful for the woman
stories would more likely be excited for especially during birth
their pregnancy ● In chances where the woman would raise
● A positive attitude would only result from the child alone or is a single mother, then
a positive outcome and influence from a the support of the family, especially the
woman’s own family parents is very beneficial
● It is very important for us nurses to be
positive, to be appealing to the mother Psychological Tasks Of Pregnancy
even though the mother is really in pain - Refers to the transition of the woman
inside the delivery room together with husband in accepting their
4. Individual Differences pregnancy until their parenthood
● Becoming a new mother is never an easy 1. Accepting the Pregnancy
transition - The shock of learning about a new
● The woman must first be able to cope pregnancy is sometimes too heavy for
with stress effectively as this is a major the new couple, so it is just proper for the
concern during pregnancy both of them to spend time recovering
● She needs to have the ability to adapt from this major life altering situation, and
effectively in any situation especially the avoid overwhelming themselves at first
pregnancy is her first, since there may be - One of the most common reactions of a
a lot of new situations that would arise couple who would be having a baby for
● Her ability to cope with the major change the first time is Ambivalence, feeling both
and manage her temper would be put to pleased and unhappy about the
test during motherhood pregnancy
5. Partner’s Adaptation 2. Accepting the Fetus
● The woman’s relationship with her partner - The woman and her partner will start to
also affects her ability to accept her merge into the role of novice parents as
pregnancy easily the second trimester closes in
● If she feels secure with her relationship - Emotions such as narcissism and
with the father of the child, she would introversion are commonly present at this
have an easier time accepting her stage
pregnancy as opposed to an unstable - Roleplaying and increased dreaming are
relationship where she feels insecure and activities that help the couple embrace
may doubt the decision of keeping the their role as parents
pregnancy
57
- At this stage, the woman and her couple - This emotion is brought about
must start to concentrate on what it will losing some of the roles that you
feel like to be parents used to have
3. Preparing for the baby 2. Narcissism
- The couple starts to grow impatient as - Self-centeredness or narcissism is
birth nears generally an early reaction to
- Preparations for the baby both small and pregnancy
big takes place during this stage - A woman who is previously barely
- The baby’s clothing and sleeping conscious of her body, dress in
arrangement are set, while the couple is the morning with little thought
excited for his/her arrival about what to wear, who was
unconcerned about her posture
Pregnancy takes your mind and body and weight suddenly begins to
through an ongoing stream of changes. concentrate on these aspects of
On a basic level, your body is making life
unusual amounts of hormones. At certain - She dresses so the pregnancy will
times this can make one feel exhausted, not show. It depends on the
forgetful or moody. On top of that it is woman’s perspective, making
normal to be preoccupied on how your dressing a time-consuming,
body is quickly changing, how to manage mirror-studying procedure
symptoms, how different your life is 3. Introversion vs. Extroversion
becoming, worrying about pregnancy - Introversion or turning inward to
going well, finances, and keeping up with concentrate on oneself and one’s
everyday life. body is a common finding during
pregnancy
The different Emotional Responses felt - However some women react in an
by the woman and the partner are: entirely opposite fashion and
1. Grief become more extroverted
- Before a woman can take a - They become more active,
mothering role, she has to give up become healthier than ever before
or alter her present roles and are more outgoing
- She will never be a daughter in - This tends to occur in women who
exactly the same way again are finding unexpected fulfillment
- She will never be as irresponsible in pregnancy, perhaps those who
and carefree as she is now again had previously doubted that they
- She will not even sleep soundly for would be lucky or fertile enough to
the next 18 years conceive. This is common among
- She must incorporate her new role women who have gynecologic
as a mother into her other roles as problems who thought that they
a daughter, wife, or friend would never have the chance to
- Her partner must incorporate a conceive
new role as a father, into his other
roles of son, husband, or friend
58
- They feel excited, happy about same degree or even more
themselves, turning them into an intensely than their partners during
extroverted version of themselves pregnancy
4. Body image and Body Boundary - As the woman’s abdomen starts to
- Body image or the way the body grow, the partner may perceive as
appears to yourself growing larger too, as he is
- Body boundary refers to a zone of experiencing a change in
separation you perceive between boundary the same as his partner
yourself and objects or other - Nonetheless it is not considered a
people disease
- These two change during 7. Emotional Lability
pregnancy and the woman begins - Mood swings
to envision herself as a mother - This psychological reaction can be
- Pregnant women find themselves caused by two factors, hormonal
extremely vulnerable as if her body changes and narcissism
were delicate and be easily - The comments that she brushed
harmed off in her nonpregnant state can
- So they may be really conscious now hurt her
about themselves - Crying is a common manifestation
- For example, a woman walks in of mood swings, during and even
the kitchen and sees a table in after pregnancy
front of her, she would provide a - We need to look into this erratic
bigger space for her way to avoid change in mood to delineate if the
her abdomen from hitting the table mother is still going through a
5. Stress physiologic (normal) change in her
- Pregnancy is a major change in behavior and mood, or if it is
roles that could cause stress something that needs to be looked
- The stress that a pregnant woman into
feels may affect her ability to 8. Changes in sexual desire
decide - Women who are on the first
- The discomfort that she feels trimester in pregnancy experience
could also add up to the stress a decrease in libido, mainly
she is experiencing because of breast tenderness,
- Assess if the woman is in an nausea, and fatigue
abusive relationship as it can - On the second trimester, sexual
contribute further to the stress libido may rise due to the
6. Couvade Syndrome increased blood flow to the
- Is a form of extreme male empathy pelvic area that supplies the
for pregnancy placenta
- Common around the world - The third trimester might bring
- Many males experience physical about an increase or decrease in
symptoms such as nausea, sexual libido due to the increase in
vomiting, and backache to the
59
the abdominal size or difficulty in
finding a comfortable position
- Estrogen increase may also affect
sexual libido as it may bring a loss
of desire
- The couple must be informed that
this changes are normal to avoid
misunderstanding a woman’s
attitude
Signs of Pregnancy 2. Nausea and vomiting

- Signs and symptoms of pregnancy vary - Most common form of discomfort
on women and is brought about by the
- The physiologic sign of pregnancy are increased level of hCG
classified into presumptive, probable, and 3. Amenorrhea
positive - First sign at 2 weeks from
➢ Presumptive Signs fertilization because of the
- Subjective reports persistence of the corpus luteum
- Signs of pregnancy that a woman is 4. Frequent urination
experiencing that makes her suspicious - Most disturbing sign especially in
and makes her think she may be pregnant the 3rd trimester due to pressure
- Based on her report of them applied by the enlarging uterus to
- Not definite, they may indicate a baby is the bladder
growing in the uterus, because other 5. Fatigue
conditions can cause these presumptive - Estrogen induced in early
signs pregnancy
- However, a woman could presume she is 6. Abdominal enlargement
pregnant - Abdominal enlargement in the
- Includes: early weeks of gestation, the
1. Breast changes uterus can be palpated over the
- Nipple tingling which happens at symphysis pubis
4th week AOG - The uterus turns from a globular
- Darkening and enlargement of shape to oval
areola - The increase in size of the uterus
- Enlargement of breast is due to the hypertrophy of
- Increased number of milk existing muscles and connective
secreting cells tissues
- There is no formation of new
muscles
7. Quickening
- Fetal movement felt by woman
- Felt stronger at 20 weeks
60
8. Linea Nigra 10. Striae Gravidarum
- Line of dark pigment on the - Red streaks on the abdomen
abdomen - Stretch marks
➢ Probable Signs
- These are signs that the doctor and nurse
9. Melasma/ Chloasma can observe and document
- Mask of pregnancy - However, these do not mean 100% that a
- Areas of the skin become darker baby is growing in the uterus (Can be due
than the surrounding skin to other causes)
- Doctors call this - Includes:
hyperpigmentation 1. Home pregnancy test
- Typically occurs on the face - Over the counter pregnancy test
particularly the forehead, cheeks, kits can detect the presence in
and above the upper lip rising HCG in maternal urine
- Laboratory tests can also detect
HCG levels in the maternal serum
2. Chadwick’s sign
- Bluish discoloration of cervix,
vagina, and perineum
61
3. Goodell’s sign 7. Braxton Hicks Contraction
- Softening of the cervix - These are painless, abdominal
- Through bimanual palpation we contractions or periodic uterine
would be able to detect this sign tightening relieved by walking
along with Hegar’s sign 8. Fetal Outline felt by the
4. Hegar’s sign examiner
- Softening of the lower uterine - Fetal outline can be palpated by
segments, specifically the isthmus the examiner through the
5. Gestational Sac via UTZ abdomen
- Characteristic ring is evident
through ultrasound
➢ Positive Signs
6. Ballottement - Means conclusive, definite, or absolute
- Rebound of the fetus against the - These signs are only present because
examining finger they can only be attributed to a fetus
- The cervix is touched by the - There is no other cause
examiner’s finger within the vagina - The woman is definitely pregnant
causing the fetus to strike against - The signs will deal with the baby being
the wall of the uterus the evidence itself
- The hand on top of the abdomen - Includes
will feel the rebound or the 1. UTZ
ballottement - Visualization of the fetus through
ultrasound
62
no formation of new muscle fibers in
2. Audible Fetal Heart Sounds pregnancy)
- Fetal heartbeat heard on ● Weight of uterus: 60g (non-pregnant)
ultrasound at 6 - 8 weeks or by a 1000g (full term)
doppler at around 12 weeks ● Fundal height: basing on the symphysis
pubis
○ 12th week = symphysis pubis
○ 20th-22nd week = umbilical level
○ 36th week = xiphoid process
3. Fetal Movement by Examiner

- Fetal movements may be felt by a
women as early as 16 - 20 weeks
of pregnancy (quickening)
- Those felt by an objective
examiner are considered much
more reliable because a woman
could mistakenly think that it is the
movement of the gas in her
intestines for fetal movement
- Fetal movements can be felt by an
- Lightening: primigravida vs.
examiner at 20th or 24th week of
multigravida
pregnancy unless the woman is
- Uterine blood flow = increases up to
extremely obesse
500-750 ml/min to supply developing
fetus (estrogen = easy compressibility of
the uterus)
- Operculum
- Hegar’s sign = softening of the lower
uterine segment, isthmus (easy
compressibility of the uterus)
- Goodell’s sign = softening of the cervix;
consistency like earlobe (non-pregnant
cervix consistency like tip of the nose,
ripe/labor consistency is like whipped
butter)
Details of Physiological Changes - Chadwick’s sign = bluish / purplish
Uterine Changes discoloration of the vaginal mucosa and
● globular to oval (due to the hypertrophy of cervix- Brought about by the increased
existing muscles and connective tissues,
63
vascularity of the perineum brought about vagina to palpate the cervix and lower
the estrogen uterine segment
- Leukorrhea = whitish mucoid non-foul ● Void first to prevent discomfort
non-pruritic vaginal secretions that are ● Position woman in a Lithotomy position
produced due to the increase of estrogen. w/ equal height of padded stirrups;
**the vagina increases acidity lessening the simultaneously place the legs on the
bacterial invasion** stirrups; ensure pressure in the popliteal
region
● Properly drape exposing only the parts to
be examined (chest to knee)
● Cervix = becomes thicker, shorter, and

more elastic.
● Mucus plug
○ edema and hyperplasia of mucus
lining increases mucus production
which makes up mucus plug
○ develops in the 7th wk of
pregnancy ● Properly position the hands across the
○ seals the cervix; prevents bacterial chest or on arm board
contamination of the uterine cavity ● Teach proper breathing
○ falls during labor letting the ● Do not distract to allow effective breathing
amniotic sac to rupture and fluid and relaxation
flow out from the vagina
Nursing Responsibility when doctor performs

IE (internal examination)
Breast Changes
● breast increase in size and firmness
● woman can feel a tingling sensation in the
nipples in 4 weeks along with breast
tenderness
● Keep the client safe and comfortable ● darkening and enlargement of the areola
despite the IE which is painful ● Montgomery glands, alveolar ducts, and
● Every time the doctor performs an IE alveoli system also enlarges
(internal examination), make sure that the ● superficial veins around breast become
woman knows the indications. The doctor prominent
will insert examination hand into the
64
● Alterations in the immune system result in
an increased susceptibility to certain viral,
bacterial, and parasitic infections. Most
babies aren’t harmed if the mother gets
sick during pregnancy
● Some infections can be transmitted
through (may have serious consequences
for the child):
○ through the placenta
○ penetrate the placental barrier
○ be transmitted during birth
1. Colostrum
○ produced within 4-5 months which
is the precursor to breast milk
○ thin, watery, light yellow, high
protein secretion from the breast
Integumentary System
○ newborn must ingest or take in the
● Changes in this system occur in the 2nd
colostrum because of high mineral
trimester onwards.
concentrations
Immune System:
● Immunologic competency during
pregnancy decreases to prevent the
woman’s body from rejecting the fetus as
if it were a transplanted organ. (it is
important that the woman should not
reject the fetus because it is considered a
1. Striae gravidarum – stretch marks or red
foreign body)
streaks on the abdomen, upper thighs,
1. IgG & WBC
and lower breasts (due to adrenal
○ IgG is decreased which makes a
hypertrophy)
woman more prone to infection
2. Striae albicans – old silvery white striae
during pregnancy.
that becomes prominent postpartum
○ there is a simultaneous WBC
3. Diastasis recti – overstretching and
increase to counteract the IgG
separation of the abdominal musculature
response.
(no formation of new muscles during
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pregnancy thus muscles are stretched out
as the uterine size increases )
○ Area will appear indented
○ Will appear as a bluish area in the
midline if the area is large
○ Postpartum modified sit-ups
strengthen and restore abdominal
muscle and abdominal support to
its pre-pregnant level with
guidance or direction of the
doctor.
○ After pregnancy it may still be
there but not as prominent image of Spider Telangiectasis
7. Palmar erythema – vascularity changes;
reddened palm; itchy
8. Diaphoresis – increased cavity of the

sweat and sebaceous gland from
4. Linea Nigra – dark line from the
pregnancy’s increased metabolic rate.
symphysis pubis to the xiphoid process;
due to the increase of estrogen
Cardiovascular System
5. Melasma – “mask of pregnancy”; dark
● Increased CO -- physiologic anemia
patches of skin on the cheeks, nose, and
○ Increased CO (cardiac output) by
neck (due to increase of melanocyte
30% on 1st and 2nd trimester,
stimulating hormone during pregnancy)
50% in 3rd trimester (to meet
6. Telangiectasia –a normal change in
increased tissue demands) this
estrogen production during pregnancy
results to an increased heart rate
causing the elevation/dilation, instability,
by 10 to 15 bpm in the 2nd to 3rd
proliferation and congestion of blood
trimester
vessels. These vascular changes
○ Palpitation in early and late
regresses postpartum (goes back to
pregnancy is due to sympathetic
pre-pregnancy state)
nervous system disturbances
○ Occurs in ⅔ of light complected
during early period while it in
and 10% of dark complected
increases intra abdominal pressure
women
in the late weeks
○ Primarily appears in face, neck,
○ Transient murmurs and slight
and arms
cardiomegaly can be noted
66
○ Systolic murmurs = due to the circulating blood volume and
increased viscosity of blood and the RBC
upward displacement of the heart ● Edema
○ BP remains constant but may drop ○ on the lower extremities due to the
slightly in the 2nd trimester pressure on the pelvic girdle
(Hypotension) this happens if the ○ if on face or arms it may imply
pregnant woman is place in the pathologic problems
supine position due to vena cava ● Coagulation factors → Thrombophlebitis
syndrome / supine hypotension ○ Progesterone also results to an
syndrome (compression of inferior increase in fibrinogen level,
vena cava leading to decrease resulting to high tendency of
venous return and cardiac output clotting= Thrombophlebitis
resulting to hypotension) ■ Thrombus means clot
■ Prevention: position the ■ Phlebitis means
mother in a left lateral inflammation
recumbent position (LLR ■ Clot formation causing
position) applying a rolled inflammation of blood
towel on right side of the vessels
back of the mother ■ Common in the
independent extremities or
legs
● Leg varicosities
○ Increased vascularity due to the
estrogen effect leading to dilation
of pelvic veins / deep pelvic veins,
varicosities, and leg varicosities. ● Homan’s sign - Actively extend
Superficial veins are prominent knee, the examiner raises the
during pregnancy in the popliteal patient’s straight leg to 10 degrees
area down to the calf then passively and abruptly
● Hypotension sec. to vena cava dorsiflex the foot and squeeze the
syndrome → LLR position calf with the other hand
● Physiologic anemia/ Pseudoanemia ○ (+) Deep Vein Thrombosis
○ increased circulating blood volume (DVT) = deep calf pain and
○ physiologic = normal tenderness
○ brought about the
disproportionate increase between
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● Hyperventilation
○ the vital capacity of the lungs
increases; an effect of
progesterone to the respiratory
center
○ Signs and Symptoms:
■ Dizziness /
Respiratory System lightheadedness
● Nasal congestion, epistaxis ■ Pallor
○ nasal stuffiness, hoarseness of ■ Tingling sensation in lips
voice, Eustachian blockage and fingertips
leading to temporary deafness ○ Intervention: let the mother
○ caused by estrogen’s ability to breathe into a paper bag or into
increase vascularity her cupped hands to prevent
● RR = increase and constant at 6 complications such as respiratory
cycles/min and it is deeper; max increase alkalosis
under normal conditions or at rest is up to
24 cycles/min (max) Vital Signs
● Chronic feeling of SOB (shortness of ● Temperature -- rises due to the
breath) progesterone regulated by the corpus
○ diaphragm rises by as much as 1 luteum until 16 weeks and increased
inch at 36-36 weeks compressing activity in the thyroid gland, temp should
the lungs upward resulting to not reach 38 degrees C
dyspnea or shortness of breath ● Pulse Rate -- increases of 10-15bpm
○ relieved when the mother ○ 10-15 bpm higher than pre
experiences Lightening (near the pregnancy rate
day of delivery; the fetal head and ● Respiratory Rate -- deep & rapid
presenting parts settles into the ○ Due to progesterone’s influence of
pelvis) the respiratory center; max
increase under resting condition is
24 cycles/min
● Blood pressure -- hypotensive when
supine thus we need to put the mother in
left lateral recumbent position to prevent
vena cava syndrome/ supine hypotension
syndrome
● Weight -- increases 20-25lbs (max =
35lbs); due to placenta, amniotic fluid,
fetus
○ Failure to gain weight is a
dangerous sign
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○ Encouraged weight gain of woman ○ Intervention: promote dental
with normal BMI (18.5-24.5) hygiene
should be 20-25lbs
○ Weight gain occurs from both fetal
growth and accumulation of
● “Morning Sickness” (can strike at any
maternal stores and increased by
time at the day or night)
approximately:
○ stomach may be displaced
■ 1st tri = (0.8kg/ 1.5 lbs per
backward, being able to palpate
month) 3-4lbs
the appendix in the right flank
■ 2nd tri = (0.5kg/ 1 lb per
area; difficulty in digestion may
week) 10-12lbs
occur due to this
■ 3rd tri = (0.5kg/ 1 lb per
○ bowel sounds may not be
week) 8-11lbs
auscultated in the 4 abdominal
quadrants
○ Progesterone decreases motility
and slows down digestion causing
the cardiac sphincter relaxes
resulting to esophageal reflux and
heartburn (acidity: when you feel
pain along xiphoid process
upwards)
○ Acid Reflux = heartburn or
pyrosis is a common discomfort
felt as a burning sensation behind
the sternum; contributes to
flatulence, constipation,
hemorrhoids, and morning
sickness (nausea and vomiting) felt
by the pregnant woman.
● Decreased peristalsis
● Gallstone formation = decreased GI
Gastrointestinal System motility affects the bladder wall resulting
● Ptyalism = increase in estrogen levels for the bowel to crystallize forming
result in an increase in saliva production gallstones
with nausea may occur. This disappears ● Hemorrhoids = part of client assessment;
after delivery can be external or internal hemorrhoids.
○ Increased saliva production with
nausea
● Gingival changes = due to increased
vascularity gingival changes occur such
as soft and swollen gums or gingivitis
leading to difficulty in chewing and gum
bleeding; hyperplasia (swollen gums) Urinary System
69
● Increased GFR (Glomerular Filtration ● Cramps = calcium and phosphorus
Rate or the amount of blood that passes imbalance and pressure of the gravid
through the glomeruli each min) since the uterus on lower extremities
plasma volume increases there will also
be an increase in urinary output with
decreased specific gravity or ratio of the
solutes present in the urine will decrease
● Pressure applied by the uterus to the
bladder causes an increase in the
frequency of voiding
○ this happens in the 1st and 3rd but
not in the 2nd trimester because
the uterus rises in the abdominal
cavity
● At risk for UTI due to urinary stasis
○ bladder and ureter relax resulting
into decreased bladder tone and
potential stasis (fluid in the organ
is stagnant) of urine causing UTI Maternal Assessment
● Glycosuria = glucose in the urine may be The major causes of death during pregnancy
present due to lower renal threshold for today for women are ectopic pregnancy,
glucose. hypertension, hemorrhage, embolism, infection,
and anesthesia related complications such as
Musculoskeletal System Intrapartum Cardiac Arrest.
● Lordosis = stress on ligaments of the
muscles and mid and lower spine result to Major Goals of Comprehensive Prenatal
backache, lordosis (excessive inward Assessment
curve of the spine) which results in 1. Define the health status of the mother and
backache and fatigue fetus
○ Lordosis due to mother trying to 2. Determine the gestational age of the
balance herself fetus, estimate date of delivery
● Waddling gait = increase in estrogen, 3. Initiate a nursing care plan for continuing
progesterone, & relaxin softens the maternity care of both mother and fetus
ligament and joints which allows the 4. Detect early any high risk condition
increase of birth canal - The important focus of all prenatal visits,
○ pelvic softness causes “duck therefore, in addition to education about
waddle or waddling gait” pregnancy, is to screen for danger signs
○ difficulty maintaining balance that might reveal any of this condition,
predisposes to slips and falls (tub screening include an extensive health
bathing is not advised because history, a complete physical examination
they are at high risk for slips and (including pelvic examination and blood
falls) and urine specimen for laboratory work).
- Manual Pelvic Measurement can be taken
to determine pelvic adequity
70
- When doing the initial assessment, always 7. Preconception visit
remember to establish rapport, gain - Preconception visit is advisable for all
information about the women’s physical women of child-bearing age and to men
and psychosocial health and obtain a who are planning to have a child with his
basis for anticipatory guidance for the wife
pregnancy. - This is to obtain accurate productive life
Subjective Assessment planning information, receive assurance
The overall purpose of the Prenatal Care is to: about fertility and identify any problems
1. Obtain Baseline data that may need correction to help ensure
- This serves as a basis for comparison fertility.
with information gathered on subsequent - Set the schedule for regular visits
visits 8. Prenatal schedule
- This will also help us nurses screen for - In the presence of danger signals of
high risk factors. pregnancy, the mother should be
2. Determine the AOG instructed to report promptly for
- There are three ways to determine the evaluation and is expected to have more
Age of Gestation: frequent prenatal visits.
○ Manually count the number of
days and weeks from the LMP up
to the date of examination.
○ Through clinical examinations,
similar to how you do the
McDonald’s rule.
○ Through ultrasound
3. Fetal development and maternal
well-being
4. Identifying risks
- List their high risk factors present in the Nutritional Assessment
woman that may pose problems towards ● Pica
the fetus or the pregnant woman herself, ○ Take note for tendencies of Pica. Pica
while minimizing the risk of possible refers to persistent ingestion of
complications that may still develop by inedible substances (such as clay,
anticipating and preventing the problems dirt, starch/chalk), or substances with
before they occur. little nutritional value.
5. Anticipatory guidance ○ Pica is considered a
6. Patient education on pregnancy, lactation, psychobehavioral disorder, and it
and newborn care does not mean that all pregnant
- We should not wait for the mother to women may manifest Pica.
reach postpartum before teaching her ○ Chronic Pica can repel to the
how to properly breastfeed and take care displacement of nutritious food,
of the newborn. interference with nutrient absorption
- During pregnancy or during the prenatal and anemia.
period is the best time to do this.
71
● To properly educate our clients, we need
to know that the non pregnant woman
● Nutrition: 1,800-2,200/day (non-pregnant) needs 1800-2200kcal/day, but when she
+ 300kcal/day gets pregnant, she needs to add up to
○ When doing a Nutrition 300kcal/day.
assessment, always start with diet ● The usual daily caloric need in pregnancy
history before giving instruction. is 2100-2500kcal/day and never less than
○ We need to obtain the Nutritional 1800kcal/day.
Profile, which include the 1. Protein: 74-76 g/day
prepregnant and current nutritional ● Protein is a body building food to
status, dietary habits in relation to ensure that pregnant women get
eating junk foods, empty caloric 74-76 g/day.
food, regularity of meals, peer ● Rich sources include milk, meat,
pressure, adequacy of food or fish, poultry and egg.
available finances, cultural and ● Sufficient intake of carbohydrate is
religious restrictions. necessary for added energy
○ There are a lot of things to ● As long as she avoids empty
consider. calories, like soft drinks.
● Another thing is to take note of the ● Fiber prevents constipation and is
mother’s knowledge of nutritional needs best taken through fruits and
and the daily recommended allowances, vegetables.
through this we will be able to outline the 2. Fat consumption
point we need to correct, supplements ● Fats are needed for the absorption
and reiterate during patient education. of vitamins, such as Vitamin A, D,
● We also look at physical findings, E and K
indicative of four nutritional status (such ● But we instruct them to avoid too
as anemia, underweight, overweight, dull much to prevent vomiting and
hair, dry or scaly skin, and pale, dull heartburn
mucous membrane). 3. Iron: 30-60mg/day
● There are also populations that requires ● Iron is the most important mineral
special attention, such as young that must be taken supplementary,
adolescent mother, primigravida or first amounting to 30-60mg/day.
time mother, low prepregnant weight, ● Best source of liver if not taken
obesity, low socioeconomic status, fully from prenatal vitamins is liver,
prepregnant debilitating conditions, strict red meat, green leafy vegetables,
vegetarians, successive pregnancies or egg yolk, cereals, dried fruits and
short interval between pregnancies and nuts.
women with knowledge deficits. ● Nursing considerations in taking
● This means to say that assessing the iron
resources available and their knowledge ○ It is best absorbed in acidic
in food and nutrition is a very important mediums, so instruct them
issue we need to take note of and to take it in between meals
intervene when the need arises.
72
and with Vitamin C rich
juice.
○ Iron can cause constipation
so there is also a need for
increased fluid, fiber or
roughage, and regular
ambulation.
○ This will also result in
having dark stools.
4. Calcium: 1200 mg/day
● Calcium is needed for maternal
calcium and phosphorus Exercise
metabolism and fetal bone and ● Another thing that we need to assess
skeletal growth. subjectively is their pattern of exercise,
● Pregnant women need ● We also take note of their own means of
1200mg/day equivalent to 1 quart doing exercise.
of milk a day. ● Walking or commuting to work can be
5. Sodium considered a form of exercise, we just
● Sodium is needed for tissue need to make sure that these exercises do
growth and development, not cause fatigue or pressure to them,
● It is contained in most foods and especially to the fetus.
should not be restricted without ● We ask the type, amount and frequency
serious indications, such as of exercise to determine a woman's
hypertension. pattern or routine pattern, and whether it
6. Folic acid will be consistent with the recommended
● As mentioned in the previous level of pregnancy as this varies greatly
videos, Folic acid is needed to among women.
meet increased metabolic ● If a woman hikes or cramps for example,
demands in pregnancy and for this type of exercise is good for her but
production of blood products. can also put her at risk for exposure to
● Deficiency can cause fetal community diseases.
anomalies, neural defects, and
bleeding complications. Hobbies
● Best source includes liver and ● We also ask for hobbies
dark green leafy vegetables. ● Certain hobbies such as working with
● Of course, intake of water soluble lead based blades and ceramics might
vitamins, such as Vitamin C and B, not be wise to continue during pregnancy
and fat soluble vitamins, Vitamin because lead is teratogenic.
A, D, E and K is a must.
Tobacco, Alcohol, Drug Consumption
● Smoke, whether first-hand or
second-hand has been shown to be
harmful to fetal growth
73
● Obtain information about the woman and partnership by questions such as, “have
her family’s smoking habits you ever been hurt by someone?” or “are
● Excessive alcohol intake cannot only lead you afraid of anyone?”
to poor nutrition but can be directly
responsible for Fetal Alcohol Syndrome Chief complaint
and preterm birth ● Always cite the chief complaint or reason
● So, also record amount of alcohol a for taking treatment.
woman consumes ● LMP
● Vague answers into these questions of the ● Method used in acknowledging
clients should be specified by probing pregnancy
questions ○ Most clients who will claim that
● If the client tells you, “I just drink alcohol they missed their period or have
occasionally.” you can ask the frequency experienced unusual nausea and
in a month and approximation of the vomiting or have identified that
amount taken per chance. they are pregnant through home
pregnancy test kits and wants to
Medication and Herbal therapy confirm that it's true
● Medication history is important to obtain
● Ask whether a woman takes any Family History
medications prescribed or ● Taking family history allows us to see or
over-the-counter because their effect on detect illnesses or conditions that are
the growing fetus will have to be transmissible such as hypertension,
evaluated diabetes mellitus, asthma, and the like
● For example, Isotretinoin - a vitamin A
preparation taken for acne is associated History of Past Illnesses include:
with spontaneous miscarriage and ● Surgeries they had
congenital anomalies ● Childhood diseases
● Many women use herbal supplements to ○ Such as measles, mumps and the
relieve the nausea of early pregnancy link to check for immunity against
● So, also ask for any herbal preparations these diseases
that a woman might be using as even ● Vaccines received and date when these
seemingly innocent alternative therapies were taken
such as these could be detrimental during ○ There are certain vaccines that we
pregnancy, if they could stimulate uterine need to allow a certain grace
contractions or in any other way interfere period to allow safe pregnancy
with fetal health. ● Allergies to avoid especially during
pregnancy
Intimate Partner Violence ● Ask about Past surgeries on the
● Pregnant women, especially adolescence, reproductive chat.
are at an increased risk for intimate ○ For example, if a woman has had
partner abuse tubal surgery following an ectopic
● Ask enough questions to be certain a pregnancy, her statistical risk of
woman is not involved in an abusive another tubal pregnancy is
74
increased because of the tubal pressure, which increases bladder
scarring present tension and causes emptying
○ If she has had uterine surgery, a ○ Stress incontinence occurs from
caesarean birth may be necessary lack of strength of the perineum
because her uterus may not be muscles and bladder support.
able to expand and contract as Commonly, this weakness has
efficiently as usual because of the occurred from difficult birth, the
surgical scar birth of a large infant, grand
multiparity, and instrumented birth
Gynecologic history ○ During pregnancy, stress
● Aside from taking note of the LMP we incontinence can become
also assess the: intensified from the increasing
● Menarche, Regularity, Duration, abdominal pressure
Frequency, and Character of Menstruation
● We also take note of the PMP or Past Obstetric history
Menstrual Period or the menstrual period Obstetric History is tracing the history of
before the last, to determine most recent pregnancy of the client. We need to establish the
pattern of menstruation obstetric score of the client on her first visit. To
● Menstruation do this we need to get familiarized with these
● Perineal self-examination terms.
● Sexual history which include methods of ● Obstetric scoring
contraception ○ Para: Viable Pregnancy
○ Occasionally, a woman may ■ The number of pregnancies
become pregnant with an that have reached viability
Intrauterine Device (IUD) in place. regardless of whether the
If this occurs, it will be removed to infants were born alive.
prevent infection during Remember pregnancy is
pregnancy. viable if it completed more
○ Another woman, not realizing she than 20 weeks and the
is pregnant, may continue to take fetus is greater than 500
an oral contraceptive for sometime grams
into her pregnancy ○ Gravida: pregnant
● Presence of Stress incontinence should ○ Primigravida: woman who is
also be assessed pregnant for the first time
○ As part of any woman’s ○ Primipara
gynecologic history, assess for the - Woman who has given birth to
possibility of stress incontinence one child past age of viability
or the incontinence of urine on ○ Multigravida
laughing, coughing, deep - Woman who has been pregnant
inspiration, jogging, or running. previously
With these actions, the diaphragm ○ Multipara
distends, increasing abdominal - Woman who has carried two or
more pregnancies to viability.
75
○ Nulligravida 3. Position her comfortably on the IE table or
- Woman who has never been and on the chair in an upright position to
is not currently pregnant. alleviate chronic shortness of breath
● 5-point system: Gravida Para especially women in their third trimester.
○ Commonly used system which 4. Drape half only exposing the body part
uses the acronym G-T-P-A-L you are currently assessing.
■ Term, Preterm, Abortion, Living 5. Make sure your hand and paraphernalia
■ Gravida: the number of times that are clean and warm.
a woman has been pregnant 6. Donning PPE is needed.
■ Term: pregnancies that reach more 7. Use the right instrument to obtain
than 37 weeks accurate results.
■ Preterm: pregnancies less than 37 8. Most of the assessments deal with the
weeks but greater than 20 weeks gravid abdomen so always remember the
■ Abortion: refers to fetus born less rule of thumb in doing this assessment.
than 20 weeks and these are 9. Follow the IAPP pattern.
nonviable pregnancies ○ Inspect first then Auscultate,
■ Living: number of children alive Percuss and lastly Palpate.
○ 4-point system: Para 10. In hearing the fetal heart sound you need
○ For the 4-point system we do not to palpate first to determine the fetal
indicate the number of back.
pregnancies
■ Term, Preterm, Abortion, Living Fetal Back
Sample: - Ideal landmark in detecting the fetal heart
Beth is 39 weeks pregnant with her third sound.
baby. She has been pregnant 3 times. Her
first pregnancy resulted in a baby girl born Leopold’s Maneuver
at 39 weeks gestation. Her second A systematic abdominal palpation to estimate
pregnancy resulted in a baby boy born at fetal size, locate fetal back and parts to
38 weeks gestation. What is her GTPAL? determine fetal position and presentation. This is
divided into four parts:
Head-to-Toe Assessment
● In doing the Head-to-Toe assessment the
nurse needs to be systematic in doing a
review of the system.
➔ What Do You Need To Do?
1. Establish rapport and explain the
procedure to the client.
2. Let the client void first as indicated.
76
a) First Maneuver 4. Afterwards, use the second wipe to clean
Also known as Fundal Grip over the opening where the urine comes
b) Second Maneuver out or the urethra just above the opening
Also known as Lateral Grip of the vagina.
c) Third Maneuver 5. To collect the urine sample, keep the labia
Also known as Pawlik’s Grip, this spread open
determines presenting parts and if the 6. Then, urinate a small amount in the toilet
fetus is engage or have settled down the bowl
pelvis 7. After, stop the flow of the urine.
d) Fourth Maneuver 8. Hold the urine cup a few inches from the
Also known as Deep Pelvic Grip, it urethra
determines the attitude if the head is well 9. Urinate until the cup is half full.
flexed. 10. The woman may finish urinating into the
toilet bowl and send the specimen fresh
Moreover, in doing the Head-to-Toe assessment to the laboratory for analysis.
we need to document baseline data on the
height, weight, and vital signs.
1.
MSCC
● Part of the laboratory test done is to
obtain urine through MSCC or Midstream
Clean-Catch, this is our typical urinary
● Proteinuria
test.
● Glycosuria
● Ask a woman to void for a clean catch
● Nitrites
urine specimen before the examination
● Pyruria
○ This reduces the bladder size and
● Albumin
makes the pelvic examination
more comfortable and allows
Weight gain
easier identification of pelvic
- Weight gain is healthy and considered
organs.
normal during pregnancy. Record the
● This also provides a urine specimen for
assessment with her pre-pregnancy
laboratory testing.
weight if available to determine how much
○ The Urine specimen is sent to the
weight she has already gained or lost.
laboratory for evaluation of
bacteria, protein, glucose, and
Pelvic exam (Papanicolaou Smear)
ketones.
- Papanicolaou smear is a pelvic
➔ Steps:
examination which reveals information on
1. Instruct the woman to sit in the toilet with
the health of both internal and external
their legs spread apart.
reproductive organs.
2. Let them use two fingers to spread their
- Internal Genitalia - nulligravid vs.
labia.
multigravida
3. Use the first wipe to clean the inner fold of
the labia and wipe from front to back.
77
It can be determined if the woman is 10. Stool at correct sitting height
nulligravida or multigravida by checking ➔ Process:
the appearance of the cervix 1. A woman is placed in a lithotomy
- Pelvic examinations have the reputation position with the legs wide open
for being painful and causing a loss of 2. The speculum is inserted
modesty intravaginally to open the vaginal
- Internal Examination (procedural) canal
➔ Steps: 3. The brush will be inserted to
1. First, an IE or Internal Exam is obtain samples (How a pap smear
done is done)
2. Afterwards, a speculum is used - If this is the first pregnancy, it may be the
which is inserted into the vagina to first time a woman has ever had this type
perform the papanicolaou smear. of examination.
- The pelvic exam is similar to performing - Having heard stories about how painful
the internal exam or IE. these examinations are may cause her to
- It entails the use of an equipment required tense just thinking about it.
which is a speculum ○ When pelvic muscles are tight and
tense, the examination becomes
painful and also gives the
examiner difficulty in assessing the
status of pelvic organs
- The patient is put in a lithotomy position
and nursing considerations are the same
as that of the Internal Exam.
➔ Materials:
1. Clean examining gloves
2. Speculum
- an instrument with movable flat
blades that can be made of metal
or plastic
3. Spatula
- Used for cervical scraping
- Also used during pelvic ➔ The Cervix
assessments (Used during pap ● Pre-pregnancy (Nulligravid cervix)
smears) ○ The cervix appears to have a
4. Lubricants dimpled area at the center (Image
5. Glass slide “Left” and “Above”)
6. Liquid collection device (for the ● Postpartum cervix
pap smear), ○ The cervix becomes soft and
7. Culture tube malleable
8. 2 or 3 sterile cotton tip applicators ○ The internal and external os
or cytobrushes for obtaining remains open for weeks.
cervical cultures,
9. Good examining light
78
● Post-pregnancy healing: vagina) until the uterus can
○ The cervix will appear (Image be felt between them
“Right” and “Below”) wherein you - If a uterus is extremely retroverted,
can see a jagged split in the it may not be palpable
middle abdominally.
- When a pap smear or a pelvic exam is ➢ Bimanual Examination On The
done even though the patient is not Ovaries
pregnant at that time and the cervix ● The right and left ovaries
appears like a post pregnancy cervix, it are identified by the same
indicates that the woman is primigravida method
or multigravida ● Ovaries are normally
➔ Other Techniques during Pelvic slightly tender so the
Examinations pressure caused by the
● Bimanual Examination palpation may cause a
- Following the speculum woman some discomfort
examination, a bimanual - Through bimanual palpation, the
(two-handed examination) is examiner may be able to detect
performed abnormal growth with the cervical
- This is to assess the position, and uterine area
contour, consistency, and - An early sign of pregnancy or the
tenderness of the pelvic organs Hegar’s sign is elicited on
bimanual examination as well
➔ Steps:
1. The index and middle
fingers of one gloved hand - After a bimanual examination, the hand is
are lubricated withdrawn from the vagina.
2. These are then inserted ➔ Steps:
into the vagina, so the 1. Insert index finger into the vagina
walls of the vagina can be 2. Then, insert the middle finger into
palpated for abnormalities the rectum.
3. The other hand is placed 3. Palpate the tissue between the
on a woman’s abdomen two fingers
4. This hand is pressed ● Through this, it is possible
downwards (towards the to assess the strength and
hand that is still in the
79
irregularity of the posterior determine chances of RH
vaginal wall incompatibility.
● This is also to check the ○ This means, the RH factor
presence of hemorrhoids. (whether its positive or
● This maneuver may be negative) of the mother and
slightly uncomfortable for a the fetus may not match
woman because of the and can cause death to the
rectal pressure involved fetus
4. After completing the examination, ● We submit the blood for culture for
any excess lubricant is wiped any signs of infection to identify
away from the vaginal and rectal the causative agent
opening. ● We determine the presence of aFP
5. Wipe from front to back to or Alpha Fetoprotein to
prevent bringing rectile determine fetal defects
contamination towards the vaginal ● Coombs’ Test also gives us an
introitus. idea for any RH incompatibility
● HIV Testing for possible infection
Lesions ● OGTT which refers to Oral
Another thing that we need to assess is the Glucose Tolerance Test helps us
presence of lesions, especially in the genital area. determine if the mother has
● Candidiasis gestational diabetes
● Gonorrhea ● Mantoux Testing or Interferon- Gamma
● Chlamydia Release Assay- Purified Protein Derivative
Specimens may be taken or advance diagnostic (PPD)
tests will be done to rule out Candidiasis or any ● Since X-ray is impossible for
Sexually Transmitted Infection, such as pregnant clients to check for the
Gonorrhea and Chlamydia presence of tuberculosis infection
● Maternal serum in the lungs, Mantoux Testing is
Maternal serum serves a wide opportunity done, or the Interferon-Gamma
of testing the mother for infection, Release Assay.
disorders, or to routinely determine fetal ● Another term for Mantoux Testing
well-being. is the PPD Testing, PPD means
● Cbc, Syphilis Test, Blood Typing, Culture, Purified Protein Derivative.
Afp, Indirect Coombs’ Test, Hiv, Ogtt ○ This is done by injecting a
● CBC gives us an idea of the level 0.1mL of liquid or the PPD
of the mother’s blood components into the epidermis of the
to rule out anemia or any forearm
deficiency ● PPD test
● We also identify the blood type of ○ Determines if someone has
the mother for possible blood developed an immune
transfusion during the delivery response to the
when the need arises or to bacterium that causes
tuberculosis
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○ If the bleb develops into a is the cervix and you can obtain the secretions for
wheal, it implies that the testing outside the cervix.
woman was infected with ○ Secretions and lesions may be
Mycobacterium obtained extravaginal or
tuberculosis. surrounding the cervix
In cases that the pregnant client is diagnosed
with any of these Sexually Transmitted Diseases,
the partner should be concurrently treated as
well.
This is how a Candida Inspection looks like, this

is caused by a yeast infection called Candida
albicans.
● The client may manifest redness, swelling,
itching, painful intercourse and a thick
white discharge from the vagina
● This could also be caused by improper
use or intake of antibiotics, or a
Ophthalmia neonatorum is a conjunctivitis of
decrease in the immune system
the newborn or a neonatal complication, brought
about by Gonorrhea or Chlamydia infection
present in the mother, especially if the newborn is
delivered vaginally.
● The newborn will manifest redness,
discharge (or it could be a profuse
discharge if its a Gonococcal infection),
and swelling of lids which may be present
and occur bilaterally
This is Gonorrhea, this is caused by Neisseria ● Complication of Ophthalmia neonatorum
gonorrhoeae, this is a sexually transmitted could lead to blindness of the infant.
disease present among male and female as well
Pelvis
This is Chlamydia, caused by Chlamydia

trachomatis, the upper hollow part of the image
81
- It is impossible to predict from the
outward appearance of a woman whether
her pelvis or her pelvic ring will be
adequate for a fetus to pass through
- Some women look as if they have wide
pelvis but in reality, have only wide iliac
crest and a normal or even smaller than
Through Pelvimetry or ultrasound of the pelvis,
normal internal brim
we can compare the size of the fetus with the
- This (the pelvic ring) matters on whether
woman’s pelvic capacity. We will also be able to
the mother could deliver her baby
identify the type of pelvis one has.
normally or through caesarean section
➢ Gynecoid
- Differences in pelvic contour and
○ Also known as, the Female Pelvis
development occur mainly because of
○ Has an inlet that is well-rounded,
hereditary factors but diseases such as
forward and backward, and a wide
Rickets and history of injury of the pelvis
pubic arch.
may also affect adequacy of the pelvis.
○ This pelvic type is ideal for
childbirth.
➢ Android
○ This is the pelvis common among
males.
○ With this pelvis, the pubic arch
forms an acute angle making the
- The false pelvis refers to the portion which lower dimensions of the pelvis
supports the intestine, specifically the (anterior-posterior part) extremely
ileum and sigmoid colon, and transmits narrow.
part of their weight to the anterior wall of ○ A fetus may have difficulty exiting
the abdomen. from the type of pelvis, so, this is
- Wideness of the false pelvis does not not ideal for vaginal birth.
guarantee adequacy or certainty that the ➢ Anthropoid
fetus may pass through the pelvis and ○ Also known as, the Ape-like
have vaginal delivery. Pelvis
- The true pelvis refers to the broad smooth ○ The transverse diameter is narrow.
quadrangular area of bone, corresponding ○ The A-P diameter of the
to the inner surfaces of the body and anthropoid is larger than normal
superior ramus of the ischium and a part ○ This structure does not
of the ileum below the arcuate line. This accommodate a fetal head as well
cavity is a short, curved canal deeper on as the Gynecoid.
its posterior than on its anterior wall, and ➢ Platypelloid
contains the pelvic inlet. This refers to the ○ Also known as, the Flattened
passageway of the fetus during delivery. Pelvis
- So, what matters to determine adequacy ○ Has a smoothly-curved oval inlet
is the true pelvis. but the anterior-posterior diameter
is too shallow.
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○ A fetal head might not be able to 2. Dental Care
rotate to match the curves of the - Regular examination of teeth and gums
pelvic cavity in this type of pelvis. should be part of the prenatal general
As of these types of pelvis, the most ideal one is physical examination, dental caries
the Gynecoid and this pelvis should be the pelvis require prompt management in pregnancy
present on a woman. but major dental surgeries should be
postponed for the postpartum period.
Care of the Mother and the Fetus during - Since the estrogen can increase
Perinatal Period vascularity of the gums and can cause
swelling, use a soft bristled toothbrush
Health Promotion During Pregnancy and gentle brushing. The concept that
Health Promotion dental caries are aggravated by
Health promotion during pregnancy begins with pregnancy is not supported by literature,
reviewing aspects of health care, we need to there is no tooth loss secondary to
ensure that the mother is independent with her pregnancy.
___ while promoting a healthy lifestyle for herself 3. Perineal Hygiene
and the fetus because pregnancy is not an - Douching is an obsolete practice and it is
illness, few special care measures other than not advisable to manage vaginal
common sense about self-care are required. discharge. Daily bath will suffice keeping
Many women however have heard different perineal hygiene
warnings about what they should or should not 4. Clothing
do during pregnancy so they may need some self - Encourage to wear loose comfortable
help separating facts from fiction so that they can clothes made of cotton, avoid restrictions
enjoy their pregnancy unhampered by around the breast, abdomen, legs and
unnecessary restrictions round garter
1. Bathing and Skin care - Wear low to moderate heeled shoes for
- We encourage women to have warm comfort and balance
baths daily, instructed to avoid soaps and - You may wear support pantyhose for
pat dry the nipples for soaps to have a varicosities but avoid knee length
drying effect and can cause excoriation stockings
(?). - Use supportive cotton lined bradgier
- Avoid tub baths because this can cause 5. Sexual Activity
injuries from accidental slipping as - Coituse is not generally cotrainidicated
pregnant women may have difficulty except in the presence of premature
maintaining balance. If they are using tub rupture of membranes, premature labor,
baths instruct to use non-skid rubber mat history of abortion, and bleeding. Late
on bathtub floor to prevent falls, bathtubs pregnancy with engaged fetal head and
are contraindicated when the client has incompetent cervix
ruptured bag of water or the amniotic sac - Like any other activity instruct the mother
has already ruptured or has bloody to avoid fatigue, suggested position is
discharges side lying position
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6. Exercise/Physical 8. Work/Employment
- Regular exercises are needed, avoid - The pregnant woman may continue
contact sports working provided the nature of work, work
- Pregnant women should not learn or try a area and conditions do not pose hazards
new routine of exercise to the health of the matter and fetus
- Make sure the exercise does not cause - Whether standing or sitting at work the
maternal fatigue pregnant woman should be advised to
- If the woman is used to doing aerobic stop and walk about every few hours and
exercises then she can continue that at least every hour to improve circulation
- Exercise in a standing position and of blood
non-supine to prevent vena cava - Adequate periods of rest should be
syndrome provided during the work day
- Excessive exercise can cause increased - Women with previous complications that
blood flow to the muscles and bones are likely to be repetitive such as
diminishing blood flow to the uterus, premature labor and abortion probabbly
placenta, and fetus. It can also cause should minimize physical work
elevated temperature which is 9. Travel
theoretically teratogenic - Long distance travel by land needs
- Exercise three times a week, 30 stopovers every hour or every 2 hours so
consecutive minutes, the 30 consecutive pregnant woman can get out of the car to
minutes is comprised of 5 minutes warm stretch out and walk
up 20 minutes for the regular exercise and - Seat belts also are needed
5 minutes cooldown - Travelling by air requires pressurizes plane
7. Sleep in late pregnancy air lines may require a
- Assess activities to identify need for rest medical certificate indicating fitness to
and sleep average number of hours of travel by air
sleep is 8 hours and may need 1 to 2 - The best time to travel is during the 2nd
hours of afternoon nap trimester because pregnant women is at
- In the second half of pregnancy advice to its most comfortable state
avoid supine position in bed rather - Danger for abortion is not high and
position in left sims alleviate with pillow the threat of premature labor is at
hug, pillow on right side (not sure sa the minimum
pillow part) - Travels close to term are discouraged
- Encourage to plan rest time during the 10. Medications
day and its best to alleviate the head of - Drugs should not be taken by pregnant
bed women when prescribed by their
- When at work get to stand and walk physician
about a few minutes at least once in every - Drugs prescribed during pregnancy
2 hours if tasked to do prolonged should have benefits or advantages
standing there should be time to walk outweighing the risks
about and sit at intervals - The best recommendation would give is
that no medication is taken during
84
pregnancy unless absolutely necessary Immunization
and prescribed - Generally vaccines that contain killed or
- Intake of illicit drugs for first semester can inactivated viruses can be given during
cause the most adverse fetal pregnancy, vaccines that contain live
malformations viruses aren't recommended for pregnant
- The so called Hard Drugs may cause women
growth retardation and drug withdrawal - Two vaccines are recommended during
which is associated with increased pregnancy
neonatal mortality 1. Flu (influenza) shot
- The most common harmful effect of - Especially those who are pregnant during
heroin on a neonate as withdrawal or flu season
neonatal abstinence syndrome 2. Tetanus Toxoid Reduced Diphtheria
- Illegal drugs carry the risk of carrying HIV Toxoid And Acellular Pertussis (Tdap)
and other STDs or sexually transmitted Vaccine
diseases - One dose of Tdap vaccine is
- Herbal supplements being natural are not recommended during each pregnancy to
always safe because of lack of consistent protect the newborn from whooping
potency inactive ingredient cough or proptosis
- General rule for natural herbs must be - These are given within 27 through 36
approved and supervise by health care weeks AOG
provider - The health care provider will recommend
avoiding vaccines that contains live
viruses during pregnancy because they
pose a theoretical risk to the fetus
- If a woman proceeds to any vaccines in
containing live viruses she should wait at
least 3 month prior to conceiving
So these is an example of correct way of wearing

seatbelt for pregnant clients
➔ Two parts
1. Shoulder Belt
- The Shoulder belt should be away
from the neck and its should cross
at the middle of the breast and
then tuck it in the other side. - According to WHO the purpose of giving
2. Lap Belt the vaccine to women with child bearing
- It is secured below the belly or age and to pregnant women specifically
below the abdomen nad it should the tetanus toxoid or the TT is to protect
fit snugly across the pelvic bone them from tetanus and to protect the
newborn infants from neonatal tetanus
- The mother and the neonate expose these
kinds of virus upon delivery because they
85
may harbor these viruses from unsanitized realize their habit is pregnancy
or improper handling of the delivery tools related as much being nervous
or instruments used in the facility. habit
- If the woman has not been previously - Encouraging a woman to stop eating the
vaccinated or if her immunization status is non food substance may not be affected
unknown we give two doses of TT 1 because the habit may be deeply
month apart before delivery and further engraved
doses based on the table (Above) there ○ This is because, Pica is a
would be a total of 5 doses but if the symptom that often accompany
woman has had one to four doses of iron deficient anemia
tetanus toxoid in the psat we give one ○ Correcting this underlying problem
dose of TT before delivery as much as 5 with an iron supplement may
doses protects a woman throughout her correct the pica
child bearing years. ○ Add some frequent visits and be
certain to assess if the woman’s
Nutrition hemoglobin is increasing
● Women that needs special attention: ○ Ask if she notices any difference in
○ Pregnant teenagers her craving
○ With low prepregnant weight; - Supplying enough knowledge for women
obsese should be one of our goals
○ Low income women, stressful - Supplement their deficits with the
lifestyle appropriate idea of what to eat and at the
○ Vegetarians same time, consider their resources
- Some believe once they get pregnant ○ It is best to look into the client’s
they're eating for two resources or their financial status.
- A lot of women say this but this does not ○ We cannot introduce which may
mean that a woman should eat enough not be in their community or in
for two adults their environment because it will
- Advice to consume enough to provide pose stress to the pregnant
nutrients for herself and for a growing woman.
fetus is enough ● Weight Gain: 25-35 lbs
- In doing this, many women will not ○ Multiple gestation: 37-54lb
increase the quantity of food they eat but ○ Underweight: 28-40lbs
they will increase the quality of foods. ○ Overweight: 15-25 lbs
● Pica ○ Obese: 11-20lbs
- It is a behaviour we need to look into as - If a woman is at a high risk for nutritional
well deficit a may more precise estimate
- Always ask women at prenatal visit if they adequate weight gain can be calculated
crave any non food items, as most basing on pregnancy BMI the weight gain
women do not supply this information to achieve may vary then
unless asked directly - Weight gain of 25 to 35 lbs this compose
○ They worry if you find their of multiple gestation which needs to have
behaviour odd or they may not 37 to 54 lbs
86
○ 1st trimester: 1.5lbs/mos. ○ Fats (Omega - Fatty Acid) = 200 -
○ 2nd and 3rd trimester: 1lb/week 300mg/day
- Weight gain in pregnancy occurs from ○ Vitamin A = 10,000 IU/day
both fetal growth and accumulation of ○ Vitamin C = 85 mg/day
maternal stores and occurs at ○ Folic Acid = 400mcg/day
approximately 0.8 kg or 1.5 lbs per month ○ Iron = 30 - 60mg/day
during the first trimester and 0.4 kg or It is taken between meals with Vit
1lbs per week during the last two C juice and it can cause
trimester constipation and can result to
- A trimester pattern of 3 - 12 - 12 having dark stools
○ As a general rule, the average ○ Calcium = 1200mg/day
woman’s weight gain is
considered excessive if it's more Nursing Management of the Discomforts of
than 3kg or 6.6 lbs a month during Pregnancy
the 2nd and 3rd trimesters. First Trimester
○ It is less than usual if it is less 1kg ➢ Breast Tenderness
or 2.2 lbs per month during the - Often one of the first symptoms noticed in
2nd and 3rd trimesters early pregnancy, it maybe most
- Women can be assured that most the noticeable exposure to cold air, so for
weight gain with pregnancy will be lost most women the tenderness is minimal
after ward and terantian something they are aware of
○ Fetus: 7 lbs but not something overly concerns them
○ Placenta: 1lb - If the tenderness is enough cause them
○ Amniotic fluid: 1.5lb discomfort encourage and woman to
○ Wt. of uterus: 2lb wear a bra with a wide shoulder strap for
○ Blood vol: 1 lb. support and to dress warmly to avoid cold
○ Wt. of breast: 1.5-3lbs. draft if cold increase symptoms
○ Wt. of additional fluid: 2lbs - If Actual pain exist then the presence of
○ Fat and fluid accumulation: 4-6 condition such as nipple fissure or other
lbs explanations to the pain such as breast
This is based on women with normal BMI abscess they need to be rolled out that is
● Food Sources (RDA) → + 300kcal from why they need to see the doctor before
pregnant cal. they can take any medication for pain
Non-pregnant women have to have because if maybe a serious condition and
1800kcal to 2200kcal per day. Once she just not a mear breast tenderness brought
becomes pregnant, she needs an about pregnancy
additional 300kcal per day, on top of that.
So the daily Kcal need for pregnancy has
a total of 2100 to 2500 kcal per day and
never less than 1100 kcal per day the
recommended
○ Proteins = 74 - 76g/day
87
➢ Palmar erythema/ Palmar pruritus 2. Avoid greasy and highly seasoned
food
3. Loose clothing at waistline
4. Stay upright position for at least 2
hours after meals always instruct
the mother not to always lay down
immediately after meals to
facilitate the digestion.
5. May use aluminum based antacids
Explain this type of itchiness in early
(Amphogel) as ordered
pregnancy is normal before she spends
6. Drink 6- 8 glasses of water daily
time and effort trying different soaps or
7. Chew Food thoroughly
different detergent or attempting to
Instruct the mother that everytime
implicate certain foods as she eats them
they pick things from the floor it is
1. Calamine lotion
best for them to bend at the knees
- Calamine lotion is soothing as
and not at the waist.
soon as a woman’s body adjust to
➢ Flatulence
the increases level of estrogen
Can be managed by having small frequent
their erythema and pruritus
feeding and avoiding gas forming foods
disappear
such as chewing gum, sodas, hard candy
- The more we scratch the hands or
and beans
a certain part that is itchy the more
➢ Constipation
it becomes itchy so always ensure
Instruct the mother to increase fluid
the mother does not scratch her
intakes at least 6 to 8 glasses of water per
hands to prevent any break down
day increase roughage in the diet as fruits
of the skin and can infections
and vegetables regular exercise observe
➢ Nausea and Vomiting (Morning
daily regular bowl movements and drink
sickness)
warm water in the morning.
1. Dry or toast bread and crackers
➢ Hemorrhoids
before arising from bed. Any
1. Avoid prolonged sitting or standing
carbohydrates will do in the
2. Knee-chest position for 10-15
morning 30 mins before getting up
mins
2. NFF, no fried foods
3. Good bowel habits
3. Drink liquids in between meals
4. Proper dietary management EOF
esp. Fruit juices Avoid highly fatty
5. Hot sitz bath
spicy and highly seasoned foods
6. Stool softeners or non-steroidal
eat small frequent meals and avoid
cream
overeating
➢ Fatigue and Headache
4. Get out of bed slowly
1. Have adequate rest and sleep its
➢ Pyrosis (heartburn)
best to have 8 hours average sleep
1. Avoid coffee, soda, and cigarettes
at night with 1 to 2 hours nap
anything that can increase the
during the day
acidity of the stomach
2. Avoid prolonged standing
88
3. Practice good body mechanics
4. Maintain Good posture
5. Report increase fatigue with
regular exercise as this is a
dangerous sign of heart disease
➢ Frequent Urination: Prevention Of
2. Underwear with a cotton crotch
Urinary Stasis
3. Check for pruritus or irritating
1. EOF
sensation in the area
- Encourage oral fluid to replace
losses except at bedtime to
Second and Third Trimester
prevent knockterial or frequent
➢ Backache: Lumbar Lordosis
voiding at night
- Practice regular voiding, perennial
hygienes from front to back
- Report any burning sensation,
disseria, cloudy urine, or tea
colored urine
2. Stress incontinence: Kegel
exercise
- Kegel exercise is like pretending to 1. Supportive shoes
urinate and then holding it, relax 2. Proper Body mechanics
and tighten the muscles that 3. Do prenatal exercises
control your urine flow, it is (Pelvic -rocking or tilt, tailor sitting)
important to find the right muscles 4. Maintain normal weight gain
to tighten its best to do this for 3 5. Heating pad
seconds with 10 repetition three 6. Supportive mattress
times per day ➢ Ankle Edema
➢ Abdominal Discomfort - Round Assume last lateral position or elevation of
Ligament Pain legs frequently promote venous return
Women should be cautious when avoid prolonged standing
observing abdominal discomfort. 1. Lie or sit with legs elevated for 20
Normally, this is related to round ligament mins
pain however this may indicate ectopic 2. Avoid tight clothing
pregnancy in the first trimester. 3. Avoid highly salted foods, eat high
➢ Leukorrhea :Whitish Vicious Vaginal protein foods
Discharge Report hand and face swelling cause this
Normal in first trimester implies pathologic condition
1. Daily bath; no tampons, no ➢ Varicosities
douching No round garters around the abdomens
and legs
1. Leg elevation
2. Stockings before waking up wear
supportive panty hose which is
89
applied prior to getting out of the (Steam inhalation modified)
bed
3. Elevate legs frequently as advised Add-ons After Class
4. Vitamin C (building blocks of veins 1. The mother undergoes or feels
and blood vessels) different emotions, different
➢ Leg Cramps: Low Calcium, High psychological changes as she
Phosphorus acknowledges that she is pregnant.
Calcium and phosphorus imbalance it is ● Her environment is also a factor in
the most important cause of left, avoid her accepting the pregnancy
prolonged standing and sitting ● Therefore, there is an erratic of
1. Knee extension, foot dorsiflexion emotions and thoughts that come
this hyper extends the muscles into the mind of a woman when
causing relief she knows she’s pregnant
2. Calcium supplement 2. How to Identify the Three Signs of
➢ Shortness Of Breath Pregnancy: Easy Way
● It is prevented by maintaining good a) Presumptive: Only detected or felt
posture and avoiding fatigue by the patient (Symptoms)
● Elevate the head by several pillows when - Ex: Patient experiencing nausea
sleep and avoid supine position and vomiting
● Avoid constricting bra and other type b) Probable: Detected by a
clothes healthcare worker
● Report any increase of dyspnea with - Ex: Woman is experiencing
minimal activity or dyspnea prior to 36 amenorrhea and the healthcare
weeks because this implies pathologic worker would assess and find a
condition Goodell’s sign or a Hegar’s sign
➢ Nasal Stuffiness c) Positive: Indicate that a fetus is
1. Steam inhalation or vaporizers indeed growing inside
2. Saline nose drops - Ex: Doctor can hear a fetal heart,
3. Self medication is discouraged fetal lining present in UTZ
All though we have a lot of over 3. Pregnancy Test Kits measure the hCG
the counter drugs we can use to levels or measure the presence of hCG
relieve nasal stuffiness ● Women normally have hCG but
4. Warm bath before bedtime hCG levels are abnormally higher
5. Take a hot drink in pregnant women
6. Conducive environment ● A more accurate result for a
pregnancy test kit is to test it
thrice (using 3 different brands of
pregnancy test kits)
● The quickest method to check for
the presence of hCG is through
blood because it is where hCG is
detected earlier in blood
compared in urine.
90
○ hCG is detected more in 7. Always take note of the scheduling of
blood than in urine the prenatal check-up
4. Increasing And Decreasing Levels Of ● If a woman thinks she is pregnant,
Libido As One Of The Changes the first thing she needs to do is to
Pregnancy visit the doctor for her first
● Because of the erratic changes of prenatal period
the hormones as well as the signs ○ This is important because
and symptoms of pregnancy this is when the positive
during the first trimester, the libido signs will be confirmed
decreases ○ First visit must be done
● The libo then increases on the immediately if the mother
second trimester because this is thinks she is pregnant.
where the woman would feel the ● Must be done every month until 28
most comfortable all throughout weeks
her pregnancy period. ○ From 28 weeks till the
● This would then decrease again in woman reaches term, the
the third trimester as the woman prenatal checkup must be
feels more weak (back problems) done twice a month or
as well as problems due to the every two weeks
increasing size of her abdomen. ○ From the time she is due to
5. Sexual Intercourse is not deliver until the time she
contraindicated during pregnancy as actually delivers, she needs
long as: to visit the doctor every
● The woman is not bleeding week
● The bag of water is intact ● These schedules may differ or
● No comorbidities (heart problems, change depending on the client’s
etc.) situation.
● The woman should be in a ○ Ex: If Client has high BP,
dependent position Cardiac problems, or renal
6. Striae Gravidarum is more prominent in problems then she has to
pregnant women than in women who go to the doctor more
have changed in size (brought about by frequently than what is
sudden loss of weight) prescribed for the normal
● More prominent in pregnant clients pregnancy.
because the connective tissues 8. Folic Acid is important in the
underneath the skin would development in the newborn’s nervous
atrophy causing the discoloration system and blood cells
● It becomes reddish to greyish but 9. Iron is taken with fruit juice (anything
during the postpartum, it is now acidic) because this would increase the
called Striae Albicans because it absorption of iron in our GI tract
has now turned white and silvery. ● If Iron is taken, the client could
have a discoloration in their stool
(black stool) but assurance must
91
be given to the client that it is
normal (that it is not blood).
● Always instruct the client to use a
straw when taking the syrup or
liquid form of iron because it could
also stain their teeth and cause
constipation
○ Iron is best paired with a
high fiber diet, increased
fluids, and promote
ambulation (if the client
tends to be constipated ● Client’s feet must be placed on the
with iron) stirrups at the same time, together.
10. Increased progesterone during the This is to prevent straining the legs
pregnancy can also cause constipation of the mother.
in the client ● To promote privacy: Always drape
● Increased progesterone can the mother with a blanket up to the
decrease the motility of your GI knee and the doctor will examine
tract the patient under the blanket
11. Two Immunizations that are allowed ● Upon IE, the doctor would insert
during pregnancy: their fingers to feel the cervix and
a. Flu vaccine then the other hand will push
b. Tetanus shot: Prevent the downward into the hypogastric
newborn from acquiring tetanus area of the mother to push
neonatorum (not only for the downward to the other examining
mother but also for the newborn) finger.
● Covid vaccine is also now given to ○ This is very uncomfortable
pregnant clients (Although not for the patient therefore
distributed with much study yet) always promote comfort
12. During the pap smear, the speculum is ○ Tell clients to do
inserted and opened to spread the deep-breathing exercises
vaginal walls and a cotton swab is when undergoing IE.
inserted to collect a specimen from the ● Doctors would conduct IE to
cervix monitor the opening of the cervix
13. When performing an IE, always position 14. Different nursing considerations taught
the mother in a lithotomy position to the clients:
● Travelling by car is not
contraindicated as long as the
mother is given time every two
hours to get down the car and
walk around
92
○ This is to promote ● >37 weeks: Preterm
circulation in the legs from ● 37-41 weeks: Term
prolonged sitting in the car ● >41 weeks: Post-term (At risk for
15. Leukorrhea is a white vaginal discharge having large babies and meconium
but it does not mean there is a vaginal aspiration)
infection
● Normal due to the increase in
estrogen levels of pregnancy
○ As long as the client does
not have other symptoms
that indicate that there is a
vaginal infection (fever,
increased bacteria in the
urine, uti, etc)
16. Ankle edema is normal during the

second and third trimester
● If it happens on the first trimester,
that is already an abnormal sign
and could indicate the presence of
pregnancy induced hypertension
(one of the dangerous signs of
pregnancy)
● Edema should only be in the ankle
level down to the feet and not on
the hands, face, and other parts of
the body aside from the ankle
17. We must know what are the normal
deviations in the health of a pregnant
client for us to know when it becomes
abnormal.
● As nurses, it is one of our
responsibilities to teach patients
when to seek medical help and
when to seek the doctor or to
teach them how to manage these
discomforts at home
○ Lessening their times in
visiting the doctor because
they don't know how to
manage these discomforts
18. For Obstetric Scoring:
● >20 weeks: Abortion
93
Nursing Management Of The Discomforts Of persistence and increased frequency, it
The Pregnancy (Continuation) indicates nutritional problems.
(As nurses, we need to assure a pregnant - Extended vomiting can deplete nutritional
woman, she has every reason to believe that she stores and can cause dehydration.
is going to have a normal, uncomplicated 5. Increase or decrease in fetal
pregnancy, as well as no reason to thinking that movements
she is going to experience any serious problems - A fetus normally moves more or less the
but if any danger signs do occur, she should same amount everyday.
inform her healthcare provider by telephone - An unusual increase or decrease in
immediately. Be certain, you give her an alternate movement suggests that a fetus is
contact number to call or locate the nearest responding to a need for oxygen and
possible healthcare facility to go to in case of requires further evaluation.
emergency.) 6. Abdominal/Chest Pains
- The uterus expands painlessly, so the
Danger Signs of Pregnancy increase in abdominal size and the uterus
1. Vaginal Bleeding compressing other organs does not result
- All vaginal bleeding or spotting needs to in any pain at all. Thus, abdominal pain is
be evaluated immediately no matter how a sign of some other problems such as
slight, because some of the serious tubal or ectopic pregnancy, separation of
bleeding complications of pregnancy the placenta, preterm labor, or something
begin with only slight spotting. unrelated to the pregnancy but perhaps
2. Sudden escape of fluid from vagina equally as serious such as appendicitis,
- When a gush of clear fluid is discharged ulcer, or pancreatitis.
suddenly from the vagina, it means that - Chest pain may indicate a pulmonary
the membranes have ruptured and the embolus (a complication resulting from
mother and the fetus are now both thrombophlebitis and is considered a
threatened, because the uterine cavity is medical emergency)
no longer sealed against infection. The last 4 sets of signs are all related to
- If the fetus is small, the head does not fit pregnancy-induced hypertension or
snuggle into the cervix and the umbilical preeclampsia - it is a potentially severe and even
cord may prolapse following membrane fatal elevation of blood pressure that occurs
rupture. In case this occurs, the mother during pregnancy.
should be brought to the hospital 7. Edema or swelling around face and
immediately and confirmed if the bag of sacrum
water has ruptured. - Edema is normal in the ankles especially
3. Chills, fever, and dysuria in the late weeks of pregnancy, but
- May indicate infections, specifically extended edema to the face indicates
Urinary Tract Infections and may mean extensive edema.
infection in the mother and the fetus. 8. Headache and blurred vision
4. Persistent Vomiting - Visual disturbances or a continuous
- Vomiting in the first semester for one to headache may signal cerebral edema or
two times a day is common in pregnancy, acute hypertension.
but if it passes twelve weeks with
94
9. Sudden increase in BP Indicators of High-Risk Pregnancy
10. Rapid weight gain 1. Maternal Age
(Women under 16 years old and over 35
➢ Nitrazine paper years old are at a higher risk compared to
women in their 20-30 years which is the
optimal childbearing age)
2. Poor nutritional status
(Overweight and underweight women
need to make significant adjustment to
meet the needs of pregnancy)
3. Low socio-economic status
(There are many interrelated
socioeconomic factors that places a fetus
at greater risk including inadequate
finances, overcrowding, poor standards of
- This is how a uterus looks like with a
housing, poor hygiene, nutritional
developing fetus. The fetus is surrounded
deprivation, severe social problems, and
with the amniotic sac, and it is filled with
unplanned and unprepared pregnancy
amniotic fluid to allow the fetus to move
especially among adolescents)
freely within the uterus.
4. Hx. of obstetrical complications
- We term this occurrence, “ruptured bag of
(Obstetric complications include history of
water”, or “rupture of membrane”, or
infertility or multiple gestations, grand
“ruptured amniotic sac”. This may not
multiparity, previous abortion or ectopic
happen abruptly or the flow of water may
pregnancies, previous losses which
not happen as a sudden gush, but it can
include fetal death, stillbirth, nenonatal or
be characterized as leaking.
perinatal death, previous caesarean
- The woman may think that she is having
section or forceps delivery, previous
urinary incontinence or stress
uterine or cervical abnormalities, previous
incontinence and mistakenly think that it
abnormal labor, or having history of
is urine instead of amniotic fluid. Thus, to
high-risk infants)
verify if it is amniotic fluid or not, we use
(Obstetric history such as miscarriage,
the nitrazine paper.
grand multipara, last pregnancy of less
- This is verified also by vaginal
that one year, problem with last
examination or with the use of vaginal
pregnancy, and congenital problems from
spec.
the last)
5. Hx. or with existing medical problems
A high-risk pregnancy is one in which the mother
(Maternal medical history include cardiac
or fetus has a significant increase of chance of
or pulmonary disease, metabolic diseases
harm, damage, injury or disability, and/or loss of
such as diabetes mellitus and thyroid
life or death.
diseases, chronic renal diseases and
chronic hypertension, seizure disorders,
cancer, and emotional disorders)
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6. Maternal lifestyle pregnancy. Other teratogens are harmful
(Maternal habits such as smoking during at any time during pregnancy.
pregnancy, regular alcohol intake, drug ● For example, for behavioral
use and abuse. teratogens, there is no safe
7. Parity period. The brain and nervous
(Increased parity makes the uterus lax and system can be harmed throughout
ineffective for further labor) the pregnancy, but we must
8. Work exposure to teratogens consider the most critical time of
(Especially in the daily environment, will organogenesis which is in the first
harm the fetus and cause congenital semester of pregnancy. Exposure
defects) to teratogen at this time greatly
9. Family or environmental violence affects the formation of organs.
(Physical assault or trauma to the mother
can cause emotional stress which is 1. Malaria - a disease caused by a parasite
considered teratogenic. Also, physical transmitted to humans through the bites
trauma induces preterm labor and of infected anopheles mosquitoes
premature separation of the placenta ● Drug of Choice: Chloroquine
which can cause bleeding and fetal death) ● Instruct mothers to avoid infested
areas and where long-sleeves and
Teratogens pants when going outdoors
- Refers to the agents and conditions 2. Toxoplasmosis - caused by the parasite,
including viruses, drugs, chemicals, toxoplasma, found in animals. It is
stressors, and malnutrition which can transmitted in the feces of cats who have
impair prenatal development and lead to ingested the infected animal or meat.
birth defects and even death ● Uncooked meat, cat stool
- Strength, timing (the factors considered ● Prenatal teaching: do not handle
that determines the influence of cat litter, wash hands after
teratogens to the fetus) handling cats, avoid raw and
➔ Strength - A certain teratogen potential undercooked meats
for causing harm increases when it is 3. Rubella (German Measles) - it is an
combined with another teratogen or acute viral infection caused by myxovirus.
another risk factor. Maternal infection is mild but effects on
● Television emits radiation but the the fetus are severe. It can cause
amount is in small quantity that it deafness, eye defects, CNS defects,
has no effect on the fetus. cardiac malformation, and/or fetal death.
➔ Timing - the effect of a teratogen on a ● How do we prevent this?
developing organism depends on what ○ Rubella vaccination of all
period in the pregnancy or in the non-pregnant, non-immune
development the child is exposed to to women of childbearing age
the teratogen ○ Women should avoid
- Some teratogens cause damage during pregnancy for at least 3
only specific days or weeks in early months after immunization
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and keep away from weeks AOG to check if the
infected people fetus was infected.
● Rubella titer (this is to measure the 7. Vaccines - live vaccines should not be
level or the amount of antibodies administered during pregnancy, rather 3
against rubella) months before pregnancy or immediate
○ If the titer is low, then the postpartum
woman (or the unpregnant 8. Alcohol - alcohol ingestion by pregnant
woman) is indicated to women is likely to cause fetal
receive the rubella vaccine. abnormalities, it can cause fetal alcohol
● Vaccination syndrome, which greatly affects brain
4. Herpes Simplex Virus 2 (Genital Herpes) development of the fetus. It has not been
- This can cause remission and determined what level of alcohol is safe,
exacerbation. Meaning, the woman can thus social drinking is considered not
be asymptomatic but symptoms may acceptable during pregnancy.
exacerbate when she is stressed or in the 9. Cigarette
presence of other infections. ● Pregnant women should not smoke.
- Signs of Genital Herpes is a painful Women who smoke during pregnancy
vaginal vesicle in the genitalia which can have smaller infants or SGA (Small for
be transmitted through genital birth. Gestational Age).
- It can also cause spontaneous ● Aside from SGA, smoking can also lead to
miscarriage or preterm birth managed by fetal prematurity, infant mortality,
having caesarean section or operative spontaneous abortion, and placental
delivery especially during active infection. problems.
5. Cytomegalovirus ● Nicotine is also known to increase the
- Can be transmitted transplacentally, it is Carbon Monoxide (CO) levels in the
transmitted through droplets as well. maternal and fetal blood which decreases
- The mother can be asymptomatic or oxygen affinity.
could have flu-like symptoms. ● Can cause CO poisoning
- It can cause neural damage to the fetus. 10. Radiation
6. Syphilis - caused by treponema pallidum, - Health effects on a fetus from radiation
the placenta has a barrier against syphilis exposure depend largely on the radiation
in the first 16 weeks; but can cross the dose. Exposure to high-dose radiation 2-8
placenta and infect the fetus after 16 weeks after conception might increase
weeks AOG. the risk of fetal growth, restriction, or birth
● Drug of Choice: Benzathine defects.
penicillin @ 1st trimester - Exposure between weeks 8 and 16 might
● Screening schedule increase the risk of a learning or
○ The regular screening is intellectual disability.
done during the first 16 - But a typical dose of a single radiation
weeks AOG to check if the exposure associated with a diagnostic
mother just had the syphilis x-ray is much lower than the high-dose
prior to pregnancy, and it associated with these complications.
should be done after 16
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always ask their healthcare provider
before taking any medication, may it be
an over-the-counter drug, and to read
labels.
- It is indicated in each drug to which
category it belongs.
- The safest category of drug is Category A.
It has adequate and well-controlled
image of a Lead Apron (used to protect from too studies that have failed to demonstrate a
much exposure to radiation especially those risk to the fetus in the first trimester of
handling x-ray machines) pregnancy, and there is no evidence of
Fetal Alcohol Syndrome risk in later trimesters.
FDA Pregnancy Categories
CATEGORY DESCRIPTION
A Controlled studies of pregnant women show no

risk in the first trimester
B Animal studies show no risk, or animals show

risk unconfirmed in humans
C Animal studies show risk, caution is advised,

benefits may outweigh risks
D Evidence of risk to human fetus, benefits may

outweigh risks in serious conditions
(This is how a child with Fetal Alcohol Syndrome
looks like. It is a condition in a child that results X Risk outweighs benefit
from alcohol exposure during the mother’s
pregnancy. Fetal Alcohol Syndrome causes brain
12. Hyperthermia - Increased temperature
damage and growth problems. The problems
that affects cell metabolism, that is why it
caused by Fetal Alcohol Syndrome vary from
is considered teratogenic. High core body
child to child, but defects caused by Fetal
temperature (hyperthermia) has been
Alcohol Syndrome are not reversible. This
shown in animal models to be a potent
includes a thin upper lip, smooth philtrum, flat
teratogen. Hyperthermia in humans
midface, short upward nose, prominent
greater than 39.5° during the first
epicanthal folds, and a low nasal bridge.
trimester increases the risk of miscarriage
11. Drugs
and neural defects. Hyperthermia can be
- Certain drugs such as alcohol, some
due to many different factors including
illegal drugs, and some prescription and
environment, hot tubs, spas, saunas,
over-the-counter medications are known
exercise, infection, fever, physiological
to cause birth defects if taken during
abnormalities of thermoregulation.
pregnancy and are considered
13. Teratogenic Maternal Stress and
teratogenic.
Emotions - produce a cascade of
- The US Food and Drug Administration
hormonal reactions, changes in blood
pointed out that pregnant women should
98
flow to the uterus, other alterations that soften in preparation for labor,
directly influence the intrauterine milieu. muscle or joint strain could occur.
● How do we help pregnant women ● Tailor-sitting
manage stress?
○ Help them relieve their
discomforts.
○ Know that discomforts of
pregnancy are only
temporary.
○ Ask the medical provider
about how to handle these
discomforts.
○ Try relaxation activities like
prenatal yoga or
meditation. They can also
help manage stress and ○ Strengthens perineal muscles and
prepare for labor and birth. makes pelvic joints more flyable.
○ Take a childbirth education ○ It could be done with one leg in
class so that they will be front of the other. As she sits in
able to know what to this position, she should gently
expect during pregnancy push on her knees towards the
and when the baby arrives. floor until she feels her perineum
○ Practice breathing and stretch.
relaxation methods that will ○ This is a good position to use to
be learned in class. watch television, read, or talk to
friends on the telephone, or file
Exercises papers on the lower cabinet at
● Prenatal Yoga work.
○ These classes are aimed at ○ It is good to plan on sitting in this
helping a woman relax and position for at least 16 minutes
manage stress better for all times everyday.
in her life, and not just pregnancy. ● Squatting
○ Yoga exercises help a woman stay
overall fit by their focus on gentle
stretching and deep breathing.
○ Caution women that as pregnancy
progresses, it will become difficult
to maintain difficult yoga positions.
○ Women should use a chair or a
wall for stabilization. They should
avoid twisting exercises late in
pregnancy because when joints ○ Also stretches the perineal
muscles and can be useful
position for fetal delivery
99
○ So, a woman should also practice ○ Another way to do this same thing
this position for about 15 minutes is to practice blowing a candle. A
a day. woman takes a fairly deep
○ For effective squatting, the mother inspiration, then exhales normally.
should be on her feet flat on the ● Pelvic Rocking
floor and not on tiptoes.
● Pelvic Floor Contractions (Kegel
Exercise)
○ Is the most important exercise for

comfort during pregnancy
○ Kegel exercise improve the tone
○ It increases flexibility of the lower
of pubococcygeal, pelvic, perineal,
back, strengthens abdominal
and vaginal muscles
muscle, shifts center gravity back
○ This is also beneficial in a
to the uterine spine, relieves
postpartum period to reduce pain
backache, improves posture and
and promote perineal healing.
appearance in late pregnancy.
○ Make sure the bladder is empty,
○ Woman arches her back, trying to
and you may lie down when doing
lengthen or stretch her spine, then
this. Tighten the pelvic floor
she holds the position for one
muscles as if you are holding your
minute, then Follows her back.
urge to void. Hold tight and count
3-5 seconds, relax the muscles,
Childbirth Education
and count 3-5 seconds. Repeat it
- Quite the number of women, especially
10x, 3x a day - in the morning,
primigravida, voice that they are afraid of
afternoon, and at night.
what will happen in labor. Those who are
young, who have low educational level,
● Abdominal Muscle Contractions
low self-rated health, and lack of social
○ Helps strengthen abdominal
network express this most.
muscles during pregnancy, and
- Thus, it is the nurse’s responsibility to
therefore may help prevent
collaborate with the interdisciplinary team
constipation, as well as help
composed of the doctor, nutritionist, and
restore abdominal tone after
the like, to conduct prenatal classes or
pregnancy.
childbirth educations
○ A woman merely tightens her
➔ Goal: Reduce pain during labor
abdominal muscles, then relaxes
- The overall goals of childbirth education
them. She can repeat the exercise
are to prepare expectant parents
as often as she wishes during the
emotionally and physically for childbirth
day.
while promoting wellness behaviors that
100
can be used for parents and families for - If practiced throughout pregnancy, a
life woman’s conditioned response to
How do we do this? contractions becomes a relaxed method
1. Explanation of the physiology of labor of breathing rather than muscle tension
and body’s responses and fear
2. Teach them Proper breathing - Taught by certified teachers
techniques c) Bradley (Partner-Coached) Method
3. Distraction techniques - Emphasizes natural childbirth with the
➔ Methods: parents working as a team
- Childbirth education is done in different - Diet and exercise are practiced
ways and the couple can choose which throughout pregnancy to prepare the
method to use and a vital part of body for the rigorous childbirth
childbirth classes is to effectively manage - Students are taught deep abdominal
pain breathing and an understanding of the
a) Grantly Dick-Read Method labor delivery process, rather than try to
- By Grantly Dick-Read block out the pain
- Believes fear and tension causes labor - Encourages concentrated awareness that
pains works through the pain
- Eliminates fear-tension pain mechanism - There is much emphasis on the education
- If a woman can prevent fear from and training of the woman’s labor and
occurring, or break the chain between birth coach
fear and tension, or tension and pain, then d) Psychosexual Method
she can reduce the pain of labor - Developed by Sheila Kitzinger in England
contractions during the 1950s
- A woman achieves lack of fear through - Stresses that pregnancy, labor and birth,
education about childbirth, and relaxation and the early newborn period are
and reduced pain by focusing on important points in a woman’s life cycle
abdominal breathing during contractions - Includes the programs of conscious
b) Lamaze Philosophy or relaxation and levels of progressive
Psychoprophylactic method breathing that encourages the woman to
- Emphasizes natural birth and offers a flow with, rather than struggle against
variety of relaxation methods to deal with contractions
pain - Most mothers who give birth in the
- Visualization, guided imagery, massage hospital according to Kizinger, are treated
and coaching from a partner, are all part like animals giving birth in a zoo
of this program - Rather than treat women in a labores que
- Best known for its patterned breathing patience subject to the decisions of other
techniques that teaches a woman to people, mothers need to understand and
focus on certain breathing patterns and a get what they really want out of the
concentration point such as a mark on a experience
nearby wall - As women learn how their bodies work,
- This technique helps blocks pain and the way hospitals work, human
messages to the brain relationships with the doctors and
101
midwives can be established so that the Birth Setting
kind of birth the mother needs can be - The couple are given the freedom to choose
negotiated their birth setting, and during prenatal classes
e) Conscious relaxation they are oriented with the facility
- Learning to relax body parts so that 1. Hospital Setting
unknowingly, a woman does not remain ● Ideal for all kinds of delivery especially for
tense and cause unnecessary muscle high risk pregnancies
strain and fatigue during labor ● There are some hospitals that offer labor,
- She practices this during pregnancy by birth, and postpartum care that can be
deliberately relaxing one set of muscles done in one single room which could
then another until her body is completely provide more ease and comfort for the
relaxed woman
- Her SO concentrates on noticing ● Skilled professionals attend to the woman
symptoms of tension such as wrinkled during birth, and emergency care is
brows, clenched fists, or a stiffly held arm readily available if the situation warrants it
f) Cleansing Breath ● The family and woman might be
- Done in all childbirth classes separated for 1 night during delivery, and
- Done in a deep and slow breath in the mother may sometimes feel that she
through the nose and out through your is not in full control of her experience
first lip mouth ● Not all hospitals have an obstetric suite
g) Effleurage but there is a certain tertiary hospital that
- Light abdominal massage done with just officer this
enough pressure to avoid tickling ● The mother goes into labor on the labor
- To do this, the woman traces a pattern on bed
her abdomen with her fingertips ● The mother is transferred from the labor
- The rate of effleurage should remain bed to the delivery room when due
constant even though breathing rates ● The stirrups are raised and the legs are
change raised so that the mother can give birth
- Serves as a distraction technique and on the same bed
decreases sensory stimuli transmission ● The radiant warmer is where newborn
from the abdominal wall, helping limit care is done after delivery
local discomfort
h) Focusing or Imagery
- Usually incorporated in Lamaze method
- It is done by using a special place
imagery or picturing to yourself on a
pleasant place and focusing on the sights,
sound, and smell of the special place
- Helps you distract yourself from the pain
and focus on positive feelings image of obstetric suite or the labor
and delivery room suite
102
2. Home birth ● The woman is expected to monitor her
● Women opt to homebirth with the desire own postpartal status independently
to: because of her brief stay in the healthcare
○ Give birth without medical setting
intervention such as pain ● Women remain at this facility 4 - 24 hrs
medications, labor augmentation, after birth because the woman can
labor induction, or fetal HR recover quickly because of the minimum
monitoring analgesia used
○ Give birth in a comfortable familiar
place surrounded by family, Alternative Birth Setting
○ Desire for freedom and control in ➢ Leboyer Method
the birthing process - Frederick Leboyer
○ Due to cultural and religious - Delivery room is kept quiet and dimly lit to
concerns spare the baby from sensory overload
○ Lack of access to transportation - Newborn is not held upside down and is
○ Home birth is given in a lower cost not spanked, and is not whisked away to
● Recommended for low risk pregnancies be examine after birth
● The assisting midwife should readily - Instead, the baby is gently placed on the
assess for any indications needing the mother’s stomach and lightly massaged
mother to be transferred to a hospital - The umbilical cord is cut only when it
3. Lying-in Birthing Centers stops pulsating
● Alternative birthing centers are wellness - After a few minutes with the mother, the
oriented childbirth facilities that baby is given a warm bath
encourage birth outside the hospital ➢ Waterbirth
setting while still being able to provide - Mother is to be submerged in water,
medical resources appropriate for any usually in a stationary or inflatable tub,
emergency that may arise, but extensive and will birth the baby in the water
emergencies that need surgeries are not - Proponents believe childbirth in water
offered results in a more relaxed, less painful
● The nurse midwife attends to the birth at experience that promotes a midwife-led
ABCs (airway, breathing, circulation) model of care
needs of the mother and fetus - However, safety has not been
● Before a woman is permitted to give birth scientifically proven and that a wide range
at an alternative birthing center, she is of adverse of neonatal outcomes have
screened for complications first to been documented such as increased
decrease the mortality rate of mothers mother/child infections, and the possibility
and infants in this setting of infant drowning
● Women are also encourage to deal with ➢ Unassisted Birthing
labor pain through nonmedical measures - Process of intentionally giving birth
● The stay of the woman at this facility may without the assistance of a medical birth
be brief so fatigue is most likely attendant
encountered after birth
103
- It may also be known as free birth, DIY ○ If there are any questions, we
birth, unhindered birth, or unassisted could address it
home birth ■ But for uncertainties, it is
best to refer them to their
Genetic Counseling genetic counselor
● Gives a couple information about how ➢ Karyotyping
genetic conditions might affect them or - Examining chromosomes through
the family karyotyping which allows the doctor to
● The genetic counselor or the other determine any abnormalities or any
healthcare professionals will collect the structural defects within the
personal and family health history chromosomes of the couple and of the
○ This information is used to newly formed fetus
determine how likely it is that the - Doctors look into the defects, size and
offspring has a genetic condition formation of the chromosome
● Genetic counseling while you are
pregnant can address certain tests that
may be done during pregnancy any
defective problems or conditions that may
affect the baby during infancy or
childhood to include
● This entails a vast field of medicine but us
nurses have responsibilities to do
especially in guiding the couple ➢ Maternal serum
undergoing the series of tests - AFP- 13th to 32nd week
1. Explaining to a couple what procedures - AFP is a glycoprotein produced by the
they can expect to undergo fetal liver that reaches a peak in maternal
2. Explaining how different genetic screening serum between 13th - 32nd week of
tests are done and when they are usually pregnancy
offered - The level is elevated with fetal spinal cord
3. Supporting a couple during the wait for disease
test results ● Usually more than twice the value
4. Assisting couples in values clarification, of the mean AOG
planning, and decision making based on - Decreased in fetal chromosomal disorders
test results such as trisomy- 21/ Down Syndrome
● We must limit our task in some ➢ Amniocentesis and Chorionic villus
procedures that may be invasive and sampling
requires informed consent - Amniocentesis which is done 14 - 16
○ It is not our responsibility to obtain weeks AOG is to obtain amniotic fluid
it, but to ensure that it is obtained sample for analysis
by the genetic counselor or the - Chorionic villi sampling is the earliest test
physician possible by fetal cells
- Sample is obtained by slender catheter
passed through the cervix to the
implantation site
104
placed into the amniotic sac through the
uterus
➢ Genetic Testing
- Preimplantation, genetic testing is used to
detect genetic defects and embryos
created through in-vitro fertilization (IVF)
before pregnancy
➢ Percutaneous Umbilical Blood - Preimplantation genetic diagnosis refers
Sampling specifically to when one or both genetic
- 17 weeks parents have a known genetic abnormality
- Done at least 17 weeks AOG and testing is performed on an embryo to
- Uses ultrasound to locate the umbilical determine if it carries a genetic
cord abnormality
- Cord blood is aspirated and tested - Done in-vitro
● Fertilization is done outside the
body, mechanically-assisted by in
the laboratory
● The doctors will scan first for
genetic defect prior to
implantation of the fertilized egg
into the uterus
Add-ons After Class

1. Any bleeding (may it be excessive or
➢ MRI slight spotting), the pregnant woman
- Does not use ionizing radiation like x ray must have a check-up with a physician
or ct-scan ● Advise them to go to their OB-GYN or the
- It uses a magnetic field and radio ways nearest hospital once they notice the
- Can last from 20 - 90 minutes depending bleeding
on the part of the body being imaged ● Danger signs
- Painless ○ Painful or not painful
- Not expected to cause any tissue damage ○ Excessive or spotting
- Can be prescribed for a pregnant woman ○ Any bleeding during any time of
or her developing baby the pregnancy
- Can image the pregnancy and give ○ Bleeding may indicate premature
healthcare providers a view of the labor or ectopic pregnancies
placenta, the baby’s brain, airway, lungs, ■ It could also indicate
and abdomen placenta praevia (placenta
➢ Fetoscopy is on the cervix)
- Utilizes a small camera or scope to
examine or perform procedures on the
fetus during pregnancy
- The scope is introduced through a small
incision on the mother’s abdomen, and
105
2. Within the first three months of ○ This can happen prematurely (still
pregnancy, vomitus is normal but if it's has not reached 37 weeks)
beyond 12 weeks (2nd trimester), it ■ This is an indication for
could be Hyperemesis gravidarum hospitalization
● This could cause nutritional deficiency ● After leaking, it’s almost always that labor
and dehydration pain will follow
● If nausea and vomiting persists beyond 6. Educate a pregnant woman when she
12 weeks, the pregnant woman must be is already at term that the labor pain
hospitalized for IV can go first or the gushing of clear fluid
○ For the rehydration of the mother will come first
○ We could not encourage oral fluid ● Regardless if there is a presence of pain
as it can induce vomiting and the woman is at term, the patient has
3. The terms “Leaking of membranes”, to immediately go to the hospital
“Leaking of bag of water”, “My water ○ This could lead to dry labor (all the
broke”, and Gushing of amniotic fluid water will be expelled)
are all the same ○ Can cause distress on the baby (if
● These terms are commonly used in the woman does not go to the hospital
OB ward immediately)
● Common indication of admission in the ○ This could also cause infection
client because the amniotic fluid is a
● Layman’s term of gushing of amniotic cushion from the vagina to the
fluid: “Nibuto ang tumatog” uterus, and when this breaks,
4. If the amniotic fluid gushes out and it there could be a possible entry of
the pregnant woman is still not due, it bacteria.
can be an indicating sign of premature ■ There are babies that
labor would undergo IV and
- During this time, there are instances that antibiotics, this is the
the mother still doesn’t feel any prophylaxis if the amniotic
abdominal pain fluid of the mother ruptured
5. If there is a leaking of fluid, it does not even before the labor starts
necessarily mean that it is the gushing 7. When the span of time between the
of amniotic fluid delivery of the child and the rupture of
● There are times that it is just like urine the amniotic membrane is long, the
● Sometimes it is just dripping or leaking of baby will be given a prophylactic
fluid or in other times, it is an antibiotic and will stay at the hospital
uncontrollable flow of fluid for a week to complete the 7 day
○ This can lead the mother to course of the antibiotic.
believe that she is experiencing ● This will be antibiotics will be given
urinary incontinence immediately and not when the newborn
● It can be determined that it is amniotic already developed a fever
fluid if it has been many hours that she
has been releasing fluid
106
8. Nitrazine paper is used to determine if 11. Preeclampsia is hypertension with an
the fluid that gushed out is amniotic increased protein in the urine but
fluid or urine. without seizure
● Nitrazine paper turns blue when it is in ● Magnesium sulfate is given to pregnant
contact with the amniotic fluid due to its women experiencing preeclampsia
acidic pH of 6.5 ○ Prevention of seizures
● Although, this is not routinely done in the 12. Mothers that are less than 16 years old
ER because an IE or a Vaginal and more than 35 years old are at
examination will be done instead by the high-risk in pregnancy
physicians. ● Women under 20 years old are already
○ Amniotic sac fluid feels hard considered high-risk as mandated by the
(“ice-water” in a plastic kind of department of health (DOH)
hard) ○ They are not allowed to give birth
○ If it is already ruptured, the in district hospitals, primary
physician will feel the head of the hospitals, and lying-ins
baby right away ■ This is also applied to
● Much less invasive and a more women that are 35 years
comfortable way to check for amniotic and older
fluid ■ They are only allowed to
9. Bipedal edema is normal if the woman give birth in secondary to
is at her third trimester. This is not tertiary hospitals
normal if it is an early edema (occurs 13. An Internal Examination (IE) will be
during 1st or 2nd trimester), and it is done to check the cervical dilation
already a danger sign ● If it is already at 8cm and above, they will
● If the edema is on the hands and face of not be referred anymore and they will be
the patient, it is already a severe edema asked to delivery the baby right away
10. Edema on the hands and face is an ● Although this is not advised to be
indication of edema and it may be a done
sign that the mother is experiencing 14. If the fetal movement in 2 hours is less
pregnancy-induced hypertension than 10 and more than 20, it is already
● In worst cases, this could cause an indication of fetal distress.
eclampsia ● There is either a decrease or depletion of
○ Seizures in pregnant women which oxygen inside the uterus
is fatal ○ Nuchal cord coil is also an
■ Most pregnant women important factor to this
experiencing eclampsia ● Once there is a sign of fetal distress (no
expire matter if it is preterm), it advised to take
○ Eclampsia does not stop unlike out the baby through cesarean section
seizures seen in children. 15. Having a history of miscarriages,
● A sign of hypertension is edema gestational diabetes, eclampsia, or
○ Anasarca (overall edema) is the preeclampsia are also indicators of a
most common sign of high risk pregnancy
pregnancy-induced hypertension
107
16. Teratogens cause fetal defects ● Compared to a young woman, their uterus
● Measles are the most common teratogens is just underdeveloped, however it has
○ The mother must live in a different more strength to carry a baby.
household when there is a family 19. Most women who are multiparity are
member that has measles, hypertensive due to their hormonal
especially when she is at her first imbalances and changes
trimester where organogenesis 20. Grand parity
occurs. Woman carrying multiple babies at once
● Cigarettes can cause Carbon Monoxide 21. Multi parity
poisoning of the fetus Woman carried babies multiple times
● Exposure of alcohol can cause Fetal 22. Only one sip or sips of wine is an
Alcohol Syndrome allowable amount of alcohol
○ This can also cause a CNS defect consumption for a pregnant or
● Category A medications must be taken by lactating woman
pregnant women as these have little to no 23. Kegel exercises are like “holding your
effect on the fetus urine”, it strengthens the pelvic floor
● With the presence of Herpes simplex virus 24. Unassisted birth settings are not
from the mother, the child cannot be encouraged in the Philippines but it is
delivered vaginally because this can be encouraged in other countries
transferred to the baby ● Home births and water births are now
○ A caesarean section will be done discouraged, this is strictly mandated by
instead the DOH
○ Herpes simplex I and II both have ○ These are discouraged due to
the same effect on the fetus increasing maternal deaths
17. Myth: When a mother’s cravings are ○ Women who give birth at home are
not satisfied, the baby will die. now penalized in the civil registrar
● Cravings manifest when there is a 25. The advantage with home births is that
nutritional deficiency in the mother the mother can decide who she can let
○ Examples: When the mother lacks in in her household while she delivers
fats, she will most likely crave the baby compared to the hospitals
lechon and when she has low where there can be restrictions.
sugar, she will crave sweets 26. A disadvantage of lying-in centers is
18. Grand parity and grand multiparity are that they cannot perform caesarean
a high risk since the uterus is already sections when complications arise
used multiple of times 27. There are mothers who prefer water
● It will come to a point that it will not be birth because it has a psychological
quite as strong anymore to hold a fetus effect
○ The uterus is “overused” and can’t ● The cold water has an effect when it
function (stretch and contract) comes to pain; It can divert or decrease
normally anymore. the pain
○ Abortions are most likely to ○ When there is a barrier between
happen due to this pain, tension, and fear. The pain
during pregnancy will decrease
108
28. A CTG can determine through its 33. In Vitro Fertilization
results if the mother will be undergoing ● The sperm and the egg cell of the parents
a caesarean section will be tested beforehand via a
mechanically-assisted incubation on the
embryo
○ As early as 17 weeks, we can
already test and check if there is a
genetic disorder on the embryo
● For the parents to make sure that their
children will not have a genetic disorder,
they undergo genetic screening
34. When it comes to genetic disorders,
image of a Portable CTG
there is no period during the pregnancy
29. Myth: Ingesting the placenta can
where you can correct it. It is
prevent “Bughat” or Postpartum
irreversible
Depression.
● This is because these are already
30. Myth: Delayed cord cutting will make
chromosomal disorders
the child smarter
● There are no interventions where genetic
● Delayed cord cutting is only important so
disorders can be corrected.
that the fetal circulation between the
35. Midwives and nurses are both capable
mother and the fetus will be complete
of assisting a mother during delivery.
○ It will only be cut when all the
36. The ideal intervention for a breech
nutrients from the placenta is
delivery is a cesarean section.
transferred from the baby and
● There are instances that there are
when there are no more pulsations
unprivileged mothers who cannot afford
or blood flow in the umbilical cord.
UTZ, they come into the hospitals with the
31. Paanakan centers and lying-in centers
baby’s feet or buttocks coming out first,
are the same
they are asked to deliver the baby
32. Genetic disorders will be informed to
normally.
the parents of the child
● Sometimes during delivery, the baby is
● Chromosomes can be screened
moved in the uterus in order for the head
(Karyotyping) for disorders
to come out first
○ A sample of the blood from the
○ This is not usually done because
fetus will be taken through
natural birth is highly encouraged
amniocentesis or percutaneous
in the hospital
umbilical blood sampling and the
37. Leboyer method is not encouraged or
chromosomes will be checked
available in the Philippines
through Karyotyping
○ The structures of chromosomes
will be examined
○ There may be a CNS or a critical
defect that will be found on the
child
109
uterus becomes stretched due to
LECTURE FOUR B fetal structure, pressure increases
CARE OF THE MOTHER AND THE to initiate labor.
FETUS DURING THE PERINATAL ● Prostaglandin theory
PERIOD: INTRAPARTAL CARE ○ Later in pregnancy, fetal
membranes and decidua increase
Labor in prostaglandin levels. This
- Series of events by which uterine hormone is secreted from the
contractions and abdominal pressure lower area of the fetal membrane.
expel a fetus and placenta from the uterus Synthesis of prostaglandin triggers
contractions, initiating labor.
Family centered nursing care is the best ● Rising Fetal Cortisol
approach for women in labor, new mothers. ○ Cortisol increase in fetus, triggers
a rise in maternal cortisol
Theories of Labor influences labor.
● Progesterone Deprivation theory
○ Progesterone is a hormone Assessment
designed to promote pregnancy. It ● EDB
is believed that the presence of ○ Estimated date of birth (ensures
this hormone inhibits uterine utility. already at term and ready for
Estrogen and progesterone delivery) does not need to be the
encourage the onset of labor. Rise exact date.
of estrogen controls rhythmic ● Start of contraction
uterine contractions. Rising fetal ○ Determines true or false labor
cortisone levels inhibit ● Show
progesterone production from the ○ Bloody discharge from the uterus,
placenta. Reduced progesterone with plenty of mucus. Originates in
production initiates labor. the loosening and expulsion of the
● Placental Aging theory mucus plug that blocks the
○ Advanced placental age cervical canal.
decreases blood supply to the ○ Inspection of vaginal discharges.
uterus. Triggers contractions, (Watery= needs immediate
starting labor. inspection)
● Oxytocin theory ● ROM
○ Oxytocin is released from the ● Allergies
pituitary gland, and the body ○ Must be reviewed as well.
becomes more sensitive to ● Past pregnancy
oxytocin. Smooth muscles of the ○ Multigravida women may have a
body (uterus) then contract. faster labor compared to women
● Uterine stretch/Pressure theory who have never given birth before.
○ Belief that any hollow organ, when ● Birth Plan
stretched to capacity will contract ○ Arranged by mother and attending
to expel its contents. Just like the obstetrician.
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● Vital signs - Assure the woman, this is not true labor
● Nature of contractions/ Pain scale d) Weight loss
○ Presence of pain levels, refer - As progesterone level falls, more urine is
accordingly. expelled resulting in weight loss. (1-3
● Urine MSCC pounds)
○ Clean catch, allow the patient to e) Ripening of the cervix
void for further inspection of the a) Ripening of the cervix: Pelvic
fetus. examination can only see this, internal
● Fetal Assessment sign only. Throughout pregnancy the
○ Leopold Maneuver cervix feels softer (earlobe
consistency), buttersoft, peaks
Clients should be changed into OB gowns and forward. Labor is very close at hand.
OB shoes.
SIgns of True Labor
Signs of Preliminary Labor a) Show
a) “Lightening” and persistent backache
- Relief of dyspnea, relief of abdominal
tightness, polyuria, shooting pains,
increased vaginal discharge.
- Mucus plug is expelled, blood is from

- Starts 10-14 days before labor actually pressure exerted from the fetus.
begins. This fetal descent changes - Pink tinge, (bloody show), women must
abdominal contour, lower and more be aware of this event to distinguish from
anterior. Relieves diaphragmatic pressure, abnormal bleeding.
lightens load. Preterm: may occur earlier. b) Rupture of Membrane
Multipara, not as dramatic. Shooting leg - Rupture of membrane is a sudden gush,
pain on sciatic nerve may occur or scanty slow slipping fluid from vagina.
b) “Nesting behavior” - Amniotic fluid continues to be produced,
- Increase of energy day of labor. Related in no labor is ever dry.
epinephrine release, decrease of - Intrauterine infections and prolapse of
progesterone triggers this. umbilical cord comes from rupture of
- Prepares women for labor ahead. membrane.
c) Braxton Hicks contractions c) Cervical dilation and Effacement
- Women notice these extremely strong - Cervical dilation and Effacement: cervix
contractions. may start to stretch, dilation.
- First-time mothers may think of these as - Prepares cervix for baby, (birth canal, and
actual labor contractions. vagina).
111
d) Uterine contractions
- True labor contraction: Feels like a
rubberband.
- Increase in pain over a few hours.
- Frightening in early labor, can vary in pain.
- Call OB immediately once labor begins. (5
minutes apart, but does depend on
woman’s pregnancy history)
True Labor vs. False Labor diameter. (Cephalopelvic disproportion:

TRUE FALSE most common cause of C section)
CONTRACTIONS CONTRACTIONS - Two types of Passageway: soft (cervix,
vagina, perineum)/ bony (pelvis)
Begin irregularly but Begin and remain ➔ 3 divisions of woman's pelvis
become regular and irregular
predictable
Felt first in lower back Felt first abd and

and sweep around the remain confined
abdomen in a wave
Continue regardless Disappears with

of level of activity ambulation or sleep
1) False pelvis: varies in size, no OB
Increase in duration, Do not increase in
frequency, and duration, frequency or significance
intensity intensity 2) True Pelvis: used in child-bearing,
canal in which the fetus must
Achieve cervical Do not achieve pass. (composed of pelvic inlet,
dilation cervical dilation
pelvic cavity, and pelvic outlet)
3) Linea terminalis: inlet, imaginary
Components of Labor (5Ps of Labor) line that separates both pelvises
1. Passage (Women’s pelvis)
- Refers to the route the fetus must travel Intrapartum Period
from the uterus to the cervix to the vagina True pelvis: (3 planes)
to the perineum 1) True conjugate (blue line)
- The fetus is the cause of disproportion, 2) Obstetric conjugate (red line)
not because the fetus’ head is too big. It 3) Diagonal conjugate (black line)
is presenting to the birth canal at less ➔ Access of birth canal
than its narrowest - True Conjugate (anterior-posterior):
Conjugata vera, measured accurately by
x-ray, adequate size11-11.5 cm or more.
- Obstetrical conjugate (antero-postero
diameter) Fetus should be able to pass
through this narrow diameter. Can be felt
with fingers upon examination, but is
112
estimated by 1.5 minus 2cm from the transverse diameter of the head to the smaller
diagonal conjugate. 12.5cm or more diameter of the maternal pelvis which is the
(adequate size) diagonal conjugate otherwise progress can be
halted and vaginal birth may not be possible, the
diameters of the fetal skull vary depending on
where the measurement is taking
● Fetus - AP skull; Pelvis - Transverse
This is the fetal head it has 7
bones 2 frontal and 2 parietal 2 temporal
and 1 occipital so the suture theses are
themed spaces in between bones or line
of junctions or closure between bones.
- The Sagittal Suture is the longitudinal
midline suture between 2 parietal bones.
This is the most important suture for this
is where it overrides or overlaps during
labor produces the biparietal diameter of
the head by 0.5 to 1 cm.
- The Frontal Suture its is an anterior
suture between 2 frontal bones the
coronal suture, anterior between the
frontal and the parietal bones
- The Lambdoid Suture between the
parietal and occipital bones the fontanal
there are two these are the two points of
intersections of cranial bones the
membranous spaces between cranial
bones during fetal life and infancy so first
is the anterior fontanel or the bregman it is
formed by two frontal bone and two
parietal bones, it is diamond shaped, it
measure 2.5 cm by 2.5 cm it asifies or
closes in 12 to 18 months of life
- Posterior Fontanel are the lambda it is
(Gynecoid pelvis above) formed by the union of two parietal bones
and one occipital bone, it has a triangular
shape it ossifies in 6 to 8 weeks or 2 to 3
Passenger (Fetus, Placenta, Amniotic fluid) months
The shape of the fetal skulls causes it to be wider
in its anterior and posterior diameter than its
transverse diameter
To fit through the inlet of the birth canal best a
fetus must present a smaller diameter which is
113
This is how the ones overlap during
molding (Left pic) and this is how the head
reshapes (Right pic) but this is just temporary.
The anterior and posterior this is wider

● Molding
than the transverse diameter of the head so
- An overlapping of skull bones along the
anterior posterior diameter this is measuring from
suture lines which causes a change in the
the front up to the posterior part of the skull while
shape of the fetal skull to one long and
the transverse diameter is parietal to parietal or
narrow a shape that facilitates passage
from one side to another side of the fetal head
through the rigid pelvis.
- It is caused by the force of uterine
contractions as the vertex of the head is
pressed against the not yet dilated cervix.
- The overlapping that occurred in the
sagittal suture line and generally the
coronal suture line can be easily palpated
on the newborn skull.
- Parents can be reassured that molding
will last a day or 2 and will not be a
permanent condition, there is a little
molding when the brow is the presenting
part because of the frontal bones are
fused, no skull molding occurs when fetus
is breached because of the buttock not
the head present first.
- Babies born cesarean birth when there
are no prepercedurely labor also typically For the anterior posterior or AP diameter
don't have molding of the skull we have three diameters to take note
of first is the occipital mental occipital meaning
occiput while mentum refers to the chin so the
occipital mental it is around 12.5 to 13.5cm from
occiput to the chin which is the widest AP
diameter.
Occipital frontal in the other hand its
11.5cm from occipital to mid frontal bone while
suboccipital bregmatic that is form the occiput to
the bregma that is 9.9 cm from below the occiput
to the anterior fontanel or bregma which is the
114
narrowest AP diameter of the head. This is the is not touching the chest but is in
most ideal presenting diameter during vaginal alert but in military position this
delivery. On the other hand transverse diameter position causes the next widest
we also have three biparietal diameter that is anterior posterior diameter the
around 9.5 cm that is the widest transverse occipital frontal diameter to
diameter bitemporal diameter that is around 8cm present in the birth canal a fair
while bimastoid diameter that is around 7cm . number of fetuses assume a
military position early in labor this
does not usually interfere with
labor however the later
mechanism of labor which is the
decent inflexion force the fetus
head to fully flex, this can still be
managed especially during the
descent of the fetal head into the
pelvis. Moderate flexion is also
called the military position
○ Partial extension a fetus in partial
flexion present the brow of the
● Fetal Attitude (Describes the degree of
head to the birth canal
flexion htat fetus assumes during labor or
○ Complete extension -
relation to the fetal part of each other, )
occipitomental the presenting
○ Good attitude -
part is the chin of the fetus, if the
suboccipitobregmatic fetus is in
fetus is in complete extension the
good attitude if it is in a good
back is arched and the nek is
flexion the spinal column is bowed
extended, presenting the occipital
forward , the head is flexed
mental diameter of the head to the
forward so much that the chin
birth canal this unusual position
touches the sternum, the arms and
usually presents to wide a skull
legs are folded on the chest, the
diameter to the birth canal for
thighs are flexed unto the
vaginal birth such a position may
abdomen and the caves are
occur in an otherwise in a healthy
pressed against the posterior
fetus or maybe indication there is
aspects of the thighs. This usual
less then usual amount of amniotic
fetal position is advantageous
fluid present are what we call
birth because it help the fetus
oligohydramnios which is not
present smallest anterior and
allowing the fetus adequate
posterior diameter of the skull to
movement space it also reflect
the pelvis and also it is because
neurological abdmornamilties in
puts the whole body into an ovid
fetus causing spasticity
shape occupying the smallest
space possible
○ Moderate flexion - occipitofrontal it
is a moderate flexion if it the chin
115
● Presentation This is the lower most part
in the pelvic inlet this part is felt in the
internal examination
1. Cephalic presentation its where
in the head presents first it could
either be:
Based on skull dimension if the fetus is in good a. Vertex where in the head
altitude it allows its smallest anterior posterior can be acutely flexed
diameter or suboccipitobregmatic messing 9.5cm b. Brow where in the head is
into the narrow pelvic of the mother and has moderately extended
higher success of vaginal delivery compared to c. Face where in the head is
the rest. Remember it was previously discussed acutely extended
that the fetus should pass through the narrowest d. Mentum where in the shin
plane of the pelvic inlet which is obstetric is presenting part
conjugate measuring approx. 10cm only - Cord prolapse
- Caput succedaneum
● Fetal lie it is a relationship of the long axis

of the fetus and the long axis of the ● Fetal attitude
mother’s uterus a) First: The fetus is in full flexion, it
○ Longitudinal It depends on which presents the smallest anterior
part enters the pelvis first posterior diameter which is the
■ Cephalic suboccipitobregmatic of the skull
■ Breech inlet in this good attitude or vertex
○ Transverse it is where the long axis presentation
of the fetus is perpendicular to the b) Second: The fetus is not
mother’s spine which shoulders well-flexed, this is called the
presents first military attitude and present
○ Oblique it is between the occipital frontal diameter to the
longitudinal and transverse line inlet or has a sinciput presentation
- Fetus impartial extensions where in there
is brow presentation and lastly the fetus
encompesses compete extension and
presents a wide occipital diameter with
the face presentation
116
● Cephalic Presentation
○ It is the most frequent type of
presentation occurring as often as
96% of the time with this type of
presentation the fetal head is a
body part that first contacts the
cervix the four types of cephalic
presentation is vertex, brow, face
or sinciput and momentum are
This is how caput succedaneum due to
mention already
the pressure of the fetal skull it could
○ The vertex is ideal presenting part
cause edema however this is just
because of the skull bones are
temporary it i also similar to
capable of effectively molding to
Cephalhematoma the other side of the
accommodate the cervix this
picture as it involved internal bleeding
exact feet may actually aid with
during childbirth however the main
cervical dilatation as well as
difference is where the blood pulls are
prevent complications such cord
located Caput succedaneum consist of
prolapse or portion of the cord
blood pool beneath the scalp a few
passes between the presenting
inches away from the parfum layer while
part and the cervix enters the
the symptoms are nearly identical Caput
vagina before the fetus during
succedaneum is not sever as
labor the area of the fetal skull that
Cefalohematoma it doesn't involve deep
contacts the cervix often become
bones or tissue damage within the skull
a dermatus from the continue
and is only limited to the scalp even
pressure against it This edema is
Caput succedaneum isn't something to
called caput csi damion in the
worry about if it doesn't go away on its
newborn that the point of
own further complications such as
presentation can be analyzed from
jaundice could possibly infections may
the location of the caput, so with
arise comparing Caput succedaneum
umbilical cord prolapse this is one
and Cephalohematoma it is one side of
of the emergency situation in
the skull while Caput succedaneum
OB-GYN
crosses the suture line
117
2. Breech presentation to maternal spine and the fetus
➢ Complete appears to lay claswise in the
○ Full breech uterus, this is how the shoulder
○ Feet and legs are flexed presentation would look.
and thighs, buttocks, and ● In cases that the fetus shoulder
feet presenting, presentation practices before is
○ Fetus squatting presenting that obstetrico secretion
favoring the most second performed the cephalic version but
stage of labor as the feet this is not commonly practiced
can be used as traction normally at this time so it's good
➢ Frank to know ECV or external cephalic
○ Incomplete breech version.
○ Thighs are flexed against at ○ It is a procedure that
the abdomen legs externally rotates the fetus
extending up to the from a breech presentation
shoulder as they lay on the to a cephalic presentation.
anterior chest ○ Successful version of a
○ Buttocks present the type breach in a cephalic
favored the most the first presentation allows women
stages of labor as a large to avoid cesarean delivery,
buttocks are good dilating as mentioned in shoulder
wedge presentation it is an
➢ Footling indication for cesarean
○ Could be either single delivery.
footling or double footling ● Also shoulder presentation is the
○ one foot or two feet largest contributing factor to the
presents they type easily incidence of postpartum morbidity
complicated by cord contrindication ECV exist either
prolapse. the procedure may put the fetus in
Take note that breech presentation the due pardi or when the procedure is
passage of meconium is not a sign of fetal unlikely to succeed clearly a
distress FHT is best heard upper quadrant above cesarean delivery is indicated for
the level of the umbilicus and with the findings of reason breech presentation
leopold's maneuver one and three ● ECV is contraindicated:
○ Placenta previa or
abruption placenta
○ Non reassuring fetal status
○ Intrauterine growth
restriction in association
with abnormal umbilical
3. Shoulder presentation artery
● Referring to the transverse line, the ○ Isoimmunization
fetal long axis lays perpendicular ○ Severe plecamptia
118
Recent vaginal bleeding
○ a) Cephalic - Occiput (O)
Significant fetal or uterine
○ ➢ The left occiput or LOA, the
anomalies occiput points towards the
➔ How ECV is done mothers left abdominal wall faces
down towards the maternal right
buttocks
➢ Most common favorable position
on the other hand OP or occipital
posterior position whether it's in
the right or left of the maternal
pelvis either left or right is a factor
of the prolonged labor
○ With the mother
experiencing much
- The fetus is in a position where in discomfort or back ache
vaginal delivery is not since the presenting part
recommended pushing or applying
- The doctor would externally rotate pressure towards the
the fetus as long as there is good posterior area
amniotic fluid index and there is no ○ it could cause severe back
record prolapse or abnormalities ache compared if the fetus
to assume a cephalic presentation is positioned on the ROA or
and resume vaginal delivery LOA comfort measure like
a. External Fetal Version side lying back rub
counters sacral pressure
during contraction could be
of help
b) Face - Mentum (M)
c) Breech - Sacrum (Sa)
d) Shoulder - Acromion (A)
● Fetal position
- The relationship of the denominator or
landmark of presenting part to the the
four imaginary reference of the mothers
pelvis, so always remember these four
presenting parts that we will be using in
taking down notes of the land mark, ➔ Quadrants that we refer the
pelvis, so this will refer to the
directions with regards to the
mothers orientation
○ Left anterior
119
○ Right anterior is on the anterior part or the front part of the
○ Left posterior abdomen LMT that's Left Mentum Transverse on
○ Right posterior the side of the abdomen LUMP that's Left
Let’s take this for example remember for Mentum Posterior its on the posterior part of the
that for vertex presentation or cephalic pelvis so this how the fetal would look like in
presentation we use O or occiput as our land these positions.
mark, so L refers left meaning were referring to
the left side of the pelvis O refers to occiput A
refers if it's in the anterior or posterior part of the
pelvis.
Example, the occiput we always refer to
the occiput which is the triangle shaped fontanel
so this is the symphysis pubis of the mother thats On the other hand for breech presentation
P and S refers to the sacrum meaning this is the we use scrum or sacral as our landmark so
view if the mother is in a lithotomy position, so look at here where the sacral located this one is
the occiput of the fetus is at the left side for the in the anterior position and this one has a
mother pelvis and it is one anterior its on front posterior on this side so the anterior is on the left
along abdomen of the mother compared to LOP side (Left most) so this was one is on the left side
or left is the left side occiput or the posterior but it is on the transverse parietal side so that
fontanel its on the posterior or back portion of LST Left Sacral Transverse(middle one) while Left
the pelvis so thats how we determining the fetal sacral posterior its on the left side the sacral is
position. your land mark.
On the other hand this picture at the
Center the occiput is at on the left side and on
the transverse thats why its LOT or Left Occiput
Transverse, so looking into to how fetus would
look like we always refer ot the occiput on the left
side of the pelvis meaning the occiput or the
back of the fetus its leaning towards the back ● Fetal lie
portion or in the side because this is transverse 1. Longitudinal
side of the abdomen and the fetus is facing to 2. Transverse
the other side or to the right side 3. Oblique
Another example now M refers to

Mentum so for face presentation we use M as
our landmark and M refers to Mentum. So for left
mentum here is the chin its on the left side and it
120
fetus is engaged fi it already has reached
downward up to the ischial spine
○ Floating
○ Dipping
● Degree of engagement
- The settling of the preceding part of the
fetus far enough in the pelvis so that it
● Station
rest on the ischial spines.
- The relationship of the presenting part of
○ Remember the most important
the fetus to the level of the ischial spines
landmark during labor delivery is
(looking at the pic) you can see there
the ischial spine so it is at level 0.
when the presenting fetal part is at the
○ This is the mid point of the pelvis
level of the ischial spine which is at 0
and the descent to this points
station which is synonymous to
means the widest part of the fetus
engagement.
the presenting part or the
- If the presenting part is above the spines
presenting skull in diameter in
the distance is measured or described as
cephalic presentation has passed
minus stations which range from negative
through the pelvis or the pelvis
one or minus one to minus 5cm.
inlet has been proven adequate for
○ So going up, this is counted as
birth.
minus 1 minus 2 minus 3 and so
- In a premepara non engagement of the
on and so forth so upon internal
head in the beginning of the labor suggest
examination as a doctor inserts
that possible complication such as
her finger the doctor will
abnormal presentation or position,
approximate how high the
abnormality of the fetal head or cephalic
presenting part, so if it's about the
disproportion exists in multi paras
ischial spines the doctor will
engagement may or may not be present
indicate or tell you that it is
at the beginning of labor the degree of
negative 1 minus 2 minus 3 and
engagement is established by vaginal or
etc. If the presenting part is below
cervical examination.
the ischial spine the distance is
- A presenting part that is not engaged is
stated as plus stations thats plus
said to be floating as similar to the photo
1, plus 2, plus 3 and so on at plus
(Below) while one has been deciding but
3 or plus 4 or plus 5 station the
has not reach the ischial spine may be
presenting part is at the perinimum
referred to us as deeping we only say the
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and can be seen if the vulva is The fetal skull is composed of several
separated and we call that as bones. The bones are united by sutures. The
crowning parietal bone, frontal bone, occipital bone are the
fetal bones. The sutures are the lambdoid,
sagittal, and frontal suture.
The fontanels are membrane-filled
spaces between the bones of fetal skulls that
allow for molding as the fetal head passes
through the birth canal. The anterior fontanel is
the diamond shaped structure at the front to the
fetal head. This is generally 3 cm x 2 cm and it
closes by 18 months after birth. The posterior
fontanel is the triangular shaped structure at the
back of the fetal skull or the occiput of the fetal
skull. This is about 1 cm x 2 cm and closes 6 - 8
weeks after birth.
Extra Video Coverage The location of the sutures and bones of
➔ Factors affecting labor (5Ps) the fetal skull are important in determining the
1. Passenger position of the fetal head and the maternal pelvis
● Fetus and placenta upon vaginal exam.
● There are several factors that
affect the movement of the
passenger or the fetus in the birth
canal such as:
○ Size of fetal head
○ Fetal position
○ Fetal lie
○ Fetal attitude
○ Fetal presentation
Fetal presentation is the part of the fetus

that enters the pelvic inlet first and leads through
the birth canal. There are 3 main presentations:
Cephalic (head first), Breech (buttocks, feet, or
both first), and Shoulder presentation. The
presenting part is the part of the fetus that is felt
when a vaginal exam is done. The most common
presenting parts in each presentation are occiput
(cephalic), sacrum (breech), and scapula
Image of a fetal head. (shoulder).
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Fetal lie is the relationship of the spine of
the fetus to the spine of the mother. There are 2
versions of fetal lie: Vertical and
Transverse/Horizontal. In the vertical lie, the fetal
spine is in line with the spine of the mother and is
seen in breech and cephalic presentations. When
the fetal spine is at a right angle of the maternal
spine, this is called a transverse lie. Vaginal birth
cannot be accomplished in this lie.
Fetal attitude is the relation of the fetal
body parts to one another. The normal attitude of
the fetus in utero is one in flexion in which the
back of the fetus is rounded so the chin is flexed This shows the different types of breech
unto the chest. The thighs are flexed on the presentation. Frank breech presentation in
abdomen and the legs are flexed at the knee. which the fetal presenting part is the sacrum. The
Variations from the normal lie can cause attitude is one in flexion except for the knees
problems during birth. which are extended.
Fetal position is the relationship of the Single footling breech has a longitudinal
reference point on the presenting part, either the or vertical lie and the presentation is an
occiput, sacrum, mentum (chin), or sinciput incomplete breech with the presenting part being
(deflexed vertex to the 4 quadrants of the the sacrum except for 1 leg extending and he
mother’s pelvis). Documentation of the fetal other is flexed at the hip and knee
position is accomplished using 3 letters. First is A complete breech has a longitudinal or
the location of the presenting part in the right or vertical lie and the spine has the same relation as
left side of the mother’s pelvis. Second is the the mother’s spine. The presenting part is the
letter of the presenting part of the fetus. The third sacrum with feet and is in general flexion attitude.
letter tells the location of the presenting part in In a shoulder presentation, the lie is
relation to the anterior or posterior of the mother. transverse or horizontal. The fetal spine is directly
In order to do this, the nurse must perform a opposite of the mother’s spine. The presentation
vaginal exam to locate the presenting part. If the is the shoulder and the presenting part is the
presenting part is the fetal head, then the nurse scapula. The attitude is flexion
locates the fontanel to locate the occiput.
If the fetal occiput and neck are to the
right side of the mother and the fetal occiput is to
the back of the mother determined by locating
the posterior fontanel, then the fetal position is
Right Occiput Posterior (ROP).
The nurse will also document station and
engagement.
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In a brow presentation, the widest part
of the fetal head which is about 13.5 cm at birth
is attempting to enter the pelvis. You can see that
there would be no way that the baby can pass
through the pelvis. This is the reason why an
attitude of flexion is important. The more flexed
and extended the head of the fetus becomes,
the wider the presenting part becomes, making it
difficult or impossible for vagina birth.
The measurements of the diameters of the fetal

head at term.
The biparietal diameter is most often
used to measure the diameter of the fetal head.
Biparietal diameter is documented as BPD
followed by the measurement.
image of the maternal pelvis

This is the way that station can be
documented. When performing the vaginal exam,
the nurse palpates through the ischial spines.
Station is documented by assessing the location
of the presenting part in relation to an imaginary
line between the ischial spines. It is measured in
cm above or below the ischial spines. If the
presenting part reaches the imaginary line, it is
documented as 0 station. One cm, 2 cm, 3 cm,
or more above the ischial spines is documented
as minus (-), while (+) if documented below the
ischial spines.
In a vertex presentation, you can plainly 2. Passageway
see the smallest diameter of the fetal head is ● Birth canal
entering the pelvis and should be able to pass ● Consists of
without difficulty ○ Bony pelvis
In a sinciput presentation, the ○ Cervix
measurement is 12 cm. This wide part of the fetal ○ Pelvic floor muscles
head is entering the pelvis. When you look at the ○ Vagina
fetal head entering the pelvis, you can see the ○ Introitus (external
pelvic bones overlapping the ischial spines. vaginal opening)
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● While the muscles of the Figure A is the inlet and the midplane. B is
pelvic floor play a role in the cavity of the true pelvis, and C is the curve of
the birth of the fetus, the the sacrum and the axis of the birth canal.
bones of the pelvis plays a The angle that the fetus must go to be
greater role as the fetus born goes down through the pelvis, then curves
must accommodate itself around the sacrum and then out.
through a relatively rigid
passageway
4 Basic Types of Pelvis

The gynecoid pelvis is the classic female
type of pelvis and the most common type found
in over 50% of women. The anthropoid and
android are less common, with the platypelloid
type being the least common. Mixed types are
The true pelvis which is the part involved more common than pure types.
in birth is divided into the inlet/brim,
midpelvis/cavity, and the outlet.
The soft tissues of the passageway

include the lower uterine segment, the cervix, the
pelvic floor muscles, vagina, and introitus. Before
labor begins, the uterus is composed of two
segments, the uterine body and the cervix. After
labor begins, uterine contractions cause the
lower segment to gradually distend to
accommodate the intrauterine contents as the
wall of the upper segments begins to thicken and
reduces its capacity. This causes downward
pressure on the fetus pushing it against the
Image of the different measurements of the pelvis cervix. The cervix thins or phases and dilates in
125
order to allow the fetal portion to descend the
vagina. The pelvic floor muscles assist the fetus
to rotate anteriorly as it passes through the birth
canal.
In figure A, you can see a normal uterus.
You can see as the uterus stretches and begins
to grow. You can see the active segment of the
uterus, the physiologic retraction ring, and the
passive segment along with the external os.
In figure B, you can see the uterine lining The effects of the primary powers on effacement
begins to thicken, and as it thickens, there is less and dilation.
capacity to accomodate the fetus. The muscle Effacement means the shortening and
then begins to push down to push the baby thinning of the cervix. The cervix is normally 2- 3
down into the lower segments of the uterus so it cm long and about 1 inch thick. As you can see
can come out through the vagine. in figure A, the cervix is not dilated or effaced.
As seen in the second figure in Figure A, As labor progresses, the cervix is
the cervix is much thicker. You can see it gets shortened and thinned until only a very thin edge
thinner and thinner until barely any cervix can be can be palpated once effacement is complete.
felt. In figure B, you can see a shortening and
3. Powers thinning of the cervix.
a. Contractions In figure C, it is becoming thinner and
b. Include both shorter. Effacement generally occurs before
voluntary and dilation in first time pregnancy (primigravida).
involuntary powers However, in subsequent pregnancies, effacement
c. Primary powers and dilation is usually present at the same rate.
(involuntary) Dilation occurs as the cervical opening is
i. Effacement widened. The diameter of the cervix increases
ii. Dilation from 1 cm to 10 cm or completely or fully dilated.
iii. Ferguson When you hear the labor nurse say the patient is
reflex “complete”, it means the patient is 10 cm or fully
d. Secondary powers dilated and ready to give birth as shown in
(voluntary) Figure D.
i. Once cervix is
dilated
ii. Bearing-down
efforts
Once a cervix has completely dilated, the

secondary voluntary powers begin, the mother
will get an intense urge to bear down and push.
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Position affects the woman’s anatomic in intensity, it is likely not true labor.
and physiologic adaptations to labor. There are
frequent changes in position that will help to
relieve fatigue, increase comfort, and improve
circulation. The laboring woman should be
encouraged to find positions most comfortable to
her.
With first time pregnancies, the body

starts to prepare for birth approximately two
weeks before term as the uterus sinks downward
and forward with a presenting part descended
onto the pelvis. This is known as lightening or Four Stages of Labor
dropping, where a woman experiences irregular a) First Stage
but strong and frequent uterine contractions ➔ Onset of contractions to full dilation of the
known as Braxton Hicks contractions. cervix
The vaginal mucus becomes more - Longer than the second and third stage of
profuse which is the result of congestion in the labor combined
vaginal mucous membranes, brownish or - Further divided into the latent phase, the
blood-tinged cervical mucus may be passed active phase, and the transition phase.
which is called bloody show. ➢ Latent phase
The onset of labor can contribute to a ○ more progression in any
number of factors including to changes in the placement of the cervix
maternal uterus, cervix, and pituitary gland; and a little increase in this
hormones produced by the normal fetal __
hypothalamus, pituitary, and adrenal cortex ➢ Active Phase and Transition Phase
probably contribute to the onset of true labor. ○ More rapid dilation of the
Many women may feel the Braxton Hicks cervix and an increase
contractions are true labor. Characteristics of true redness in the presenting
labor include strong, regular, rhythmic uterine part.
contractions that cause cervical dilations, if the b) Second Stage
woman can walk and the contractions decrease ➔ Full dilation to birth
- Two phases:
➢ Latent phase
○ Fetus continues to
passively descend to the
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birth canal and rotate in an Mechanism of Labor
anterior position as a result
of an ongoing uterine
contraction.
○ The urge to bear down
during this phase is not
strong (some women may
not feel it at all)
➢ Active pushing phase
○ The woman has a strong
urge to bear down as the Figure A: Posterior fontanel and the baby are to
fetus continues to descent the left side of the mother. The occiput showing
and presses on the stretch the posterior fontanel is to the anterior of the
receptors of the pelvic floor mother, and so its left occiput position, this is the
c) Third Stage LOA position.
➔ Birth of the fetus until delivery of the Figure B: In this LOA position, the fetal head
placenta begins to move down; it is becoming more flexed
d) Fourth stage Figure C: As it moves down it is moving even
- Lasts 2 hours post-delivery of the more, it starts to somewhat extend and as it
placenta extends it starts to internally rotate so that the
- When homeostasis is restored posterior fontanel is directly under the symphysis
- Parent-child bonding and attachment pubis.
begin Figure D: The fetal head is moved down and has
- Assessment for complications such as began to extend as it comes out of the vagina
abnormal bleeding takes place Figure E: The head is once again turned back the
way it was in Figure A.
Figure F: The fetal head turns again till it is
transverse and it’s coming so the rest of the fetus
can be born.
Fetal Adaptation
➔ These changes occur in:
a) Fetal Heart Rate
● Average: 140bpm
● Normal Range: 110-160bpm
● Earlier in pregnancy: 160bpm at 20 wks
AOG
● The rate decreases progressively as the
maturing fetus reaches term
● Temporary accelerations and slight early
decelerations in heart rate can be
expected with spontaneous fetal
movement, vaginal exam, fundal pressure,
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uterine contractions, abdominal contractions is increased by 51%
palpations, and fetal head compression above baseline of pregnancy
b) Fetal Circulation values a term
● Affected by maternal position, uterine ○ Cardiac output peaks about 10 to
contractions, blood pressure, and 30 minutes after birth and returns
umbilical cord blood valve to pre labor baseline within the
● Most fetus can compensate for the first postpartum hour
decrease in circulation that occurs during ○ The systolic and diastolic blood
contractions pressure increase during
● The umbilical cord usually ___ freely in the contractions and return to baseline
amniotic fluid however it can be levels between contractions
compressed leading to decreases in the ○ Supine hypotension occurs when
fetal heart rate and decreased circulation the ascending vena cava and the
of the fetus descending aorta are compressed
● There are changes in the chemoreceptors ○ WBC levels can also increase
in the aorta and carotid bodies ● Respiratory changes
immediately after birth ○ Hyperventilation cause respiratory
○ Changes include: alkalosis hypoxia and hypercapnia
■ Clearing the fluid from the and the unmedicated woman
air passages as the fetus action consumption almost
passes through the birth doubles in the second stage of
canal labor
■ Decrease in fetal oxygen ● Renal Changes
pressure ○ Voiding may be difficult during
■ Increase in the carbon labor because of tissue edema
dioxide pressure discomfort and analgesia and
■ Decrease in arterial pH embarrassment
■ A decrease in bicarbonate ○ Protein Urea 1+ is normal during
■ A decrease in fetal labor
respiratory movements ● Integumentary Changes
during labor ○ Integumentary changes are
c) Fetal Respiration evident due to the stretching of the
perineum, despite ability to
As a woman progress through stages of labor, stretch, minut tears in the skin
various body system adaptations cause her to around the vagina may occur
exhibit both objective and subjective symptoms ● Musculoskeletal changes
● Cardiovascular changes ○ In labor, musculoskeletal system is
○ During each contraction an stressed, diaphoresis, fatigue
average of 400 ml of blood is proteinuria, can possibly increase
emptied from the uterus into the temperature that go along with the
maternal circulation increased muscle activity
○ By the end of the first stage of
labor, cardiac output during
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○ The labor process and the woman ● Before doing this:
pointing her toes can also lead to ○ Make sure that the mother has
leg cramps already voided. It is very important
● Neurologic Changes to have an empty bladder to allow
○ Euphoria in early labor gives way comfort for the patient
to increase seriousness then to ○ Position her on the bed with flexed
amnesia (?) between contractions knees or dorsal recumbent
in the second and finally to elation ○ Have warm hands upon touching
and or fatigue after giving birth. the patient
○ Endogenous endorphins raise the 1. First Maneuver (Fundal Grip)
pain threshold and produce - Palpate the fundal area
sedation (?) - Check for breech or cephalic
○ Physiologic anesthesia of the ○ Usually if it is breech you will feel a
perineal tissues caused by soft globular and non-ballotable
pressure of the presenting part part on the fundus
decreases the perception of pain 2. Second Maneuver (Lateral Grip)
● Gastrointestinal changes - Palpate sides of the abdomen
○ The gastrointestinal motility and - Check for smooth, resistant, back, and
absorption of solid foods are irregular small fetal parts of the fetus
decreased during labor, nausea ➔ To check if it is cephalic or breech:
and vomiting are common. ○ Check which of these sides is a
● Endocrine changes fetal back and which side is a fecal
○ Metabolism increases during labor front
there is also a decrease of ■ Fetal back is smooth
progesterone levels and increasing ■ Fetal front is where nodes
levels of estrogen, prostaglandins, are felt: these are the
and oxytocin knees, arms, and elbows of
the fetus
Leopold Maneuvers ○ Once you have already determined
These are systematic methods of observation the fetal back, check for the fht by
and palpation to determine fetal presentation and auscultation.
position and are done as part of our physical ■ The fetal back is a best site
examination. to determine the fetal heart
● It is part of our nursing considerations to tone
always access the fetus by palpating the
abdomen.
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3. Third Maneuver (Pawlick’s Grip) abdominal muscles to push until the
- Palpate area just above the symphysis cervix is fully dilated.
pubis ○ Doing so impedes the primary
- Check for cephalic or breech force and could cause fetal and
- If it's cephalic: Check position and cervical damage.
mobility of head ● Braxton Hicks Contraction
- Grip check if it's ballotable - We should not be confused between true
- If it's not yet engaged, you will be able to contractions and braxton hicks.
feel the fetal head bounce in between - Braxton hicks is one of the premonitory
your fingers signs of labor
4. Fourth Maneuver (Deep Pelvic Grip) - Happens at 3 to 4 weeks before labor
- Palpate the midline downwards and just - It is considered as a false labor
above 2 inches from the poupart’s contractions
ligaments - Irregular
- Check for position and descent of the - Does not cause cervical dilatation
head including the degree of flexion - Can cause abdominal discomfort,
- Try to palpate from the sides however, it’s relieved by walking, enema,
simultaneously and clasp your hands at or any changes in activity
the symphysis pubis - It is generally painless but may be quite
- If you are able to smoothly reach uncomfortable
your hands together, this means ● Uterotubal junctions
the fetus is in good flexion - Uterine contractions like cardiac
- If there is resistance on one side, contractions labor contractions begin as a
this means the head is not fully pacemaker point located in the uterine
flexed myometrium near one of the uterotubal
junctions
Power (Uterine contraction and abdominal - Each contraction begins at a point and
muscles) then sweeps down over the uterus as a
● Another important requirement for a wave
successful labor is effective powers of - After a short rest period, another
labor. contraction is initiated and the downward
○ This is the force supplied by the sweep begins again.
fundus of the uterus and - In early labor, the uterotubal pacemaker
implemented by uterine may not operate in a synchronous
contractions which causes cervical manner.
dilatation and an expulsion of the ○ This makes contraction sometimes
fetus from the uterus. strong, sometimes weak, and
● After full dilatation of the cervix, the somewhat irregular.
primary power is supplemented by use of ○ This mild incoordination of early
secondary power source, which is the labor improves after a few hours
abdominal muscles. as a pacemaker becomes more
● It is important for women to understand attuned to calcium concentrations
that they should not bear down with their
131
in the myometrium and begins to ● Dilatation of the cervix which is
function effectively. the opening, widening, enlarging,
- In some women, contractions appear to increasing in diameter of the
originate in the lower uterine segment cervical os from 0 to 10 cm
rather than in the fundus ○ Contractions can cause
○ These are reverse and ineffective increase maternal blood
and may actually cause tightening pressure due to increased
rather than dilatation of the cervix. peripheral arterial pressure
● Primary and Secondary Power ○ It's very important to check
- Uterine contractions could be primary or maternal blood pressure in
secondary. between contractions for
a) Primary power accurate results
● Aka the uterine contractions itself ■ If we take BP during
● It is involuntary, rhythmical, regular contractions, this
activity of uterine musculature could cause or this
● Occurs intermittent by allowing for could result to
a period of uterine relaxation falsely high blood
between contractions causing pressure.
uterine and maternal rest and ● Myometrial contractions constrict
restoration of uteroplacental blood vessels, decreasing
circulation and sustained fetal uteroplacental circulation, thus it
oxygenation can decrease oxygenation to the
○ Always remember that fetus
every time the uterus ● Prolonged uterine contractions can
contracts, this will serve as cause fetal hypoxia, cervical
a stressor to the fetus dilatation during the first stage,
○ Thus, everytime the uterus contractions with pushing and
relaxes it is a time for the bearing down expel the fetus and
fetus to be able to fully the placenta during the second
accept oxygenation as and third stages of labor
blood flow towards the respectively.
uterus continues b) Secondary power
● The purpose of uterine contraction ● Refers to the maternal bearing
is to propel presenting part down or pushing.
downward and forward and ● The readiness for pushing of the
effacement of the cervix as well mother when highly effective.
○ Thinning out, pulling up ● This is effective during the cervical
shortening of the cervical dilatation at 10 cm or fully dilated
canal. when the fetal station is at +1, low
enough to stimulate Ferguson
Reflex
○ Ferguson Reflex is a
maternal involuntary urge
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to push, stimulated by ■ Because there will be a
stretch receptors in the separate contraction on the
pelvic floor. upper portion and another
➔ Correct pushing: contraction originating on
○ Take a deep breath as soon the lower part of the uterus.
as the next contraction
begins
○ Then with breath held exert
a downward pressure
exactly as though she were
straining a stool
○ Discourage prolong
maternal breath holding of
more than 6 secs during To perform labor watch is to religiously
pushing. monitor the pattern of contraction, taking note if
○ Support involuntary the client is already in the first stage of labor or if
pushing, grunting groaning, the labor is progressing. This is done by
exhaling or breath-holding monitoring the pattern of contraction.
for less than 6 secs ○ Phases of Contraction
○ Four or more pushes per a) Increment
contraction - “Crescendo”
● Bandl’s ring - Phase of increasing or building up
of contraction
- First phase
- The longest phase
b) Acme
- Height or the peak of contraction
c) Decrement
- “Decrescendo”
One of the problems with power or pathologic
- Phase of the decreasing
conditions with regards to uterine contractions is
contraction letting up or the last
the presence of Bandl’s Contraction ring.
end phase
● Pathologic retraction ring form when the
The length of time for each contraction must be
upper uterine segment is as active as the
examined.
lower uterine segment.
A: Start of one contraction
● Contractions originate from the fundus at
B: End of one contraction
the uterotubal junctions and it makes a
C: Start of another contraction
wave fashion expelling the fetus out of the
vagina, however, if there is a pathologic
● Relaxation time
ring (Bandl’s Contraction Ring) there will
● Uterine contour
be an abdominal indention ring.
○ This would signify impending
rupture of the uterus if not
Labor watch
managed
133
● Intensity ○ This refers to the relaxation, in this,
○ The strength of the contraction there should be a minimum of 2
during acme mins relaxation in between
○ Can be determined by palpation. contractions.
➔ Steps: ○ The time for checking maternal BP
1. Place ur hand on the fundus with and FHT
fingers spread ■ Delivering the fetal head in
2. Determine if it is mild, moderate, or precipitate labor or prevent
strong by judging the indentability lacerations and the time for
of the uterine wall during acme. maternal sleep and
● Strong: when the uterine relaxation during labor.
fundus is very firm and
cannot be indented with Electronic Monitoring (FHR Patterns)
fingers. Once we already know about contractions, it's
● Moderate: Difficult to time to coordinate your contraction with the fetal
indent heart rate.
● Mild: Fundus is tense but ● To monitor this, we use the
can be indented easily with Cardiotocogram Machine (CTG)
fingertips. ○ It is used during pregnancy to
● Duration monitor fetal heart rate and uterine
○ The length from the beginning of contraction
the increment (A) to the ○ It is most commonly used in the
completion of the decrement of third trimester and its purpose is to
the same contraction (B). monitor fetal well-being and allow
○ Expressed in seconds early detection of fetal distress
○ Maximum duration under normal ○ An abnormal CTG might indicate
circumstance is 80 secs found the need for further investigations
during the transition phase and and potential interventions.
the second stage of labor. ○ The device used in Cardio
○ Maximum normal duration of one Topography is known as the
contraction is 80 secs (A to B). Cardiotocogram or
● Frequency Cardiotocograph
○ Period of time from the beginning ■ It involves the placement of
of one contraction (A) to the two transducers
beginning of the next contraction ○ The Tocometer monitors the
(C) contraction, it is placed on the
○ Expressed every 1-3 minutes. fundus
● Interval ○ The Transducer monitors the
○ Period from the decrement (B) of heart rate
the first contraction to the ○ The CTG is assessed by the
increment of the second doctor or by the nurse to check if
contraction (C). there are any abnormalities.
○ Interval is B to C.
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● Baseline - minimum of 2 mins with and immature cardiac node
contraction function.
○ The Baseline fetal heart rate is ○ Variability can be recorded as
determined by analyzing the place absent, minimal, moderate and
of the fetal heart beats with the marked
minimum of 2 minutes obtained ■ Absent
between contractions. ● No amplitude range
○ A normal rate is 110-160 beats per is detectable
minute ■ Minimal - <5bpm
● Variability ● Is detectable but is
○ The difference between the 5bpm or fewer
highest and the lowest heart rates ■ Moderate - 6-25bpm
shown on a strip is one of the ● Normal
most reliable indicators of fetal ● The amplitude
well being. range is 6-25bpm
○ Variability is reflected on FHR ■ Marked - > 25 bpm
tracing and the slides irregularity ● The amplitude
are jitter to the wave range is greater
○ The degree of baseline variability than 25bpm
increases by 5-15 beats per ● FHT
minute when a fetus moves, it ○ Sounds like a clock ticking
slows when a fetus sleeps distinctly
○ If no variability is present, it ○ Other sounds that may be
indicates a natural pacemaker auscultated includes, maternal
activity of the fetal heart, which souffle and the fetal souffle
effects of the sympathetic and ● Maternal souffle - utérine bruit
parasympathetic nervous system ○ Is the sound produced as ---
of the fetus may be affected. moves in the uterine vessels and is
■ This may occur as a synchronous to maternal pulse
response to narcotics or ○ Maternal in origin and does not
barbiturates administered guarantee fetal life
to the woman in labor, ○ To check if its true FHT and not
which are used as pain Maternal souffle, the nurse counts
relievers. maternal pulse simultaneously as
■ But the possibility of fetal she auscultates FHT
hypoxia and acidosis must ○ The finding of synchronous
also be considered and sounds is an ominous sign, which
investigated. means, that it needs to be
■ Very immature fetuses reported immediately because this
show diminished baseline may signify fetal death
variability because of a ○ It should not be synchronous
reduced nervous system ● Funic souffle - through umbilical arteries
response to stimulation
135
○ Fetal in origin and this is one of the ● Oxygen should also
indicators or positive sign of be administered
pregnancy, it is produced as blood immediately
hisses through umbilical arteries. ● Periodic changes
○ It is synchronous with FHR and ○ Periodic fetal heart rate changes
guarantees fetal life are transient changes in FHR in
○ In fetal heart rates we also termed association with contractions
bradycardia and tachycardia ○ Non periodic fetal heart rate
■ Bradycardia changes are transient changes in
● is when the FHT is FHR not associated with
equal to or less than contractions, although they can
100 per minute for occur during contractions.
severe or less than ○ Acceleration
110 beats for ■ is an increase in FHR
minute for mild above the baseline level
cases with the return to baseline
● May be caused by within 10 minutes
multiple causes ■ An increase in FHR lasting
such as maternal longer 10 minutes is
hypotension, drugs, classified as an increase in
late fetal hypoxia, FHR baseline
congenital cardiac ■ Accelerations are the most
anomalies, common type of FHR
prolonged umbilical change
cord compression, ○ Deceleration
● And it is always ■ A distinct decrease below
important to the baseline with the return
administer oxygen to baseline within 10
immediately. minutes.
■ Tachycardia ■ Classified by their shape
● Means that the FHT and timing in relation to
is more than 180 uterine contractions
beats per minute for ■ May be Early deceleration,
severe cases or Late deceleration,
more than 160bpm Prolonged deceleration and
for mild cases Variable deceleration
● It may be caused by ■ In cases of deceleration,
maternal fever, one of the things that we
ammonitis, drugs, need to do immediately is
early fetal hypoxia, to perform fetal
neurologic resuscitation.
immaturity, or ■ If oxytocin is administered
dehydration. to the mother to facilitate
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contraction, immediately minute. One small box has a duration of
stop the oxytocin infusion 10 seconds
and hydrate plain fluids - The highlighted blue area refers to the
without any medication. baseline recorded by the CTG machine
● Provide oxygen at
4-6 liters per minute Electronic Monitoring (Fhr Patterns)
via face mask.
● Position the mother Moderate Variability
in a left lateral
recumbent position
and/or in a knee
chest position,
most especially for
prolapse, if present
a) Early deceleration - head
compression
b) Late deceleration - utero - This is a normal variability wherein there
placental insufficiency will be an amplitude change of 6-25 beats
c) Prolonged deceleration - cord per minute from the baseline.
compression/maternal
hypotension Early Deceleration
d) Variable deceleration - cord
compression
● Nursing management:
○ Oxygen
○ LLS
○ Knee-chest position
○ Hydrate
- This is early deceleration, or you will see

there a U shape
- FHR decreases but not below 100 beats
per minute. It occurs early before ---- (?)
characterized by gradual onset at the
beginning of a contraction and a slow
return to the baseline soon after the
contraction ends.
- This is how a CTG Strip would look like,
- So it is somehow like a mirror of the
each big square on the example CTG
contraction, so as the contraction peaks,
Chart is equal to 1 minute.
there will be a nadir or a deep in the fetal
- It is divided with a red line, so each box or
heart rate. This indicates fetal head
rectangle is counted or has a duration of 1
compression in early contraction, which
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stimulates the Vagus Nerve to decrease Prolonged Deceleration
FHR.
- Usually, our normal or benign, a reflection
of compression of the fetal head as it
enters the birth canal
- Usually needs nursing intervention.
Late Deceleration
- These are the decelerations that are a

decrease from the FHR baseline of 15
beats per minute or more and last longer
than 2-3 minutes but less than 10
minutes.
- They generally reflect an isolated
occurrence but they may signify a
significant event such as cord
compression or maternal hypotension. For
these reasons, they must be reported and
documented
- It is usually gradual in onset - If a deceleration last longer than 10
- Nadir in deceleration usually occurs after minutes, it is considered a baseline
the peak of the contraction change
- Nadir , the lowest point of the fetal heart
rate, its after the peak Variable Deceleration
- FHR decreases rarely below 100 beats
per minute. It occurs late after acne (?)
usually begins as contraction peaks and
does not return to baseline by the end of
contraction.
- Caused by uteroplacental insufficiency or
compromising blood flow from the
placenta to the fetus, which can cause
fetal distress.
- This is an abnormal or ominous sign ● Variable Deceleration has V or W shape, it
which requires nursing action or fetal occurs in any point but most frequently
resuscitation, such as discontinuing the after rupture of membrane, when there is
oxytocin if on, position the mother in left less amniotic fluid to provide a protective
lateral recumbent, give oxygen for mask, cushion around the cord
increase hydration or run plain IV faster ● With an abrupt swings in FHT and rapid
and prepare for delivery as indicated return to baseline, believed to be caused
mostly by cord compression may also be
138
caused by fetal movement or head health or the biparietal diameter passes
compression, loops of umbilical cord through the pelvic inlet, and head is fixed
around the fetal neck or shoulder a cord in the pelvis
through knot or cord prolapse - As mentioned before, fetus is in a military
○ It’s usually not an ominous sign position, there is still a chance for it to be
○ Requires continued nursing fully flexed as it engages down into the
assessment maternal pelvis
● Descent
Nursing Action - This is the first requisite for the birth of the
➔ Change maternal position to relieve baby
pressure on cord - The progression of the fetal head through
➔ but if there is no improvement, administer the pelvis.
oxygen - It may occur earlier in nulliparous women
➔ Stop the oxytocin if infusing before labor, it usually begins with
➔ Prepare for internal examination to identify engagement in a multiparous woman
cord prolapse - The degree of descent is measured by
station
- In addition to FHR, the fetal well-being ➔ There are 4 Forces to Descent:
can also be engaged by evaluation of fetal ● Amniotic Fluid pressure, thus
movement in labor, there should at least some --altruism elect (?) to rupture
be 3 movement per hour the bag of water by amniotomy to
- Passage of meconium on non-breech enhance labor progress
presentation, which is cephalic and ● Direct pressure of the contractions
shoulder presentation, is a danger sign of from the fundus
fetal distress ● Effects of the contraction on the
Cardinal Movements of Labor diaphragm and abdominal muscle
- During the labor process, the fetal head contraction
and body must change in position to ● Fetal body extension and
accommodate the irregular maternal straightening
pelvis ● Flexion
- This positional changes are returned - Flexion is the mechanism that
cardinal movements, otherwise called the occurs when the head meets the
mechanisms of labor resistance from the cervix, pelvic
Engagement, Descent, and Flexion floor and pelvic walls, causing the
head to flex, so that the chin is
brought in contact with the chest
- Results in the smallest
anterior-posterior diameter of the
fetal head, which is the
suboccipitobregmatic diameter,
that is 9.5cm to present into the
● Engagement
maternal pelvis
- This is a mechanism by which the
greatest transverse diameter of the fetal
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Internal Rotation suctioned gently and shallowly using a
bulb syringe in order to prevent
meconium aspiration.
- The duration of the extension is controlled
by the attending practitioner, breaking all
the bag of water is done if it has not been
broken to prevent aspiration of fluid. An
episiotomy may be done by the physician
to prevent tearing of the perineum.
Shorten the second stage or lessen
trauma to the fetal head
- A clean surgical perineal incision
- This mechanism is the turning of the fetal episiotomy is done primarily to prevent
head from left to right, aligning it with a laceration.
long axis of the maternal pelvis and - Episiotomy allow a bigger opening and
causing the occiput to move anteriorly allow more room for the head to be
towards the synthesis pubis expelled
- The face will now be facing the sacral ○ The median episiotomy is not
area of the mother commonly done as it easily
- The fetal skull rotates from transverse to extends to the anal region,
anterior posterior at pelvic outlet increasing risks of asepsis
associated with descent Restitution and External Rotation
- After the internal rotation, the occiput is
just under the synthesis pubis
- Not accomplished until the head is
engaged, it occurs mainly during the
second stage of labor ● Restitution
Extension - It is after the head is extended, the
neck is twisted so that the head
needs to externally rotate to
realign with the long axis of the
fetus.
- Since the shoulders are still in its
transverse position, so we need to
- This is the delivery of the head in vertex rotate the head, for it to be aligned
presentation or when the head leaves the with the body
pelvic outlet ● External Rotation
- There is gradual emergence of the occiput - After it is aligned, external rotation
until under the synthesis pubis, followed happens next, as a continuation of
by the face and then the chin. restitution, the shoulders align to
- It is very important to note that as soon as the anterior posterior diameter,
the head is out, even before the chest is causing the fetal head to continue
born, the mouth and then the nose are to rotate, the trunk navigates
140
through the pelvic cavity with the hypotensive syndrome or vena cava
anterior shoulder descending first syndrome. This would avoid the supine position
- First thing that is delivered is the as well.
anterior shoulder, so the doctor
The optimal position may vary and may range
would pull the head downward
from sitting to squatting to semi-reclined position
first to deliver the anterior
or to ambulating posture. If the bag of water is
shoulder, and then upward to
intact, the client may still ambulate. However, if
deliver the posterior shoulder.
the bag of water has ruptured already, she may
Expulsion
still ambulate provided that the station is at least
Station 0 or the plus stations to prevent cord
prolapse. If with an intravenous line, a movable
pole should be used to allow ambulation, if so
desired and if not contraindicated.
In the choice of position for labor, consider the

maternal, physical, and psychologic needs and
the fetal well-being.
- Lastly is the Expulsion, or the final birth
of the baby, gentle but firm downward For the second stage of labor or the actual fetal
pressure traction of the head is done to delivery, the mother should assume a fetal
deliver the anterior shoulder, then the position which is commonly used and favors the
head is gently raised to deliver the care provider. Ensure that there is equal height of
posterior shoulder and the entire body the stirrups, the stirrups should be padded, and
follows without much difficulty. there should be simultaneous placement of the
- The head is the biggest part of the baby. legs on the stirrups. Avoid any pressure on the
After the head passes out, the rest of the popliteal region to avoid complications.
body follow with no difficulty
- When the entire body of the baby
emerges from the birth canal, birth is
complete. This is the time of birth
recorded and entered in the birth
certificate
3) Position
There are different positions assumed by the 4) Psyche (Psychological response of the
mother or the client during the different stages of mother)
labor. A pregnant woman’s general behavior and
influences upon her also affect labor progress.
During the first stage of labor or while waiting Some factors that may favor a meaningful
for the full dilation of the cervix and effacement, positive or negative event were identified by
the mother would assume a left lateral recumbent Clark and Alphonsus.
position which is the most comfortable and best
for fetal well-being as this prevents supine
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First is Cultural Influences, Integrating is very important to provide
maternal attitudes, How a particular society therapeutic communication.
views childbirth, Expectations and Goals for ○ Anticipation of pain can also
the labor process whether realistic, increase emotional tension which
achievable or otherwise, and Feedback from can increase pain perception.
other people participating in the birthing
process as well could be very beneficial. Even though perception of childbirth pain is
greatly influenced by a lot of factors such as
psychosocial factors, there is a physiologic basis
for discomfort during labor.
Pregnant women psychological response to

uterine contractions
Fear and anxiety affect labor progress. A woman
who is relaxed, aware of, and participating in the
birth process usually has a shorter, less intense
labor.
Other factors that affect psychological response
of the mother include:
● Childbirth preparation process or having
childbirth classes
○ Considered as a valuable
tranquilizer during the birth
process.
○ Decreased need for analgesics in
labor is proven to happen if the
client had childbirth classes.
● Support system
○ The husband’s presence in the
Labor & Delivery Unit can provide
emotional support which can lead
to less anxiety, less emotional
tension, and less pain perception.
○ The attending nurse should
provide a supporting and caring
environment, respect the client or
family’s needs and attitudes, and it
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The Labor Process fetal head and the pelvis of the
Stages of Labor mother.
1. Dilatation and Effacement - A woman who is psychologically
This begins in the initiation of two labor prepared for labor does not tense
traction and ends when the cervix is fully much during contractions, latent
dilated phase contractions cause only
- Primigravida: 12.5 hrs minimal discomfort and woman
- Multigravida: 7.5 hrs can do or should continue to walk
The first stage of labor is divided into and preparation for birth
three phases: b) Active Phase
a) Latent Phase - Cervical Dilation: 4-7cm
- Cervical Dilatation: 0-3cm - Duration: 40-60 secs
- Duration: 20-40 secs - Frequency: q3-5 mins
- Frequency: q10 mins
- Latent or preparatory phase starts - In an active phase of labor cervical

on the onset of regular uterine dilation occurs more rapidly
contractions and ends with rapid increasing for 4 to 7 cm.
cervical dilation. - Contractions grow stronger lasting
- Contractions during this phase are 40 to 60 sec and occurring
usually mild or short lasts 20-40 approximately 3 to 5 mins.
sec, cervical effacement occurs in - This phase will last for about 3
cervical dilation 0-3cm this phase hours in new parous patients and
lasts 6hrs in a newly parous 2 hours in a multiparous patient
patient for .5 hours in a and an increase of the vaginal
multiparous patient. secretions is also observed.
- A woman who enters labor with a - Perhaps spontaneous rupture
non ripe cervix will have a longer membranes may also occur during
than latent patient although the this period.
women denied Mg shot point we - This can be a difficult time for
need to consider giving an Mg women because contractions
shot too early may prolong the grow so strong, last longer and
latent phase another reason for begin to cause true discomfort.
latent phase is cause of cephalic - It is an exciting time because a
pelvic disproportion or CPD. woman realizes something
- This condition is observed when dramatic is happening and it can
there is disproportion between the be a frightening time as she
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realizes that labor is truly mins before she enjoyed having
progressing and her life is about to her forehead wiped with a cool
change forever. cloth now she wipes the wipers
- During this period a maximum hands away, another a moment
dilution proceeds at its most rapid before she enjoyed having her
pace averaging 3.5cm per hours in partner rub her back now she may
a newly parous patient and 5 to 9 resist being touched push that
cm per hour in a multiparous person away.
patient, administration of analgesic - Her focus at this time is entirely
at this point has as little effect on inward on the task of birthing the
the progress of labor. baby.
c) Transition Phase ➢ Vaginal Examination (Internal Examination)
- Cervical Dilation: 8-10 cm ○ Dilation
- Duration: 60-80 secs ○ Effacement
- Frequency: q2mins ○ Station
- During the transition phase ○ Presentation
contraction reaches its peak of ○ ROM
intensity occurring every 2 to 3 This procedure is to monitor labor,
mins with a duration of 60 to 80 particularly the descent of the baby,
sec, this causes the maximum outcome of dilatation and effacement,
dilation of the cervix, cervical Station, Presentation and also the status
dilation at this time is 8 to 10 cm. of bag of water is also often heard upon
- If the membrane was not internal examination. This is best
previously ruptured by amniotomy, performed during contraction and should
they will rupture in the role of be kept at a minimum to prevent infection.
dilatation by the end of this phase ➢ Amniotomy (Artificial rupture of
full dilatation cervical effacement membrane or AROM)
is achieved. Nursing considerations:
- A woman at this phase may ● Empty bladder
experience intense discomfort so ● Prepare instruments: amnio hook
strong that for some women it may or amnio allis
be accompanied with nausea and ● Position: Dorsal recumbent
vomiting because of the intensity ● Perineal prep
and the duration of the ● Monitor FHR immediately
contraction.
- Women may also experience loss
of control anxiety, panic or
irritability.
- The sensation in her abdomen
may be so intense it may seems
labor has taken in charge of her an
example of this change of
behaviour is when a women few
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● Another procedure often surges during pregnancy who does not medically
the transition phase is amniotomy also need the intervention.
called artificial rupture of the membrane - Elective labor might be
or AROM. appropriate in some instances
● This is done by intentionally rupturing the indications would include, rupture
amniotic fluid of the baby to facilitate of membrane a bag of water has
descent and this is often performed by an ruptured and is not initiated labor
obstetrician. and going beyond the term period
● There are nursing considerations we need of pregnancy.
to look into and prepare prior to the - Ways to do this include cervical
procedure. ripening, amniotomy and infusion
○ Enter the bladder of the patient of oxytocin through IV similarly on
and prepare instruments to make how we do the oxytocin challenge
sure they are sterile (Instruments test except for therapeutic goal to
like the amnihook or an amino achieve labor.
allis) - First is the cervical ripening
○ Position the patient at dorsal which can be done in many
recumbent and ready for perineal ways, stripping the
prep. membrane is a way to
○ After the procedure, monitor right induce labor it involves the
away or immediately for the fetal doctors ripping the gloved
heart rate any change. fingers between the thin
➢ Induction of Labor membrane of the amniotic
○ Indications: sac in the uterus, It is also
■ Pre-eclampsia known as membrane
■ Prolonged rupture of sweep. This motion helps
membrane separate the sac it
■ Post maturity stimulates prostaglandins
○ Cervical ripening compounds that act like
■ Stripping of membrane hormones and can control
■ Prostaglandin insertion certain processes in the
○ Amniotomy body. One of these
○ Oxytocin IV infusion processes is labor, in some
■ Monitor for cases the doctor can
hyperstimulation gently stretch or massage
- This stimulation of uterine the cervix to help it start
contractions during pregnancy softening or dilate.
before labor begins on its own to - Medications can also be given to
achieve vaginal birth. help in softening dilatation of the
- Elective laboring abduction is cervix, Oral or vaginal suppository
initiation of labor for convenience drugs such as ibprin and other
and in a person with a term prostaglandin are also commonly
used to ripen the cervix.
145
- Lastly oxytocin IV infusion so the administer oxygen at 4.6 liters per
piggy back here (on the right) min via nasal cannula and closely
would signify Oxytocin IV infusion, monitor the fetal heart rate. In
use oxytocin with great caution for cases of cord prolapse you can
fetal distress can occur from hyper position the mother in a
stimulation and rarely uterine trendelenburg position or knee
rupture can occur. chest positon.
- Multiparous women are at higher
risk for uterine rupture, the
affected does of oxytocin varies
greatly between women cautiously
administering oxytocin in IV fluids
it may be dextrous or normal c
line. Gradually increase the rate IV
infusion until good labor is
established, maintain this rate until
delivery. The uterus should
contract between contraction,
make sure the woman is on her
left side, record observation on a
partograph every 30 mins, take
note of rate of infusion of oxytocin ➢ Augmentation of Labor
note in the changes of arm Labor augmentation promises helping
position can alter the flow rate. along slow or stalled labor that has
- Next duration and frequency of already begun, it means giving labor that
contractions, lastly is fetal heart has already started a boost if the labor or
rate, you need to listen every thirty the contraction become irregular in
mins always after immediately a frequent or stop altogether or if the cervix
contraction, is a fetal heart rate is is not dilating any further ways to do this
less than 100bpsm stop the is similar to inducing labor.
infusion. Successful labor have
three contractions in 10 mins with
at least 2 mins interval
hyperstimulation is characterized
with 5 contractions in 1 min prior
to 80 sec short or less than 2
mins. In cases of hyperstimulation
your primary nursing consideration
is to stop the oxytocin and round
the other IV main line (Pic on the
left) as order this is to flush out the
oxytocin. Position the mother to
the left lateral side lying and
146
➢ Nursing Management During Latent ○ Monitor the progress of labor
Phase including the FHR and vital signs
As we know that our possible nursing so when we say progress of labor
problem for this patient is this instales labor watch so
○ Reduce anxiety so we need to monitor the duration frequency
focus our management on how to and the intensity of labor.
reduce the anxiety level of our ○ Food and fluid intake Latent phase
patient is the longest phase from the three
○ Establish rapport and carry-out phases of the the first phase labor
hospital admission procedures to so we need to provide food and
make our patient comfortable we fluid for our patient
need to orient our patient on the ➢ Nursing Management During Active
physical set up of our area Phase
○ Carry out initial assessment ○ It is important to Continue to
○ Render physical preparation monitor uterine contractions, FHT,
○ Enema as prescribed and vital signs
○ Provide comfort measures ○ Place client on Sim’s left positon
○ Provide necessary health to prevent supine hypotension
teachings syndrome
■ Ex: Breathing techniques ○ Coach on breathing techniques
During the latent phase the mother ○ Monitor for the spontaneous or
is still comfortable and cooperative artificial rupture of membranes
this is the best time for us to give ○ Comfort measures
health teaching particularly the ○ Administer IV fluids and
breathing techniques medications as ordered
○ Promote bladder care ○ Promote support person (DOULA)
■ Full bladder: resonant ○ Support pain management needs
■ Empty: dull ➢ Nursing management during transition
If the patient is still able then we phase
will let our patient void time to time ○ Encourage mother to rest in between
but if the patient is confined to the contractions This is to decrease
bed then we offer a bed pan for fatigue and to conserve energy
her. In assessing the bladder the ○ Monitoring of vital signs and FHT for
patient upon percusion a full any deviation from the normal that
bladder would sound resonant and appropriate management can be
an empty bladder would sound done
dul. ○ Observe for the onset of the second
○ Promote proper position Part of stage of labor like example
the discomfort of pregnancy is complaints of pressure on the rectum
supine hypotension syndrome or and bulging perineum or crowning thi
Vena Cava syndrome so position si sto prevent precipative delivery
client on proper position ○ Prepare for the delivery procedure
147
➢ Pharmacologic Interventions narcotics is the increase
○ Goal: relax and relieve discomfort sleepiness or drowsiness, so it is
with minal systemic effect on very important to facilitate the
uterine contractions client especially abulating the toilet
○ Analgesia this is used to reduce rather it is best provide bedpan for
awareness of pain them than ambulating.
○ Anesthesia it causes partial or b) Lumbar Epidural Block
complete loss of pain sensation (Bupivacaine) this medication or
○ Drugs that easily cross placental these kind of management numbs
barrier from the waist down and can be
■ <600 Da (Molecular used in both vaginal and cesarean
Weight) delivery. In an epidural a fine tube
■ Fat-soluble medications is inserted in the woman’s back
○ Drugs that slowly crosses specifically into space between
placental barrier the spinal cord and its outer
■ >1000 Da (Molecular membrane.
Weight) - This is done whole the woman is
■ Protein - binding drugs laying on her side or sitting up and
a) Narcotics most common leaning on something once the
management for the clients - tube is in place anesthesia
Meperidine (Demerol) it can cause medication is delivered through
nausea and vomiting so its ideal the tube into the space on the
given 3 hours before birth, it can woman's back sometimes epidural
reduce gastric motility, these medication may be reduced or
drugs can be given intravenously stopped when the woman needs
injecting into the muscle, the to push, to make that stage labor
intravenous administration more effective.
provides pain relief faster then the - Low blood pressure or mother’s
IM. blood pressure could drop
- If a narcotic is provided as an suddenly posing a risk to the
injection it is better to have mother or baby because of this
frequent injections of small doses the mothers blood pressure will be
rather than on injection with a monitored during the time the
large dose. epidural is placed. If the mother
- Large doses of a narcotic or a develops low blood pressure
doses that are given close to the intravenous fluid or medication will
time of delivery can make the fetus be given to counteract the
too sleepy to suck after they are problem and with regards to the
born and can lead to breathing fetus then we will perform fetal
problems especially during the first rotation in case of deceleration
few hours of life. due to low blood pressure and
- The one thing you need to monitor since the mother’s ability to sense
for clients taking or receiving that their bladder is full then we
148
need to perform bladder care
specifically straight catheterization
to facilitate an empty bladder and
lastly to couch the mother in
pushing through contraction is not
affected by lumbar epidural block
however the mother sensation to
the contraction may be lessen.
● Causes hypotension: fetal
bradycardia
● Does not affect uterine
contraction
● Monitor systemic
manifestations
● Nursing considerations:
■ Fetal resuscitation
■ Bladder care: Straight
catheterization
■ Coach in pushing
c) Local infiltration this is how it
looks like the most common drug
used in these kind of management
or pharmacologic management is
lidocaine this is also called the
pudendal block are a safe and
simple type of pain relief in - This is how epidural block and
childbirth. A pudendal block along spinal block looks like so the route
the needle is inserted to th is different. A spinal block can be
evaginal wall where the is a nerve given before vaginal delivery or
called the pudendal nerve. cesarean section in a assisted
Anesthetic or lidocaine is injected vaginal delivery forceps are
through this needle. Pudendal vacuumed and obstruction is
block reduce pain but do not needed to ease the babies delivery
eliminate it entirely, so we do this from the birth canal.
or the doctor would infiltrate the - A low spinal block can be used to
medication into the vaginal wall completely block sensation under
specifically the fourchette before the waist. When the cervix is fully
making an incision or what we call dilated and the baby is ready to be
the episiotomy delivered for cesarean section the
dose for anesthetic is given higher
than for additional vaginal delivery.
- The spinal block is injected in one
single dose into a part of the
149
spinal column, the mother lays on This can be avoided in the mother
her side with her back arched and in general anesthesia as close time
her neck flex in order to receive to delivery possible this reduces
the injection, the pain relieving the amount of drugs the baby
effect of a spinal block are almost receives, the other major risk of
instance and they last for about an general anesthesia or GA is the
hour and an half hour after the possibility might vomit and ask
injection, spinal block anesthesia aspirate or inhale the vomited
is very affected by blocking pain material this can cause the mother
lastly general anesthesia which to develop breathing difficulty and
puts the woman to sleep is used serious problems, sometimes
occasionally for emergency for women are asked to refrain from
cesarean section and for other eating and drinking during labor
surgery as require general just in case they might have
anesthesia works rapidly and surgery during general anesthesia.
therefore used no time wait for However fasting does not reduce
original bloc to take a affect the risk to the mother because the
intravenous general anesthetic stomach juices themselves are
drugs are easy to administer work acidic and can cause problems
extremely fast and can be when inhaled. If you do need GA a
controlled to allow it for recovery. tube will be deeply inserted
d) Spinal Anesthesia through the mouth through your
● Used for CS/ emergency cases throat and to reduce the chance of
● Nursing considerations: aspiration.
○ Monitor for spinal - Upon admission to the labor unit it
headache: hydrate, is important to greet and introduce
hydrocortisone, cold ourselves to the client. We then
compress on forehead admit the client and orient the
○ Fetal resuscitation physical setting, review common
○ Lie flat with pillow under procedures so the patient will
the head know what to expect. Take the
e) General Anesthesia history such as gravidity, parity,
- For Cesarean Section EDC, last meal, allergies, onset of
- Risk for aspiration, intubated labor this includes frequency,
This is how a client looks like duration of contractions, status of
when they are placed in general bag of water, and intent to
anesthesia, the two major risk breastfeed. We also assess the
taking general anesthesia however client's knowledge about labor
one is that because the mother is whether or not she had childbirth
sedated the baby can be sedated, preparation, take initial vital signs
all general anesthetic can cause and FHT, perform leopold's
the placenta and enter into the maneuver, make sure to have an
babies central nervous system.
150
empty bladder and flex the knees dry and promoting sleep and
and have warm hands. adequate rest.
- Perineal preparation is also - Disruption is one of the methods
important to preserve the principle to increase relaxation and to cope
of sepsis, rendering anema if with discomfort of labor when
ordered never a routine procedure contractions are mild to moderate.
but done to prevent infection, - Form of disruption would include
retardation of labor progress and conversation, light activities such
postpartum discomfort. as reading, card playing, duel
- You also obtain specimens for lab games. Ambulation only distracts
tests such as urine, protein, effective leave and enhances labor
acetone, blood for hemoglobin, progress.
hematocrit, white blood cells - Concentration on pleasant
verinial diseases, cross matching. experience, visualization, massage
- Monitor also for uterine as effleurage, back pain as
contraction check aslo the associated with labor relief related
bladder, FHT, and perineum. to pressure to lower back or
Check for bag of water to the schrial area, in a presence of a
presenting part, bulging, cord normal position occiput posterior
prolapse, bleeding, and ability to position back ache is unusually
manage pain. severe.
- Take note of the BP, RnRR every - To manage repost the mother to
hour and active phases every 30 her side with fist on her hand
mins or 15 mins in the transition apply a counter sachrial pressure,
phase if in normal range. promote safety, monitor signals
Temperature every 4 hours if in such as strong or weak
normal range, every hour if above contractions, bleeding, passage of
37 C or if membrane rupture. mechanical stain semiotic fluid,
- The leading complications of bag cephalic presentation, severe
of water is infection headache, dizziness and blurring
- FHR is monitored every 30 mins in of vision.
the latent phase and every 15 mins
in active and transition phases if
normal characteristics are present.
If electronic fetal monitor assess
for reactive non stress test.
- Prevent supine hypertensive
syndrome so position the client on
left lateral recumbent, provide
physical and psychological
comfort and support. Comfort
measures would include assisting
positional change, keeping clean
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2. Fetal Delivery opening of the vaginal
- Primigravida: 80 mins orifice, less risk of
- Multigravida: 30 mins extending into the anus.
● Crowning: Uncontrollable urge to ➔ Disadvantages: more
push , as the fetal head turns to blood loss, postpartum
the side of the perineum,it begins pains, more scarring)
to bulge and the anus appears
tense (stool may be expelled). The
fetal scalp appears at the opening
of the vagina.
● Laceration
○ Vaginal tears during
childbirth. When the baby's
head comes out of the
● Episiotomy: vaginal opening. Relatively
○ Made to facilitate the birth common, typically heals
of the baby and to lessen within a few weeks.
laceration. Surgical incision Extensie tears will require
of the perineum to release treatment by a physician.
pressure of the fetal head ● Types Of Lacerations
and birth. 1) First Degree Tears
● Two Types Of Episiotomy - Involve only the perineal
1) Medial skin. Mild pain, and
- Blunt tape scissor makes stinging during urination.
incision at the perineum at May or may ot require
the midline but away from stitches. (below)
the rectum, (advantages:
little blood loss, and less
scarring, less postpartum
pains.
➔ Disadvantages: will extend
to the anal sphincter and
will also give limited
enlargement of the vaginal
opening. 2) Second Degree Tears
2) Medio-Lateral - Involve the skin and the
- Incision is made with blunt muscle of the perineum
scissor, made directly at and may go deep into the
midline but directed vagina. Require stitches
laterally away from the and heal within a few
rectum. (advantages: larger weeks.
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3) Third Degree Tears ○ Involves applying upward
- Extend into the muscle that pressure from the coxal
surrounds the anus. region to extend the head
Requires repair with during actual delivery.
anesthesia within an Thereby protecting the
operating room rather than musculature of the
a delivery room. May take perineum.
longer than a few weeks to ■ As crowning
heal. (Leakage/painful occurs, exert
intercourse) pressure from the
4) Fourth Degree Tears perineum, into the
- Most severe. Extends from front of the coccyx.
anal sphincter to mucus ■ The other head will
membrane. Require repairs apply pressure to
with anesthesia in an the occiput.
operating room, more ■ Direct woman to
specialized repair. Healing pant and do small
may take more than a few pushes until the
weeks. (Fecal incontinence, baby’s head is
painful intercourse) delivered.
● Nuchal cord ■ Keep two fingers on
○ When the umbilical cord the baby's head to
wraps around the baby’s keep it flexed and
neck. bent.
○ This poses a significant risk ■ Continue to gently
of blood flow and hypoxia; support the head
interrupt normal blood flow, until it is fully
nutrients, and oxygen delivered.
exchange.
○ Can cause serious issues
for the baby. Must be
managed immediately
● Cord clamping:
○ Leave cord alone until the
child is breathing well, dry,
and starts to become pink.
The baby is more or less
● Ritgen’s Maneuver level with the placenta
○ Used to control delivery of inside the mother.
the fetus. ○ Once the baby is breathing,
put two clamps on the
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umbilical cord about an ➢ Nursing Management During Fetal
inch from the baby’s Delivery
abdomen. ○ Transfer of the client to the delivery
○ Delaying cord cutting has room ( Some institutions, the labor
been a new practice for the room is a distinct place from the
past ten years, it has delivery room)
shown an increase of ○ Positioning client for delivery
hemoglobin levels at birth, (Lithotomy)
improved transitional ○ Preparation of the perineum
circulation, and better ○ Prepare for the set-up (sterile
establishment of blood instruments)
volume, and less chance of ○ Teach on effective pushing
blood transfusion, ○ Prepare place of birth
intraventricular hemorrhage ○ Perineal cleaning
in premature babies. ○ Unang Yakap
○ The cord has no nerve
endings so mother and Maternal Behavior
baby will not be able to feel - Eagerness and anxiety, with need to bear
it. down in order to push with uterine
○ Make sure the cord stops contractions.
pulsing or the pulsation has - Take into account pushing and grunting
stopped before cutting the sounds coming from the mother.
cord. - Increase bloody show with leg cramps,
○ Apply proper identification (Early second stage is the best time for
bands into the newborn. It the water bag to burst).
is important to immediately - Immediately check the fetal heart tone
write down the after water bursts.
identification upon the time
of birth . PRIEST Mnemonics
■ Apply on the ankle P Praise
of the client. R Reassure
I Inform mother of progress
E Encourage
S Support system
T Touch
Bear down only during contractions. Mother will

rest during rest periods.
Primigravida: 10cm with bulging with

contractions
Multigravida: 8-9cm transfer to DR
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Place mother in lithotomy position with
padded stirrups, pressure on the popliteal region.
Equal height of legs, alternate with Fowler’s or
squatting as desired by policy.
Peri-care: front to back motion, wash with ➔ Types of Delivery

betadine wipes and gauze. From mons pubis to a) Vaginal Delivery
labia, both labias going down. Gauze should be - With episiotomy, lacerations, or
used on one side going down. Include the legs, intact perineum
upward going down as well. - Method of childbirth experts
● Head extension: feel the cord of the recommend for women with full
child, check for nuchal cord. term births. Simplest kind of
● Clear mouth and nose with suctioning. delivery process.
● Dry and wrap infants to keep them warm b) Operative delivery
after delivery. - Forceps delivery
● Ensure eye-to-eye contact for bonding. - Type of assisted vaginal delivery.
● Verbalize familiarities, allow touching and Health care provider will apply
stroking. forcepts to the baby’s head to help
guid the child out of the birth canal
Unang Yakap during pushes. Empty bladder and
- mandated by the government, to promote ruptured water bag, and no
mother and child bonding. cephalopelvic disproportion.
- Conceptualized for early initiation of ➔ Risk factors: minor facial injuries,
breastfeeding. temporary facial paralysis,
- As early as delivery. Child is placed on the temporary facial trauma, skull
mother’s breast in order to start latching fracture, bleeding within the
immediately when the newborn is hungry. skull/cephalohematoma, seizures.
- Respects readiness of baby to breastfeed,
as manifested from feeding cues.
Indiginous oxytocin release to help uterine
contraction.
155
c) Cesarean Section health problems from
Surgical procedure for delivery. C-sections.
When complications for pregnancy ■ Trial of Labor after
that make delivery difficult. Cesarean section (TOLAC)
➔ Scheduled: Planned early during Attempt to have a VBAC.
pregnancy. Mothers who have had Successful if it becomes a
history with c-sections, or have VBAC. (infection,
transverse or breech blood-loss, c-section scar
➔ Emergent: At times emergency on uterus which may
C-section is needed due to rupture)
complications during childbirth. ■ Birth of Infant
➢ Postoperative Nursing
Reasons For C-section Consideration
1) Neurological disorder ○ Pain management
2) Baby’s head is too big for the mother’s ○ Postpartum Hemorrhage
pelvis (no greater than 1000mL)
3) Baby is coming out breech ○ Constipation management
4) Early pregnancy complications ○ Bladder care
5) Maternal (high blood pressure/heart ➢ Types of Incisions
disease) ○ Abdominal and uterine
6) Mother has active genital herpes incisions
7) Previous C-section ■ Classical Incision:
8) Problems with placenta Vertically over the
9) Problems with umbilical cord umbilicus.
10) Reduced oxygen supply to the baby ■ Low transverse incision:
11) Stalled birth most common, just above
12) Baby is coming out transversely the mons pubis. Less
painful and visible, good
➢ Pre-operative Nursing Consideration for women who want to
○ Deep Breathing minimize scarring.
○ Incentive Spirometry Necessary during an
○ Turning emergency C-section.
○ Ambulation
○ Informed consent
○ GI prep
➔ Client may be NPO post midnight
➢ Intraoperative Nursing Consideration
○ Goal is to reduce microorganisms
within the skin of the baby.
■ Skin Prep and Surgical
Incision
■ Vaginal birth after Cesarean
section (VBAC) avoids
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d) Vacuum Extraction ○ Placenta is visible at
vaginal opening
○ Calkin’s sign
■ Change of the
shape of the uterus
from a discoid to an
ovoid shape
3. Placental Delivery: 30 mins b) Placental Expulsion
- This begins with the birth of the infant and Has 2 presentations
ends with the delivery of the placenta 1. Duncan presentation
- This has 2 stages: - The dirty side of the
a) Placental Separation placenta appears first upon
● After the birth of the infant, the delivery
uterus can be palpated as a firm, 2. Schultz presentation
round mass, just inferior to the (most common)
level of the umbilicus - The shiny portion of the
● After a few minutes of rest, uterine placenta appears on the
contractions begins again and the vaginal introitus
organ assumes a discoid shape There are 2 basic interventions to
● The organ retains its shape, until help deliver the placenta as part of the
the placenta has separated active management of this 3rd stage of
approximately 5 minutes after the labor: Fundal Pressure and the
birth of the baby Controlled Cord Traction
● As contraction continues, a ➢ Crede Maneuver
disproportion between the ○ AKA Fundal Pressure
placenta and the contracting walls ○ Involves placing one hand
of the uterus, aids in the on top of the uterus or the
detachment of the placenta uterine fundus and
● Active bleeding on the maternal squeezing it between the
surface of the placenta begins thumb and the other
with separation fingers to help placental
● This bleeding helps to separate the separation and therapy
placenta still further by pushing it
away from its attachment site
● As separation is completed, the
placenta sinks into the lower
uterine segment of the uterus
● The following are the signs of
placental separation ➢ Controlled Cord Traction
○ Lengthening of umbilical ○ Involves traction on the
cord umbilical cord while
○ Sudden gush of blood maintaining
counterpressure upwards
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by placing a hand on the - Is the shiny, clean bluish
lower abdomen side that is first delivered
○ Should only follow signs of - Less external bleeding
placental separation because blood is usually
➢ Both of these interventions, if concealed behind the
performed incorrectly, may have placenta
adverse outcomes including pain, - The type where separation
hemorrhage, and inversion of the starts at the center then to
uterus the edges, causing an
➢ Mechanisms inverted umbrella shape
○ Duncan
- Less common and is
present in 20% of cases
- Rough, dirty, reddish
maternal side out first
- More external bleeding so
it appears bloody
➢ Nursing Management During
- The amount of blood loss
Placental Delivery
in delivery, whether
○ Gradual delivery of the
placenta is delivered by
placenta, inspect the
Schultz or Duncan
placenta for completeness,
mechanism, is 250 - 300
first nursing action as the
mL
placenta is delivered
- Blood loss of 500 mL or
○ Always assess vital signs,
above is considered
presence of lacerations,
postpartum hemorrhage
complete placenta,
which is the leading cause
bleeding
of maternal mortality
○ Lower her legs slowly and
- This mechanism is an
if allowable by hospital
umbrella shaped placenta
policies, allow mother time
delivered sideways
with infant to promote
attachment or bonding,
and breastfeed right on the
delivery table
○ Massage fundus
■ Feel the fundus for
contraction or
firmness
○ Schultz ■ The terms soft,
- Is more common and is boggy, and
present in over 80% of nonpalpable mean
cases uterine atony
158
■ The initial activity of ○ Monitor for uterine
the nurse is to inversion
massage the fundus ■ Observe the
until firm principle of
○ Monitor for hemorrhage placental delivery
○ Pharmacologic intervention stage such as
■ Inject ordered watchful waiting,
oxytocin after watch and wait for
placental delivery signs of placental
but not during separation and not
■ Commonly used doing fundal
drugs would include pressure with pull at
methergine, the cord, especially
ergotrate if the uterus is
■ The action of this is relaxed, as these
to increase uterine actions can cause
motor activity inversion of the
through direct uterus which is the
stimulation, and the leading cause of
target is the hemorrhage in the
endometrium 3rd stage of labor
■ This is to prevent ○ Assess placenta:
postpartum cotyledons, AVA,
bleeding from membrane
uterine atony and ■ Check if the
subinvolution cotyledons are
■ Evaluation of its complete
effect ■ Check the cord
● Look for firm vessels if there are
fundus 1 vein and 2 smaller
■ Side effects would arteries
include nausea, ■ Check if the
vomiting, dizziness, membranes are
headache, complete
hypertension, ○ Precipitate Labor
tinnitus, and ■ Also take note for
hypersensitivity chances of
○ Ice pack precipitate labor
■ Ice pack may be ■ Occurs in primipara
applied to further if cervical dilatation
contract the uterus occurs 5 cm or
but never hot water more per hour,
bags while multipara,
159
they may reach full associated with pain we call after
dilation within an pains
hour ○ Characterized as short, sharp
■ Primipara: 5cm or cramps that the client may feel in
more/hr the abdomen a couple of days
■ Multipara: 10cm/hr after giving birth
○ Often while nursing, are the
4. Immediate Postpartum sensation of the uterus contracting
● Last stage which help expel blood clots
● Period of recovery, stabilization, and ➢ Lochia
homeostasis - Vaginal discharges that a woman
● Usually 1- 2 hours after placental delivery postpartum can have after vaginal
or at most up to 4 hours delivery
● Power in this labor would include uterine - Has a stale musty odor, like menstrual
contractions to prevent bleeding from the discharge
placental sides a) Lochia rubra: 1-3 days after
● As nurses we need to monitor the delivery
following signs ivolution, uterine atony, - Dark red in color
after pain, and vaginal discharges - A few small blood clots no longer
● Involution than a thumb are normal
○ Process by which the uterus is b) Lochia serosa: 4-8 days after
transformed from pregnant to non delivery
pregnant state - More watery and pinkish to
○ This period is characterized by the brownish in color
restoration of ovarian function in c) Lochia alba: 9-10 days after
order to prepare the body for a delivery
new pregnancy - Creamy or yellowish to whitish
● Uterine atony color
○ Atony of the uterus It is very important to monitor
○ Serious condition that can occur lochia for this will give you an idea if the
after childbirth client is bleeding or not
○ Occurs when the uterus fails to Having lochia rubra past 3 days or
contract after the delivery of the more than 10 days would mean
baby postpartum hemorrhage
○ Can lead to potentially ➢ Nursing Management During
life-threatening conditions namely Immediate Postpartum
postpartum hemorrhage ○ Monitor the fundus
○ This is characterized as soft, ■ Take note that after
boggy, and nonpalpable uterus placental delivery, the
● After pain uterus is palpable at
○ Involution or the continuous umbilicus level. Thus it is
contraction of the uterus is important to take note of
this landmark to indicate if
160
the uterus is contracting or her newborn to continue
not mother and child bonding
■ Palpate the fundus every ○ V/S q 15 mins until stable
15 minutes. Check fundal ■ Report abnormal
height position in relation fluctuations
to umbilicus and ○ Blood loss
consistency ■ Blood loss during delivery
■ Before any palpation is averages 250 mL with a
done, ask the mother to normal upper limit of 500
void to ensure an empty mL
bladder. This will not only ■ Postpartum bleeding is
promote maternal comfort, defined as the loss of 500
it will also promote mL of blood and more for
accurate findings on normal spontaneous
palpation vaginal delivery (NSVD)
■ In the recovery stage, the ■ Because of the blood loss
fundus is firm midline and and the lifting of the gravid
ends at the level of the uterus from the
umbilicus surrounding vessels, blood
■ If relaxed, massage until is redistributed into the
firm venous beds
■ Do not overmassage as ■ This results into a moderate
this can tie the uterine drop of systolic and
muscles causing relaxation diastolic pressure,
■ If placed to the side, the increased pulse pressure,
first nursing action is to feel and slight to moderate
the abdomen for a tachycardia
distended bladder. ○ Perineal care
■ When the bladder is ■ Check the perineum
distended, stimulate ■ Note general appearance,
voiding redness, swelling, bruising,
○ Mother and child bonding vaginal and suture line
○ Rooming-in bleeding
■ Best done and is mandated ■ Administer oxytocin
by the government medications if ordered
■ After the mother is ■ Check BP before and at
discharged from the intervals after
recovery room and ■ Monitor fundal contraction
transferred to her regular and lochia after
room, it is best to be administration
accompanied or be ■ Check episiotomy wound
transported together with or lacerated wound for
161
bleeding, hematoma, or hours without
edema catheterization
■ Ice bag to the perineum ○ Promote sleep and comfort
immediately after delivery ■ Keep warm
can help reduce edema ■ Chills are common in the
and swelling. It can also be 4th stage of labor
placed on the hypogastric ■ Causes of chills are
area to promote maternal excitement,
contraction sudden drop in maternal
○ Perilite hormones, and release of
■ Application of dry heat to intra abdominal pressure,
perineal area in order to fetal blood in circulation
provide comfort, increase ■ Give partial bath pericare
blood circulation and ● Make sure to do it
hasten wound healing from front to back
especially after episiotomy and change wet
by means of perineal lamp linens
■ This lamp is placed 20 — ○ Assess afterpains
50 cm or 18 — 24 inches ■ Reassure that this
away from the body to be secondary to uterine
exposed contractions
○ Assess lochia ■ Ice Pack to relieve or
■ In the 4th stage, lochia is analgesic as ordered
bright red and can saturate ■ Provide nourishment as the
1 — 2 perineal pads in 1 mother may be thirsty and
hours hungry
■ A reddish color may be ■ Take note that the diet of
maintained for more than 2 the client depends on the
weeks but when it persists anesthesia used
for 2 weeks it either ● They can eat a
indicates retention of small regular diet if they
portions of the placenta or had a pudendal
imperfect involution of the block
placenta site or both ● However in cases of
○ Check for bladder distention other anesthesias,
■ Determine first voiding and they need to
voiding pattern maintain strict NPO
■ A full bladder displaces the followed by liquid
uterus to the side, a factor diet after a few
to uterine atony hours
■ Make sure that after
delivery, the mother will be
able to void within 4 — 6
162
Maternal Responses to Labor ● Inadequate or Prolonged Contraction
1. Blood Loss - 300 — 500 mL ○ Inertia
a. Normal blood loss for NSVD ○ Contractions should be regular
should range from 300 — 500 mL ○ Absent of contraction or presence
and not more than 1000 mL for CS or soft, boggy and palpable uterus
2. Hypertension is a sign of uterine atony or uterine
a. Due to series of events that occur inertia (uterus not contracting)
during labor and delivery wherein ○ This is possible if the bladder is
the mother is required to exert so distended which results to the
much effort, maternal VS are displacement of the uterus to
frequently monitored either side of the lower abdomen
b. It is expected that they may have ● Abnormal Lower Abdominal Contour
high blood pressure but must ○ The possible result of uterine
recover immediately within the inertia
normal range ● Increasing Apprehension
3. Leukocytosis - 25.000 — 30,000 ○ Indicates low oxygen perfusion to
cells/mm3 the brain brought about by
a. Also expected hemorrhagic shock
4. Hyperventilation
a. In cases wherein they are unable Fetal Responses to Labor
to manage to follow correct ● Increased ICP
breathing techniques is also ○ The evident effects of labor and
expected delivery to the fetus is greatly
5. Diaphoresis affected by the pressure exerted
a. Basically their VS are heightened by the pushing force of the uterus
same with their temperature and the mother to the fetus
causing diaphoresis against the cervix
● This includes Early deceleration or a
Maternal Danger Signs of Labor minute drop of the fetal heart rate
● High or Low BP especially during contraction or pushing
○ Normal during the process during the second stage of labor
○ Inc. of 30 mmHg SBP, 15 mmHg ● Petechiae/Ecchymosis on PP
DBP ○ Petechiae and Ecchymosis on the
○ Elevation of systolic blood presenting part due to the rupture
pressure of 30 mmHg and diastolic of minute blood vessels in that
blood pressure of 15 mmHg is certain area associated with Caput
detrimental succedaneum
○ Decrease of BP is also a sign of ● Caput succedaneum
shock or hemorrhage together ○ The type of swelling around the
with tachycardia and tachypnea skull which can give an infant a
● Abnormal Pulse conehead appearance and
○ An irregular pulse poses a risk for increased intracranial pressure for
clients with heart problems cephalic presentation
163
● Chest compression through the pelvis ● This will last the first to 6 weeks after
○ Is only evident for NSVD birth.
○ This is somehow beneficial to the 5. During the first stage, upon
fetus as this helps stimulate the hospitalization or coming into the
fetus to initiate breathing hospital, carry out assessment in order
extrauterine to know the status of both the baby
● Partogram and the mother.
○ CTG Paper ● Admission = we need to determine the
○ Reflects the FHR and Contraction contraction whether it coincides with true
○ Provides a good picture of the labor
fetal wellbeing during the whole ● Assessment = we need to regularly
intrapartal period monitor the regularity of the contraction
○ Check for the location, ask the
Fetal Danger Signs of Labor characteristic, how often is the
(Fetal distress related to uterine contractions) contraction, and the degree of
● High or Low FHR discomfort
● Meconium Staining ■ By getting the baseline
○ Green-colored amniotic fluid info, we will definitely know
● Hyperactivity inside the uterus where in the phases of the
● Low oxygen saturation first stage the patient is.
○ Requires an invasive assessment ○ Ask for the duration, frequency,
of the fetus and intensity (how strong is the
○ Always remember the steps in contraction)
fetal resuscitation in case this ○ Assess regularity
occurs or in case for fetal danger ○ Check for presence and
signs, and continuously monitor characteristic of vaginal
the fetus until delivery. discharges
■ Assess Show - is it watery
Add-ons After Class or was it a bloody first
1. The first stage is full dilatation and discharge?
effacement stage. ● If watery, let the
● This begins during true labor until full patient describe if it
dilatation and effacement of the cervix is a full gush of fluid
2. The second stage is expulsion of the or seeping or
baby or the delivery of the baby. leaking. If so, this is
● From full dilatation and effacement to the a ruptured bag of
delivery of the baby. The full expulsion. water. Ask when it
3. The third stage is the placental stage. ruptured, specific
● This is accomplished when the placenta is time is preferred so
delivered. that we can take
4. The fourth stage is the immediate note whether we
postpartum. have an early
rupture or a
164
spontaneous blood extraction, CBC,
rupture. urinalysis, HBsAG, blood
■ Status of the Amniotic typing to pre-condition the
Fluid mind of the patient and
○ Take the obstetric history lessen anxiety.
■ Include the history of ■ If the patient is
present pregnancy - how hypertensive, include
often the patient visits her another set of laboratory
obstetrician or how often examinations such as the
they go to the health center BUN (Blood Urea Nitrogen),
for a prenatal check-up. creatinine, and liver
● If there are enzymes.
laboratory results ○ Patient is attached to a fetal
such as an monitor to monitor the fetal
ultrasound, we need wellbeing.
to ask details on ■ If the patient is attached to
that and what are a fetal monitor, assess for
other laboratories Non-Stress Test
that the doctor ■ Basically, patient is
ordered for her attached to a
during the prenatal Cardiotocogram (CTG)
period. ■ Includes the contraction
● If she has all the and FHT
documents during ○ Perineal preparation is carried out
the prenatal period, ■ Ask the patient to collect
might as well ask urine, inform them how to
for it for her do it - basically asking
management. them to do hygienic
■ Status during the entire measures prior to
pregnancy collecting the urine
○ Do a physical examination and specimen.
assessment ■ If there is a need for an
■ Entails a General Physical internal examination
Assessment - do performed by a doctor on
cephalocaudal an obstetrician, then we
assessment, get the need to do perineal
baseline vital signs, and do preparation such as
the leopold’s maneuver to flushing and shaving but
assess for the status of the perineal shaving is not
baby. done nowadays for
■ Inform the patient to infection control practices.
expect laboratory Online flushing and
examinations including
165
application of perineal care ● If the descending to sigmoid has a lot of
minus the shaving. content, it can obstruct the passageway
6. Patient is allowed to ambulate during and can delay or slow the descent of the
the early stage of labor. baby.
● Helps to shorten labor pains and aches. ● It can lead to UTI if there is stasis.
7. The first phase (latent phase) is the ● If the patient cannot urinate for how many
longest phase of the three so, we offer hours and is super distended, inform the
food to the patient at this phase of doctor right away so that they can order
labor but it is usually a light diet. straight catheterization to drain the
● Rationale why we have to put the patient bladder.
on a light diet: Digestion is delayed during 9. During this phase, we take note of the
labor. A full stomach interferes with danger signs of fetal distress.
bearing down. ● Monitor for the FHT
● If the patient has a lot of food prior to ○ Baseline FHR:
delivery, stool will often come out first 110 - 150 bpm
because of the pressure of the big uterus. ○ Below 100 = bradycardia, signify
● When the baby’s head descends, it will hypoxia to the baby
push out all the remaining waste in the GI ○ Above 160 = tachycardia, happens
tract first. when the baby has an infection or
● If there is so much food, then the excess there is amnionitis
waste is expelled which can contaminate ■ This is often seen in the
the preparation, that is if the patient early rupture of the
defecates due to the pressure of the head membrane. Kanang dugay
during descent. As such, additional kaayo niadto ug hospital
preparation and set-up must be in place ang mother. Always inform
to make sure that everything is sterile for the client nga do not wait
the safety of the baby and the mother. for a bloody show if
● A light diet will limit or lessen the risk of mubarak na ang bag of
aspiration, as this may occur during water, whether seeping or
transition when the anesthesia is inducted leaking. They have to go to
in case of an emergency cesarean section the nearest hospital so that
for reasons that we need to resuscitate the patient can be given
the baby or save the baby or the mother prophylactic antibiotic to
first. protect the baby from
● A light diet or no output or NPO for the ascending infection.
past 6 hours, we still have gastric acids 10. Tachycardia would mean infection for
that can be a cause of aspiration but at the baby
least, at a very low risk. ● Could also be an early sign of hypoxia
8. Remember to tell the patient to empty start of fetal distress
the bladder for at least every 2-3 hours. ○ Start with tachycardia
● A full bladder can delay the fetal descent ■ Eventually it will lower until
same as a full stomach. it becomes bloody
● Sign of distress
166
11. Early deceleration is due to fetal head 15. Danger signs of fetal distress includes
pressure as it goes down to the birth Tachycardia, Bradycardia, and
canal. Meconium staining in the amniotic fluid
● Its normal but great deceleration will only 16. Also take note on the Maternal Distress
be seen if the baby is hypoxic ● Which includes:
○ Experiencing fetal hypoxia usually ○ Hypertension
due to uteroplacental ○ Abrupt decrease in BP with signs
insufficiency of shock.
● How to resuscitate if you see ○ Pallor
deceleration: ○ Restlessness
○ Change the position of the mother ○ Increased pulse rate and
○ Hydrates respiration rate
○ Stop oxytocin and oxygen. 17. Bright red vaginal bleeding or
● Variable declaration happens if there is a hemorrhage is usually seen if there is
umbilical cord compression placenta previa or if there is uterine
○ Cord around the neck or between fracture.
some parts of the fetus ● Need to take note as it is an abrupt
12. The intervention for non-reassuring scenario
fetal heart rate is changing position ○ Take note of the BP
from supine to dorsal recumbent or ■ If it drops right away
side-lying left. ○ Take note If there is increase in:
13. We offer oxygen therapy usually 2 to 6 ■ PR
liters depending on the doctors orders, ■ RR
● If the patient is having oxytocin ■ Pallor
sometimes the physician (if the ■ Profuse bleeding
deceleration is severe) would stop the 18. Pharmacologic management during the
oxytocin drip to increase the flow of the first stage must be noted and the
main line fluid different medications must be
● Physicians, if they often see remembered
decelerations, will assess the actual 19. Second stage would include
cause positioning of the mother on the
○ Internal examinations will be done delivery table.
○ Prepare sterile gloves for a vaginal ● Proper positioning is the lithotomy
exam position.
■ To rule out cord prolapse ● Position the legs properly:
■ Sometimes non-reassuring ○ To prevent adverse effects
can be seen if the cord is ○ To prevent complications such as:
presenting on the internal ■ Thrombophlebitis
os ■ Deep vein thrombosis.
14. If the baby is in distress, tocolytic is
usually given
● If it is late deceleration, anticipate for
cesarean section if it is not relieved
167
20. Bearing down techniques by ● If not done properly,
encouraging mother to deep breathe this means
● Avoid the valsalva maneuver during this additional time for
phase suturing by the
○ If the mother does valsalva doctor
maneuver during crowning the 23. The third stage is the Placental Stage.
newborn will be vacuumed back in assess for signs of placental
● Teach your client the right timing for separation
proper bearing down ● Take note of preliminary signs of the
○ In case the patient attempts the delivery of the placenta
valsalva maneuver, let the patient ● Note the method of placental delivery
open breathe through their mouth whether it's Schultz or Duncan.
to catch up with another push ● Doing aftercare on the third stage
21. Oxygen administration if the mother includes:
becomes Anoxic ○ inspecting the placenta
● Sometimes because of pushing efforts ○ Taking note of the cotyledons if
the face darkens they are complete or not.
○ Especially if the technique for ■ If it is complete, the doctor
pushing is more on her neck and or the obstetrician must be
face told right away
■ The blood vessels will ● Especially if the
burst method of placental
■ This is one of the ways to delivery is duncan
know if the mother is doing ■ If it is not checked, the
the wrong pushing patient will bleed until the
■ Coach and guide the last cotyledon is removed.
patient on how to push ● The physician will
22. Episiotomy is done to prevent do manual
lacerations extraction of the
● Episiotomy is a clean cut retained placenta
● Laceration is a tear and with an irregular fragment
appearance 24. Determine the degree of uterine
● Ritgen maneuver must be done to prevent contraction by palpating the uterus or
perineal laceration or the extension of tear fundus with a light massage.
going to the anus. ● To prevent the uterus from coming out or
○ For perineal support uterine inversion
○ Students in some other institutions 25. Place an ice pack over the hypogastric
are the ones who will assist the area or abdomen after placental
doctor and do the ritgen's delivery
maneuver
■ Supporting the perineum to
prevent a tear
168
26. Drugs that need to be given during the ○ If the bladder is full or if there is
third stage include: bladder distention, the uterus will
● Methergine not fully contract.
○ Do drug study on: ■ It is shifted to the side and
■ Do’s and don'ts obstructs the proper
■ When it is safe to give or contraction of the uterus
when not safe to give ● Leads to increased
27. Nursing priority is to get postpartum vaginal discharge.
vital signs as soon as the placenta is ○ Vaginal
delivered. discharge
28. During the third stage, assess the indicates
perineal laceration. improper
- After the delivery of the placenta, the contraction
doctor will assess the degree of the tear of uterus
or what is the involvement of the ○ Check bladder every 2 hours,
laceration when they do an episiotomy. ■ Encourage the mother
29. Take note on the extent of first to fourth (especially during
degree laceration immediate postpartum
30. On the third stage we also assist for where the client is
perineal repair or episiorrhaphy or exhausted) to drink
perineorrhaphy ■ Anticipate after 2 hours as
31. The use of lidocaine and estimation of soon as the patient is
blood is part of our responsibility transferred to the
● Normal blood loss for normal postpartum unit
spontaneous vaginal delivery: 250-300 ● Encourage the
○ Above 500 would indicate patient to urinate so
suspicion of hemorrhage that she will achieve
32. For the aftercare of placenta, check the a well contracted
placenta and place it in a plastic bag uterus
separated from spoiled linens ○ Take note of vaginal discharge
33. Common indicators for Cesarean ■ Monitoring would include
section: every 15 minutes
● Dystocia (failure of labor to progress) ■ From time to time, check
● Repeat cesarean section the vaginal flow if it is
● Breech presentation for primigravida within normal.
● Fetal distress ● Minimal to
34. Fourth stage is Immediate postpartum moderate during the
● Monitor the fundus every 15 minutes for immediate
one hour and every 30 minutes for the postpartum
next succeeding hour ■ Any sudden change made
● Assess and check the bladder every 2 by the patient would
hours during the first 6 hours of increase vaginal flow
immediate postpartum
169
■ During first two hours of adequate fluid to
immediate postpartum, replace those that
expect minimal to were lost during the
moderate vaginal flow labor phase.
○ Inspect the perineum every 8 ■ Initial nourishment: Afford
hours for 3 days including the time to rest to regain
condition of episiorrhaphy. energy
○ Acronyms of the areas that need ○ Do not forget to place an ice pack
to be assessed will be given for over the perineum
easier assessment. ■ When the patient does not
○ For comfort measures instruct the know how to bear down or
patient since they are able. push early, the perineum is
■ Assist them or tell them to usually swollen.
do perineal care as often ■ If the patient has swollen
as 2x a day perineum or vulva, apply
○ For Hygienic measures, update ice pack over the area and
them on the routines so that their the hypogastric area
superstitions and beliefs would be ● To reduce enema
corrected. ● To decrease pain
■ Patients have lacerations sensation (after
that need to considered to pains during
avoid infections. immediate
■ Body will transition from postpartum)
pregnant to non-pregnant ○ Mild analgesics are also given
state, therefore, assist during the postpartum period.
them with hygienic needs ○ If the patient has a laceration, they
○ Give initial nourishment during the are given pain relievers or
immediate postpartum. anesthesia.
■ In the first 2 hours, we ■ Right after delivery, after
allow the patient to eat. like 6 hours or so, as soon
■ Anticipate the patient to be as the patient is able to eat
hungry after days of light or is already on full diet,
diet pain relievers can be given.
■ If it is a normal delivery, the 35. For the care of an immediate newborn,
patient can eat any food needs of the newborn must be addressed
right after, as tolerated. right away:
■ Usually some patients are ○ Monitor the baby
very exhausted after long ○ Get the anthropometric
labor measurements
● We respect what ○ Regulate the temperature.
they want, and offer ○ As soon as the baby is delivered,
foods like biscuits institutions would practice turning
as long as there is off their facilities’ air conditioning
170
to help the baby adapt to the
environment so that their
temperature would easily go stable
○ Assess for the cry
○ Balance scoring (Usually done by
physician)
○ Thermal regulation
■ If baby is thermo regulated,
maternal infant bonding is
carried out
● Latching on during
the first 2 hours of
delivery
1
FIRST SEMESTER A.Y. 2021-2022
MATERNAL AND CHILD NURSING
LECTURE FOUR C Unang Yakap

CARE OF THE MOTHER AND THE - A campaign launched by the Department
FETUS DURING THE PERINATAL of Health (DOH) with support from the
PERIOD: POSTPARTAL CARE World Health organization (WHO) based
on an administrative order issued in
Immediate Care of the Newborn December 2009 on the guidelines on
The newborn period extends from birth to four Essential Newborn Care.
weeks or 28 days. - Drawers on the support of the whole
hierarchy of the DOH and its attached
The first embrace of the mother is the first step to
agencies, other public and private
a healthy happy baby. This is what Unang
providers of healthcare and development
Yakap, a Department of Health project backed
partners implementing the Maternal,
by the World Health Organization is all about. The
Neonatal, and Child Health and Nutrition
hospital-based program was developed as a
(MNCHN) Strategy.
result of data showing that newborns' deaths are
due to stressful events or conditions during labor, Millennium Development Goals
delivery, and the immediate postpartum period. 1. Eradicate extreme poverty and hunger
2. Achieve universal primary education
Neonatal deaths account for 37% of deaths of
3. Promote Gender equality and empower
children under five from 2000-2003.
women
Essential Newborn Care (ENC) is a simple 4. Reduce child mortality
cost-effective newborn care intervention that can - The ENC Protocol adopts
improve neonatal as well as maternal care. It is international evidence-based
an evidence-based intervention that emphasizes standards set by the WHO that
a core sequence of actions performed directly addresses this MDG.
methodically or step by step. 5. Improve maternal health
● It is organized so that essential time 6. Combat HIV/AIDS, malaria and other
bound interventions are not interrupted diseases
and fills a gap for a package of bundled 7. Ensure environmental sustainability
interventions in a guideline format. 8. Develop a global partnership for
development
Unang Yakap: Essential Newborn Care (ENC)
The Philippines: one of 42 countries accounting
1. Immediate and thorough drying
for 90% of mortality rates in children under 5 year
- Provides warmth to the child and prevents
old.
hypothermia from setting in
Studies have shown that 70% of Newborn
2. Early skin to skin contact
deaths may be averted during labor, delivery, and
- Established mother and child bonding
immediate postpartum.
and minimized the risk of sepsis and
hypoglycemia “It is in the first few seconds and minutes of life
3. Properly timed cord clamping and cutting that every newborn Filipino is given the chance to
- Prevents anemia and hemorrhage survive and to have a better life - during those
4. Non Separation of the newborn and mother first few moments in the arms of a mother in the
for early initiation of breastfeeding first embrace, sa unang yakap.”
2
Protocol procedure: Benefits of proper cord clamping
● Preparation: - Waiting for 1-3 minutes or until the cord
1) Lay out 3 pairs of surgical gloves, two of pulsations have stopped prevents Anemia
which will be used by the obstetrician and - Lowers rate of intraventricular
the remaining pair by the pediatrician. hemorrhages in preterms
Two warm blankets, a bonnet, cord 9) Inject 10 IU of oxytocin into the mother’s
care set, erythromycin (eye care), arm to prevent uterine atony.
vitamin K, hepatitis B shot. 10) While maintaining skin to skin contact,
2) Wash your hands following the prescribed check on the mother’s condition and
1 to 5 counts per each movement. deliver the placenta. Check how heavy
3) Put on both sets of gloves. This is the her bleeding is and examine her
double gloving step. perineum, lower vagina, and vulva for
● The procedures during the first three tears. Clean the mother and keep her
minutes within birth prescribed by ENC: comfortable.
1) Once the baby is delivered from
perineum, call out the time of birth. Benefits of Skin to Skin Contact (SSC)
2) Use the first linen to towel-dry the body of - Promotes bonding between mother and
the newborn. Dry the baby for at least 30 child
seconds this will stimulate the baby to - Increases chances of overall success of
breathe. Do not wipe off the vernix as this breastfeeding or colostrum feeding
continues to provide a natural protective - Colonization with maternal skin flora
cover for the baby. - Protection from hypoglycemia
○ Do not wash the baby within its
At about 30 minutes to an hour after birth the
first six hours of life as washing
baby will start licking, rooting, and tounging
could lead to hypothermia and
movements - cues that he is ready to breastfeed.
infection.
3) Carry out a rapid assessment of the ● Encourage the crawling reflex -
baby’s breathing as you dry the newborn. encourage the mother to nudge her
4) Remove the wet cloth. newborn towards the breast to seek out
5) Initiate the all important skin to skin the nipple. Council on positioning and
contact by placing the baby prone on the attachment.
mothers’ abdomen or between her breast.
After the baby completes his first breastfeed and
6) Cover the baby’s back and head. Place
detaches from the breast while he is with his
the bonnet on the newborn's head and
mother, carry out the eyecare procedure and
use the second linen to cover the baby’s
administer vaccines.
back both to keep the infant warm.
7) Next step is removing the first set of Let the infant remain in the mothers arms as she
gloves prior to handling of the cord. Do recovers from giving birth. The newborn stays
not cut the cord immediately. Allow the with the mother as she is brought to her room or
cord pulsations to stop without milking the ward. The baby may be washed at least after
the cord. six hours.
8) Clamp the cord at 2 cm from the base of
the umbilicus. Apply the second clamp at The global infant and young child feeding
5 cm from the base of the umbilicus. Cut strategy recommends giving the baby nothing
the cord. but breastmilk for 6 months. After 6 months of
3
exclusive breastfeeding, the child can continue to ● Crying with mucus still in the
breastfeed in addition to other foods up to two newborn's mouth and nose can
years of age or beyond (complementary feeding cause aspiration of mucus and
of solids). meconium resulting in meconium
aspiration. Thus, never stimulate
Essential Newborn Protocol the newborn to cry prior to clearing
1. Immediate and thorough drying of his air passages.
a) Drying for at least 30 seconds with ● Suctioning of secretions starts
rapid assessment of breathing and from the extension of the head,
tone even though the rest of the body
2. Early skin-to-skin contact is still inside the mother. We need
3. Properly timed cord clamping to suction immediately the mouth
4. Non-separation for early breastfeeding first and then the nose.
a) Carry out eyecare and ● Wipe of mucus from mouth to
immunization procedures nose. Suction the mouth gently
b) Rooming in and then the nose using the bulb
i) Exclusive breastfeeding for 6 syringe.
months ● Mouth to nose suctioning prevents
the stimulation of the sensitive
Principles of Immediate Newborn Care nerve receptors in the nasal
a. Maintain Patent Airway mucosa which can cause the
b. Maintain body temperature newborn to gasp for breath,
c. Carry out APGAR scoring thereby, favoring the reflex
d. Prevention of Hemorrhage inhalation of pharyngeal secretions
e. Prevention of Infection in the trachea and bronchi causing
f. Infant identification aspiration.
g. Maternal - Infant Bonding ● The use of a bulb syringe
h. Continue further assessment guarantees shallow suctioning.
Shallow suctioning prevents
These principles are followed through a series of stimulation of the vagus nerve
steps we perform right from the time the newborn which could result in
is delivered and continuously done throughout its laryngospasm, bradycardia, and
development. even cardiac arrest.
● Suction briefly.
Principles of Immediate Newborn Care ○ Suctioning time is 5 to 10
1. Maintain Patent Airway seconds in full term and
- Our priority goal. lower risk newborns and less
- This is to establish respiration than 5 seconds in preterm
➔ How it is done: and other high risk
● Clear the neonates' air passages newborns.
with extension of the fetal head ● Brief suctioning prevents
even before the chest is born, with breathlessness of the newborn.
expulsion, thoracic pressure, or ● After expulsion, place the newborn
squeeze is relieved causing the in a slight trendelenburg position
newborn to cry.
4
about 10 to 15 degrees angle with ■ In order to prevent and
head down. manage asphyxia,
○ The number one reason for ensure a patent airway
the proper positioning of a first.
newborn at birth is for the
drainage of
nasopharyngeal
secretions. This position will
also prevent abdominal
contents from compressing
the diaphragm which can
compromise breathing.
○ Take note that the head
down position is
contraindicated in any
conditions that will place the
newborn at high risk for
developing increased ICP or
intracranial pressure as in
post forceps birth or difficult
delivery of a preterm
newborn.
● Oxygenate the newborn between ● Note that the newborn is an obligate nasal
suctioning time. Suctioning the breather so we ensure that the nostrils are
newborn may necessitate patents.
oxygenating him. ● Gently stimulate cry and turn every two
○ Applying oral and nasal hours to fully inflate the alveoli to
suction does not only clear stimulate cry in the newborn.
mucus or secretions but also ● Gently rub his back or gently slap his
air thus the need to soles to stimulate.
oxygenate in between ● To use a bulb syringe, first squeeze the
suctionlings. bulb until it collapses. Place it in one
○ Oxygenation is not routine in nostril about ¼ to ½ inch or inside of the
the admission care. When cheek and quickly release the bulb.
improperly used, oxygen ○ This action pulls the formula or
may cause retrolental mucus into the bulb.
fibroplasia or neonatal 2. Maintain Body Temperature
blindness because of oxygen ● Dry and wrap the newborn to prevent heat
toxicity. loss. The newborn’s temperature at birth
○ Take note that asphyxion is even higher than that of his mother but
unitorum is the failure to it starts dropping continuously thereafter.
initiate breathing in the first ● Wrap the newborn. May cover the head
60 seconds of life commonly with a fabric insulated or knitted bonnet.
due to clogged air passages.
5
● The newborn’s temperature stabilizes in 8
to 10 hours, until then, he must be kept
warm.
● The head is ¼ of the newborn’s length
and will lose a lot of heat from this big
surface area so keep it covered.
● Place the newborn under a gooseneck
lamp to gain added heat by radiation.
● Maintain a temperature between 36.5 to
37.5°C/axilla
● Radiation
● Hypothermia is a condition wherein the
○ A heat loss due to cool surfaces not in
newborn’s temperature falls lower than
contact with the body like walls, floors,
36.5°C.
ceilings etc.
● Check initial temperature per rectum.
○ Most of the newborn’s heat is lost by
○ This is to check for the patency.
radiation.
○ Using a digital thermometer, apply
○ To prevent heat loss by radiation, wrap
a minute amount of K-Y jelly or
the infant.
lubricating jelly onto the tip of the
○ The use of a goose neck lamp while
thermometer. Insert slowly into the
rendering the newborn immediate care is
rectum about half to an inch and
primarily to keep him warm.
check for the core temperature.
● Conduction
○ The loss of heat to cold surfaces in
direct contact.
○ To prevent heat loss by conduction. do
Mechanism on Heat Loss
not put the newborn on a cold and lined
● Convection
surface such as a weighing scale.
○ This is the loss of heat to the cool air.
○ In taking his weight, either you line the
○ To prevent loss of heat from convection,
weighing scale with a thin linen or weigh
it is important to wrap him and promote
his clothes first then put them on him.
flexion to minimize body surface
○ Later, subtract the weight of the clothes
exposed to cold air.
from the newborn’s weight.
○ Avoid unnecessary exposure when
○ To gain heat by conduction, rest him on
performing procedures.
the maternal abdomen or give him to the
mother or father to hold.
○ The maternal abdominal temperature
is the same as the temperature in the
incubator.
6
● Evaporation
○ Loss of heat as water evaporates from
the infant's body/
○ To prevent loss of heat by evaporation,
dry him right away at birth.
● Brown Fat
image of a radiant warmer

● It is also important that we prewarm the
baby’s clothes and properly wrap the
newborn while maintaining
thermoregulation and to prevent cold
stress.
● The radiant warmer produces heat from
● Newborns don’t shiver and when they are the upper area. In some machines, the
exposed to cold stress, they produce heat lower part where the infant is placed can
by burning brown fat. be used as a weighing scale.
● Brown fat is located around the scapula,
sternum, kidneys and adrenals. 3. APGAR Scoring
● This is easily burned and produces a lot of ● Determines well-being.
heat in the process. ● It is a scoring method that gives a
● It is the major source of heat production, numerical expression of the newborn’s
if in excess it may result in metabolic adaptation to extrauterine life performed
acidosis. at 1 and 5 minutes after birth.
● Increasing activity or metabolism, this ● A 10 minute APGAR is performed when
process utilizes more glucose and oxygen the 5 minute score is under seven.
which may result in respiratory distress ● The 1 minute scoring detects the
and hypoglycemia. cardiorespiratory function of the newborn,
● The nurse should keep the newborn warm his general condition, and the need for
and prevent heat loss in order to prevent resuscitation.
these complications of cold stress such ○ Resuscitation must be initiated
as metabolic acidosis, hypoglycemia and immediately and must not be
respiratory distress. delayed for the assessment of the
1 minute score.
Nursing Management in Thermoregulation ○ The need for resuscitation can be
- Dry baby at once right after delivery more accurately assessed by
- Place the newborn on the mother’s evaluation of the newborn’s heart
abdomen and then under a radiant rate, respiratory activity, and color
warmer than by the APGAR score.
- Wrap the baby accordingly ● The 5 minute scoring detects the
- Provide Gooseneck Lamp newborn’s adjustment to the new
- Monitor Vital signs accordingly environment.
○ It detects prognosis as well.
7
○ In nursing care planning, we use 0 1 point 2 points Points
the second APGAR score. points totaled
● To interpret the APGAR Score:
Activity Absent Arms and Active |
○ 0 to 3 means poor and needs (muscle legs flexed movement
resuscitation tone)
○ 4 to 6 is fair. May need suctioning
Pulse Absent Below 100 Over 100bpm |
and oxygenation, and the newborn bpm
is condition guarded
Grimace Flaccid Some Active motion |
○ 8 to 10 is good. No signs of (reflex flexion of (sneeze, cough,
immediate distress, needs only irritability) extremities pull away)
admission care and no special
Appearance Blue, Body pink, Completely pink |
care is needed (skin color) pale extremities
● The most important APGAR score is the blue
heart rate or the pulse. Respiration Absent Slow, Vigorous cry |

○ Without the heart rate, all the irregular
others will also not be observed V
● Color is the least important. Severely Depressed 0 - 3
○ A score of 9 means acrocyanosis Moderately Depressed 4 - 6
due to a sluggish peripheral Excellent Condition 7 - 10
circulation in the newborn in the
4. Prevention of Hemorrhage
first 24 hours.
➢ Vitamin K or Phytomenadione
○ To manage, gently stimulate the
● To prevent hemorrhage, we administer
thigh to improve peripheral
vitamin K phytomenadione IM.
circulation.
● Vitamin K: we give 0.5 mg or 1.0 mg
● Reflex irritability evaluation should not be
phytomenadione to all newborns to
limited to the ability to elicit cry or
prevent bleeding due to deficiency in the
sneezing upon stimulation.
clotting factor in vitamin K.
○ The demonstration of reflexes in a
● Usually 0.5 mg are given preterm while
newborn like the moro reflex
1.0 mg is given to term infants.
means irritability and also
● The newborn’s gastrointestinal tract is
deserves a perfect 2.
initially sterile, meaning to say there is no
● Good cry means he is breathing well,
bacteria such as e.coli to stimulate the
Score Respiration = 2
production of Vitamin K, a cofactor in the
○ There is no need to count his
normal clotting process.
respiration rate.
● Thus, the absence or low Vitamin K level
○ If the newborn cries loudly or cries
would lead to poor blood clotting and can
vigorously, then we can give the
cause neonatal hemorrhage.
newborn a score of 2
● Central nervous hemorrhage commonly
● Add everything and you will get the
occurs in infants not given Vitamin K.
APGAR score
● The best site to give Vitamin K is the
anterolateral aspect of the thigh or the
vastus lateralis. Alternate sight would be
the medial thigh or the rectus femoris.
8
● Dose is usually 1 mg - that is the ideal non-specific bacterial infection of the
dose. The stock dose of phytomenadione cord.
is 10 mg/mL. so we give 0.1 mL per IM. ● Check the number of cord vessels: one
bigger vein should be apparent and two
smaller arteries.
● The presence of a single cord artery
requires further evaluation of the newborn
for a genitourinary or kidney anomaly.
5. Prevention of Infection
● We promote drying up by using 70
➢ Crede’s Prophylaxis
percent alcohol application once or twice
● The admission of eye care by a
a day or PRN.
prophylaxis against ophthalmia
● The cord stump drops off by seven to ten
neonatorum or gonorrheal conjunctivitis
days on its own. If not, silver nitrate
which can lead to neonatal blindness.
cauterization is employed.
● A legal responsibility given to all
newborns whether or not the mother has
gonorrhea.
● Drugs to be used can be silver nitrate
(however, this can cause black staining),
tetracycline, and the most common is
erythromycin.
○ All four medications may cause
chemical conjunctivitis of the eye
within the first 24 hours after the
application. 6. Infant Identification
● Rinse eyes before application and no ● We perform proper identification by
rinsing should be done after. means of using an ID band bracelet or
● Eye care may be delayed for about 1 to 2 foot tags.
hours after birth in order not to interfere ● The identification bracelet should include
with the bonding process. the mother’s name, mothers hospital
● If bonding is promoted early in the number, date of delivery and time of
operating room, then there is no need to delivery and the sex of the baby.
delay eye prophylaxis. ● Identify the newborn properly in the
delivery room and not in the nursery.
● The identification of the newborn is done
before the newborn is separated from the
mother. This is to prevent the possibility of
switching, misidentification, or abduction.
● Each newborn must be first properly
identified before he is separated from the
mother.
➢ Daily Cord Care ● The nurse practitioners must be familiar
● We always observe strict asepsis and with the infant security system used in the
core dressing to prevent infections such area of practice.
as tetanus neonatorum caused by
clostridium tetani and omphalitis, a
9
● As for home birth, it is very important that extrapolated to the gestational age of the
the infant is identified properly before he fetus.
is transported into a health facility. ● These criteria are divided into two:
○ First is the physical maturity
○ Second is the neurological
criteria
● This scoring allows for the estimation of
age in the range of 26 weeks to 44 weeks.
● The scoring relies on the intrauterine
7. Mother-Infant Bonding changes the fetus undergoes during its
● Promoting mother-infant bonding is to maturation.
allow parents to hold the newborn to ● Whereas the neurological criteria depend
promote bonding. mainly upon muscle tone, the physical
● Encourage breastfeeding right on the ones rely on anatomical changes.
delivery room table. ● The neonate is in a state of physiologic
● Delay eye prophylaxis or crede hypotonia, this tone increases throughout
prophylaxis for 1 to 2 hours after birth. the fetal growth meaning a more
● Eye prophylaxis is delayed in order not to premature baby would have lesser muscle
interfere with the bonding process. tone.
● The blurred vision that follows the ● Under physical maturity, we will be able to
application of eye ointment does not look into the skin, lanugo, plantar creases,
permit eye to eye contact which is the breast, ear, and genitals of the newborn.
most important prerequisite to early ○ This will give us an idea of how
bonding. well the fetus has matured.
● We also implement early rooming-in. ● Neuromuscular maturity covers posture,
● An infant delivered by normal square window, arm recoil, popliteal
spontaneous delivery or NSD may be angle, scarf sign, heel to ear.
roomed 30 minutes after birth. ○ We base the response of the
● An infant delivered by cesarean section newborn onto the given drawings.
may be roomed-in as early as 4 hours ● Each of the above criteria are scored from
after birth barring any maternal infant 0 through 5 in the original ballard score.
complications or contraindications. ● The scores will then range from 5 to 50
with the corresponding gestational ages
being 26 weeks and 44 weeks.
● An increase in the score by 5 increases
the age by two weeks.
● If your total maturity score is 30, it means
the newborn is 36 weeks of gestation by
ballard score.
8. Ballard Scoring/Ballard Maturational

Assessment/Ballard Scale
● A commonly used technique of
gestational age assessment.
● It assigns a score to various criteria and
the sum of all of which is then
10
Physical Score Rec
Maturity ord TOTAL MATURITY GESTATIONAL AGE
sign
0 1 2 3 4 5
scor
e
SCORE (WEEKS)
here
5 26
Skin Gelati Smooth Superfici Crackin Parchm Leathery
nous pink, al g pale ent, cracked
red visible peeling area, deep wrinkle 10 28
transp veins &/or rare cracking
arent rash, few veins no
veins vessels 15 30
Lanugo none Abunda Thinning Bald Mostly
nt Areas bad
20 32
Plantar No Faint red Anterior Crease Creases 25 34

creases crease marks transver s cover
se anterior entire
creases 2/3 sole 30 36
only
Breast Barely Flat Suppled Raised Full

35 38
perce areola areola areola areola
ptible no buf 1-2mm
bud
3-4mm
bud
5-10mm
bud
40 40
Ear Pinna Sl Well-cur Formed Thick 45 42

flat, curved ved and cartilage
stays pinna: pinna:so firm ear stiff
folded soft with ft but with 50 44
slow readily instant
recoil recoil recoil
Genital Scrotu Testes Testes Testes

s (Male) m
empty
descend
ing few
down,
good
pendulo
us deep
“Neonate”
, no rugae rugae rugae ● The newborn is a child during the time of
rugae
complete delivery to 28 days old.
Genital Promi Majora Majora Clitoris
s nent and large and
● It is also called the neonatal stage, and
(Female clitoris minora minora minora the newborn-infant is also called the
) and equally small complet
labia promine ely neonate.
minor nt covered
a
TOTAL PHYSICAL MATURITY SCORE

Part of the newborn assessment is to take the
anthropometric measurements of the newborn:
1) Weight
● The average weight of a newborn is
300-400 grams, ranging from 2500 grams
to 4000 grams (maximum).
● It is important to make sure that we have
the raw data by weighing the infant naked
or subtracting the weight of the clothes
from the total weight.
2) Body Length
● A full term newborn’s length varies from
18-22 inches or an average of 50
centimeters from heel to crown.
● Note the highest point of the head - from
the crown up to the heel of the newborn.
Straighten the legs for accurate
measurements.
11
3) Head Circumference - Demand feeding is the best feeding
● To determine the head size (fronto schedule, which is feeding according to his
occipital circumference or FOC), measure biological need for food whenever he is
in centimeters with a measuring tape hungry and not whenever he cries.
placed around the largest part of the - In infancy, crying is the baby’s only means of
occipital area and gathered over the communication. Thus, crying would give us a
forehead resting above the eyebrows. signal that the newborn may be hungry.
● Tape measure should be cleaned before - Adequacy and consistency in meeting the
using. infants needs, particularly satisfying the
● 33-38cm or 34-35 cm is the normal head infant’s oral needs such as feeding and
circumference range for a term infant. sucking, is essential to the development of
● Three measurements should be done and the foundation of personality and sense of
the largest of the three is recorded by the trust.
nurse.
● 0.5 - 1 inch per month or greater than 1 ➢ Important Parts of Breast Milk
inch per month increase may indicate the ● Colostrum is a thin light yellow fluid
presence of hydrocephaly or water in the present in the breast from pregnancy into
brain. the early postpartum period.
● The head is the biggest part of the body ○ It is the first breast milk.
and ¼ of the body’s length. ○ It is very thin and rich in antibodies
4) Chest Circumference and proteins, compared to mature
● Chest circumference ranges from 32-33 breast milk.
cm and is usually equal to abdominal ○ It binds bilirubin and acts as a
circumference. laxative to promote excretion of
● Using the nipple line is a landmark, take meconium.
the abdominal circumference. ● Transitional Milk is produced after
● The abdominal circumference ranges from colostrum and immediately before mature
31 to 33 cm. milk.
● Foremilk is a thin watery breast milk
secreted at the beginning of a feeding.
○ It is low in calories but high in
water soluble vitamins such as
vitamin D and vitamin C.
● Hindmilk is a thick, high-fat breast milk
secreted at the end of a feeding.
○ It has the highest concentration of
calories.
● Mature Milk contains 10% solid for energy
and growth
● Pre-requisites of Breastfeeding
○ Physiologic Readiness of the
Mother
Breastfeeding
○ Absence of emotional stress
- This is the best infant feeding.
○ Sucking of the newborn which
- Maintain rooming-in to promote
stimulates the first let-down reflex
breastfeeding.
12
○ Rest, exercise & diet now, receive Hepatitis B Immunoglobulin
○ Absence of Contraindications (HBIg) immediately after birth + a dose of
Human Hepatitis B vaccine, followed by a
Composition of Human Milk and Formula
second dose at the week of age or later
- Human breast milk is the best milk.
● Drug abuse or such as narcotic addiction
- It contains the essential quality and
○ There is a possibility of the infant
quantity of food nutrients needed by
receiving a substantial amount of
babies for growth and development.
the drug through breast milk.
- Compared to cow’s milk, breast milk is
● Mothers that are positive for HIV antibody
higher in carbohydrate, fats, and water
(to avoid postnatal transmission)
contents, but lower in proteins, vitamins,
● HIV maternal infection (to prevent prenatal
and minerals. Although lower in quantity,
transmission)
the protein in human milk (lactalbumin) is
a better protein because it is easy to
➢ Infant Contraindications to Breastfeeding
digest and hypoallergenic.
● Newborn conditions that will not allow
- The most important advantage of human
normal sucking and swallowing or
milk is that it contains antibodies that
grasping of the nipple are the only real
protect the nursing infant from common
conditions
diseases of childhood to which his mother
● Diagnosed inborn errors in metabolism
has immunity.
may necessitate cessation of
Breastfeeding is the healthiest way to feed most breastfeeding
newborn babies during the first 6 months, and
along with other food, breast milk can be a major ➢ Pharmacologic contraindications to
part of the child’s life for 2 years or more. breastfeeding would include:
● Those drugs that pass into breast milk
The ideal feeding schedule would be every two to such as cocaine which can harm the fetus
three hours. Regardless of the time of the day, and nursing infant, and it should never be
the newborn must be awakened just to feed him. used by a breastfeeding mother.
● Most medications appear only in small
The risk-to-benefit ratio must be weighed by amounts in breast milk.
the clinician and the mother to arrive at the best ● Few drugs are contraindicated for
decision for both the mother and infant. breastgiving mothers as well.
● Those drugs that are contraindicated in
Contraindications of Breastfeeding
lactating women should not be used
➢ Maternal Contraindications
because these may suppress lactation
● Life-threatening conditions: Severe
and the toxic effects of these drugs have
Cardiac Diseases and Cancer
been reported or predicted on theoretical
● Breastfeeding is incompatible with
grounds, such as:
chemotherapeutic agents
○ Analgesics or anti-inflammatory drugs
● Severely debilitating diseases/conditions
■ Indomethacin
as extensive surgery
○ Antibiotics
● Acute contagious diseases like Hepatitis
■ Chloramphenicol
C virus in the mother is a contraindication
■ Isoniazid
but not Hepatitis B virus
■ Tetracycline
● All infants born to mothers who have
active Hepatitis B or who are carriers
13
○ Hormones Correct Infant Latch-On Position
■ Estrogen
■ Iodine salts
○ Anticoagulants
■ Reserpine
○ Antineoplastics
○ Atropine
○ Drugs acting on the CNS
○ Lithium
○ Meprobamate
TAKE NOTE:
● It is not contraindicated to breastfeed if
the mother has an inverted nipple
because a nipple shield may be used. INEFFECTIVE LATCH EFFECTIVE LATCH
● Cytomegalovirus (CMV) is also not
● Nipple pain or ● The rooting reflex is
contraindicated because milk has
trauma initiated and the baby’s
appropriate antibodies to protect the ● The baby’s lips are mouth will be wide open
infant from this infection. rolled inwards with both lips relaxed on
● Smoking’s negative effect and harm to the ● Clicking or the breast and flanged
smacking sounds outwards
infant may be offset by breastfeeding due
at the breast ● The baby’s head is slightly
to the effect of hormones in breast milk. ● Biting sensations extended and the chin
○ A study suggests that children of during the feeding pressed to the breast
smoking mothers who were breastfed ● The nipple slips ● Rhythmic jaw movement
out of the mouth with wriggling of the ears.
scored better in tests of mental when the baby ● Swallowing sounds heard
development than those whose pauses or observed
mothers smoked and did not ● Poor weight gain ● The baby’s nose is free
● Poor output without the mother
breastfeed.
○ Low urine needing to hold back her
○ If the mother cannot and would not output breast
stop smoking, she should be ○ Low stool ● Absence of clicking
encouraged to breastfeed as long as output sounds
the mother doesn’t smoke while
breastfeeding. Different Positions Assumed to Ensure
Comfort during Breastfeeding
1. Cradle Hold
- Traditional and most commonly used hold
when feeding and cuddling the infant.
- The mother cradles the newborn’s head in
the bend of the elbow of the nondominant
14
hand with her forearm reaching around 5. Side-lying Position
the outside of the infant’s body to grasp - The baby is placed on the bed while the
his outer leg. mother is feeding and positioned on the
- The mother’s dominant hand and forearm lateral side towards the baby.
help support the infant’s back and - It is important to indicate that the child's
buttocks. head should be elevated to prevent
2. Cross-Cradle Position aspiration during feeding.
- Similar to the Cradle Position, however,
the mother is using the dominant hand, After feeding, it is important to burp the baby so
and the nondominant hand supports the as to expel gas out from swallowing and sucking.
head and breast. Thus, we need to teach the mother how to
3. Football Hold perform the shoulder hold.
- Safe and secure hold for shampooing ● This is the most common position
newborns and young infants, and during assumed by the mother during burping or
breastfeeding as well bubbling an infant.
- Recommended if the mother is feeding ● Using two hands, the mother holds up the
twins simultaneously. infant against one side of her chest and
- About half the length of the newborn’s the shoulder. One hand supports the
body is supported by the mother’s infant’s buttocks and the other hand
forearm, while his head and neck rest on supports the infant’s head and upper
her palm. The rest of the newborn’s body: back.
his buttocks and legs, are firmly wedged ● In burping, the hand supporting the head
between the mother’s elbow and hip. and upper back may be momentarily
- This hold leaves the mother with a free withdrawn to pat the back gently from the
hand to shampoo the hair or grasp waist upward to the shoulders. Repeat
something, or other essentials while until the infant burps.
carrying the newborn.
Bathing
● The WHO recommends delaying the

baby’s first bath until 24 hours after birth
4. Laid back position or waiting at least 6 hours, if a full day is
- Not ideal as the mother may fall asleep in impossible.
this position.
- It is important that we emphasize to the ➢ Considerations when Bathing
mother that they should not fall asleep ● Body Temperature and Blood Sugar of the
while feeding the baby for the baby may newborn
be at risk for fall or may not be attended
to.
15
○ Babies who get baths right away mild, neutral pH soaps without
may be more likely to become cold additives.
and develop hypothermia ● Cleaning gently with a soft cloth to wash
○ The minor stress of an early bath the baby’s face and hair may be useful
can also make some babies more but it must be used carefully not to scrub
likely to have a drop in blood sugar or tug the skin.
or suffer from hypoglycemia ○ You may massage the entire scalp
● Bonding and Breastfeeding gently including the area over the
○ Taking the baby away for a bath fontanelles or the stuffed spots.
too soon can interrupt skin-to-skin ● After bathing, it is important that the
care, mother and child bonding, newborn should be wrapped with a towel
and early breastfeeding success around the head and the body to help him
● Dry skin stay warm while he is still wet.
○ Vernix is a waxy, white, and ● Bathing a baby of any age is a wet work
cheesy substance that coats a and may need safety especially
baby’s skin before birth. It acts as preventing trips or falls.
a natural moisturizer and may have
antibacterial properties. Sleep
○ It is best to leave the vernix on the ● The average newborn sleeps much of the
newborn’s skin for a while to help day and night, waking only for feedings
prevent their delicate skin from every few hours.
drying out ● There is no set schedule of sleep at first.
■ This is especially important Many newborns have their days and
for preterms as their skin is nights confused - they think that they are
highly prone to injury. supposed to be awake at night and sleep
● Check the water temperature during the day.
○ Fill in the basin with two inches of ● Generally, newborns sleep a total of about
water that feels warm, that is not 8-9 hours during the day, and a total of 8
hot to the inside of the wrist or the hours at night.
elbow. ○ But because they have small
○ If filling the basin from the tap, turn stomachs, they must be awakened
the cold water on and off last to every 2-3 hours to be fed.
avoid scalding the child. ● Most babies will not sleep through the
○ It is important to keep the baby night until at least 3 months of age, but
warm. After undressing the this can vary a lot.
newborn, place the newborn in the ○ Some babies do not sleep through
water immediately so that the the night until closer to 1 year.
baby does not get chills. ○ In most cases, the baby will wake
○ Use one of your hands to support up and be ready to eat at least
the head, and the other to guide in every 3 hours - how often would
the feet first. depend on what the baby is being
● Use soap sparingly as well. fed and on his age.
○ Soaps can dry out the baby’s skin. ● Watch the newborn’s sleep pattern.
○ If a cleanser is needed for heavily ○ If the baby has been sleeping
soiled areas, it is important to use constantly and suddenly is waking
16
more often, there may be a Cardiovascular System
problem. ● Decreased pulmonary artery pressure
○ If the baby is going through a ● BV = 300ml
growth spurt and needs to eat ● Acrocyanosis: a pink body with the
more often, some sleep extremities blue-ish or cyanotic (normal
disturbances are simply due to during first 24 hours of life)
changes in development or
because of overstimulation.
● Mothers should be instructed on the
prevention of SIDS: sudden infant death
syndrome
○ Unexplained death usually during
sleep, or a seemingly healthy baby
less than a year old
○ Also known as crib death
because the infants often die in
their cribs.
○ Although the cause is unknown, it
appears that SIDS might be
associated with defects on the
portion of an infant’s brain that
controls breathing and arousal
from sleep.
○ As nurses, we reiterate to the image of acrocyanosis in the extremities
parents that they should put the ● After the cord is being clamped and cut,
baby to sleep on the back and not the newborn needs to establish its own
in a prone or side position. Use a circulation and breathing. Thus, on the
firm steep surface, and keep fluffy first 24 hours of life, the extremities (both
blankets and stuffed animals out upper and the lower) would manifest
of the crib; not overheating the cyanosis while the body is pink.
baby in his room when he sleeps; ● Hemolysis will be present as well despite
no smoking during pregnancy and having High RBC, HCT & WBC (increased
no one should be allowed to destruction)
smoke around the baby; and the ● Circulatory changes that occur after birth
importance of breastfeeding. would include:
○ Umbilical vein and arteries, and
ductus venosus close with
clamping of the cord
○ Foramen ovale and ductus
arteriosus close functionally with
the establishment of respiration
caused by increased pressure in
the left side of the heart as a result
of increased pulmonary blood
flow.
17
■ It only becomes ■ If there is a need for
permanently anatomically anticoagulant therapy in
closed after several months pregnancy, the safe drug to
(around 3-4 months) and use is Heparin as it does
this explains why murmurs not cross the placental
could be heard and are barrier.
common in the first month
Respiratory System
of life.
- Newborns are Obligatory nose breathers
● Apical pulse is detected at the level of the
● They mainly breathe through their
3rd to 4th interspace to the left of the
nostrils.
midclavicular line
● Initiation of respirations is caused
○ Normal Rate: 110-160 bpm
by a variety of factors. This would
● Pulses reflect systemic circulation and
include:
easily palpable pulse is found at the
○ The increase of carbon
femoral and brachial pulse site
dioxide and the decrease
○ It is difficult to palpate the radial
of oxygen, thus having
and temporal for newborns
lower pH
● The initial sterility of the newborn’s GIT is
○ Decreased pulmonary
absent which results to low levels of
vascular resistance
vitamin K and possibility of bleeding
○ Increased pulmonary blood
○ If there is a bleeding problem,
flow
intake of cow’s milk restores
○ Decreased alveolar surface
prothrombin time faster than
tension from adequate
breast milk because breast milk
surfactant
contains only a quarter of the
○ Recoil of chest causing
amount of Vitamin K per dL of
replacement of fluids
cow’s milk.
○ Change from
○ Coagulation factors synthesize in
weightlessness to
the liver and are activated under
gravity-controlled
the influence of Vitamin K.
environment
■ These vitamin K-dependent
- Respiration may be irregular with short
factors such as Factor II,
periods of apnea
VII, IX, X increase in
- Respiration is a time-swallowed
response to dietary intake
abdominal, nasal, quiet, and rapid at
and bacterial colonization
30-60 cpm.
of the intestine.
- It is very important when you look into or
■ Anticoagulant Coumadin
monitor the respiratory rate, you look into
(Warfarin) is not given to
the abdomen.
pregnant women because
- Surfactant is a requisite for mature lung
it crosses the placental
functioning. Respiratory secretions may
barrier and accentuates
be abundant through this.
existing vitamin
- One thing that we need to look into that
k-dependent factor
would give us an indication that the
deficiencies
newborn is high-risk is the presence of
retractions
18
● There would be intercostal - We compute the Gastric Capacity by
retractions and there could be following the Age of the Newborn (in
sternal retractions. months) + 2 ounces
- Aside from that, if the infant would be - They can only digest simple
observed to have mucous membranes carbohydrates and protein, and not those
that turns to bluish or cyanotic, this is the complex carbohydrates.
most reliable indicator of central color in - They cannot also digest fat due to
all babies. insufficient lipase.
● Central Cyanosis or the - The liver is immature which would cause a
bluish/cyanotic color of the decreased liver enzyme glucuronyl
mucous membrane would give us transferase.
an indication that the newborn is ● This would result in having poor
having low oxygen saturation bilirubin conjugation thus, resulting
blood level and demands urgent in physiologic jaundice or normal
attention due to hypoxia or jaundice.
congenital defects. - The normal blood sugar for newborns is
30-50mg per dL and the caloric
requirement is around 400 calories per
day.
- Infants would benefit from the
immunoglobulin IgA enzymes and
Lactobacilli from breastmilk, and they
need to have 17.5 ounces per day of fluid.
- The stomach of the newborn empties
around every three hours.
- They secrete a stool which we call the
meconium, which has a characteristic
depending on the feeding.
● May have more formed
consistency after taking solid
Gastrointestinal System foods.
- Newborns often spit up mucus in the first - The newborn stool would include the
24 hours of regurgitation and it is meconium, which is viscous or pasty, has
common in the first three months. a dark green or black color that passed
- Immature or relaxed cardiac sphincter of within 24-48 hours.
the stomach would cause the self-limiting - The first stool may be passed during the
vomiting common in the first three months second period of reactivity which is 4-6
or achalasia. hours.
- So, we nurses need to emphasize the ➢ Transitional stool
need of small, frequent feedings with the ○ Loose or liquid stool that are
infant in a semi-upright position. greenish, yellow, or brown in color
- Avoidance of overfeeding can prevent that are passed within 2-4 days
regurgitation and vomiting ○ Because of this type of stool that
- The Gastric Capacity of the stomach is resembles diarrhea, parents often
only 45-60 mL
19
become anxious. So, we need to - The urine could be cloudy due to the high
reassure parents that it is normal. albumin content.
➢ Milk Stool - The urine or the first void would amount
○ Passed within 4-6 days to 15ml/void on the first day and
○ It could be brought about by 300ml/day on first week
breastfeeding or bottle feeding - Initially, 6-10 times a day would be the
○ Breastfed newborn stool are pattern of voiding, then, 20 daily on the
golden, yellow, mushy soft, 2nd week
sweet-smelling and often out after - Increased uric acid in urine, red spots on
feeding the diaper or brick spots are normal
○ Bottle fed newborn stool are more occasional signs.
formed, light yellow, and foul
smelling Immune System
○ If the newborn is undergoing - The immune system of the newborn is still
phototherapy, the stool becomes immature and is not fully developed yet,
greenish due to the evacuation or which is why newborns are prone to
release of bilirubin infection.
○ A bile duct obstruction will turn it - Because of the immaturity of the immune
into grey due to the decrease in system, the newborn lacks the
bile competency of localizing infections. Thus,
○ Lactose intolerant newborns could local infection of the cord or omphalitis,
have watery, loose stool may readily become systemic neonatal
sepsis.
STOOL DAY CHARACTERISTICS - They are capable of some body
responses to immunizing agents.
Meconium 24 - 48 hrs Black
- Fever may not indicate infection in the
Transitional 3rd Loose & greenish newborn because it is commonly due to
dehydration.
Breastfed 4th Golden Yellow, soft,
- Neonatal infection or neonatal sepsis
odorless
may have hyperthermia or hypothermia as
Bottle Light yellow, formed manifestation.
fed with odor - IgG offers passive, natural immunity for
most of the major childhood diseases or
Phototherapy Greenish
the communciable ones, provided the
Bile-duct Grey mother is immune. It is transferred
through the placenta.
Lactose Watery & loose - IgM is produced by the fetus around 12
Intolerance
weeks while IgA is a secretory
immunoglobulin secreted by the
Urinary System breastmilk and colostrums, it protects the
- Newborns Must void within the first 24hrs infant from some infections especially in
of life the GI that cannot be destroyed by the GI
- It turns out to be pale yellow because the enzymes.
kidneys are too immature that they can’t - We need to emphasize that even if the
concentrate urine. baby is breastfed, he still needs to receive
20
immunization against common childhood
diseases because the available antibodies
received from the maternal placenta and
breastmilk are temporary.
- Take note, immediately after birth, the two
important vaccines that we give as
immunizations to the newborn, are the
BCG and Hepatitis-B vaccines. The rest
will follow as scheduled and completed
before the child reaches or has his first
birthday.
Assessment of the Skin

➢ Jaundice
○ Normally, the newborn has pinkish
skin and maybe darker if with more
pigmentation, and depending on the
race of the newborn.
○ Bluish or cyanosis, we’ll have to
look into the mucus membranes. This
Physical Assessment is the most reliable indicator of central
➢ Taking the Vital Signs color in all babies
○ The ideal way to take the pulse rate of ○ Central cyanosis occurs in the
the newborn is to take the apical tongue and mucus membranes that
pulse. turn into blue due to low oxygen
■ Apical pulse is located at the saturation blood levels. This would
third or fourth interspace to the demand urgent attention and maybe
left of the midclavicular line. due to hypoxia or congenital defects.
■ We follow 120-150 bpm. ○ Yellowish or Jaundice may be
○ Respiration is done by observing the physiologic or pathologic.
rise and fall of the abdomen and we ■ The first action to do is to
count it for 1 full minute. identify the age of the newborn.
○ Blood pressure is rarely done or part ■ It is considered pathologic
of the routine vital signs monitoring jaundice if jaundice happens
unless if the newborn has cardiac within the first 12-24 hours and
problems is due to hemolytic disease or
○ Temperature is taken at the axilla erythroblastosis fetalis.
route for routine V/S monitoring and ■ If it happens >24 hours or within
we follow 36.5-37.5°C 2-7 days, it is considered
physiologic jaundice.
■ If accompanied by undue
lethargy, poor feeding, unstable
body temperature, and vomiting
21
it may be due to infection or ■ To check, blanch the skin on the
neonatal sepsis. forehead or the chest region.
○ Pallor ■ To diminish incidence:
■ It is unlikely for a newborn to be ● Prevent cold stress
pale because of fetal ● Provide early feeding
polycythemia as this promotes
■ It may be due to anemia, so, the urinary and fecal
first nursing action to identify excretion of bilirubin
this is to blanch the forehead or ○ Breastfed infants have increased
the chest region to detect the jaundice because of pregnanediol in
presence of jaundice. breast milk which renders the liver
○ Anemia and hyperbilirubinemia are enzyme glucuronyl transferase not so
characteristic signs of erythroblastosis effective in conjugating free bilirubin,
fetalis and occurs after physiologic jaundice.
■ It may also be due to ○ Breastfeeding may be discontinued
hypothermia, hypoglycemia, for 12-24 hours for severe
and newborn bleeding. breastfeeding jaundice, and
○ Reddish, plethora, or ruddy phototherapy may be used.
■ Plethora - having a hematocrit
of >70%
■ Polycythemia or elevated
RBCs - gives rise to reddish or
ruddy color
■ Red and wrinkled is common
among premature infants.
■ Red and smooth is common
among full term infants. ➢ Bili Light And Bili Blanket
○ Greenish skin would indicate that the ○ This is how phototherapy looks like:
newborn is being stained with
meconium due to chronic fetal
hypoxia
■ If green, dry, discommiting,
parchment-like, it means to say
that the newborn is post-mature
and chronically hypoxic due to
aged placenta.
○ Another characteristic of jaundice is
to look into the sclera.
■ Aside from the skin, the sclera
would also turn yellow.
○ Physiologic Jaundice occurs because
of an immature liver.
■ It occurs after 24 hours.
■ First, it manifests in the head
then progresses to the chest.
22
○ Phototherapy is able to transport the nurse gives the infant
bilirubin from the skin to the blood ample sensory
then to the bile, where it is excreted stimulation.
and passed out through stool. ■ Turn the infant every 2 hours for
○ Infant is continuously exposed to 3-6 maximum exposure of skin
fluorescent light tubes with a total surfaces.
strength of 200-500 foot-candles. ■ Increase fluid intake - give fluids
○ Photodecomposition is the normal in between feedings and
alternate route of bilirubin conversion. monitor temperature every 2
○ The exposure to light increases the hours.
rate of conversion. ● During phototherapy, the
○ It is important to place the newborn newborn gains added
16 inches away from the baby except heat through radiation
if we use the bili blanket. which can lead to
○ To prepare the newborn for hyperthermia.
phototherapy: ● The body temperature
■ First, undress the newborn and must be monitored
cover the eyes and genitalia frequently.
● Covering the eyes ● The heat in the isolate
prevents possible retinal must be turned down
damage and blindness during temperature taking
● Covering the genitalia and the portholes left
prevents possible painful open to prevent
penile erection or overheating and
priapism and sterility inaccurate temperature
● Make sure the eyes are reading.
closed before applying ■ Assess for side effects and
eye dressing or cotton manage as necessary.
balls before finally ■ Explain to the parents that
securing with an having bronze skin is temporary.
additional dressing to It is also expected to have dark,
prevent corneal damage. concentrated urine, thus we
■ Provide continued care need to increase the fluids.
throughout the treatment. ● Bright green loose stools
■ Follow a regular schedule of are also expected from
feeding which is every 2-3 excess bilirubin excretion;
hours to prevent metabolic and when we explain, we
acidosis. need to reassure parents
■ Remove the infant from under that this is not diarrhea,
the light. ○ To prevent priapism or painful
■ Remove the eye shield and erection, turn the newborn to a prone
cuddle him during feeding. position and cover their genitalia.
● By regularly removing the ○ To prevent retinal damage, prevent by
eye shield and cuddling shielding the eyes.
the infant during feeding,
23
○ For dehydration, increase fluids, give
sterile water between regular milk
feedings.
○ For elevated temperature or fever,
monitor temperature and provide
adequate hydration.
○ Turn off lights if blood is to be
extracted for serum bilirubin
determination, and obtain a darkened
container for the blood specimen.
■ This is to get accurate results
because bilirubin is destroyed
by light. ➢ Nevus Flammeus: Stork Bites
○ Common along the nape and behind
➢ Harlequin Sign the ears of the newborn
○ This is when the newborn is placed
on the side - the lowered dependent
portion of the body is darker in shade
than the upper independent portion
due to sluggish peripheral circulation.
➢ Strawberry Hemangiomas
○ Elevated areas formed by immature
capillaries and endothelial cells
present at birth.
○ May be present upto 2 weeks
➢ Nevus Flammeus: Port-Wine Stain
following birth, may continue to
○ Birthmarks or hemangiomas are
enlarge from the original size upto 1
vascular tumors of the skin,
year, then shrink in size or be
○ One example is the Port-Wine Stain
absorbed.
which is a macular purple or dark red
○ At 7 years old, 50-75% of these
lesion. It is present at birth generally
lesions would have disappeared.
over the face or over the thigh region.
○ Complete absorption happens after
○ While the lesion over the bridge of the
10 years.
nose tends to fade, others are less
likely to.
24
➢ Desquamation
○ Dry peeling of the skin particularly on
the palm and soles
○ More on post-mature newborns
○ Requires no treatment
➢ Mongolian Spots
○ Considered a benign and self-limiting
skin mark that is a greyish-blue patch
and/or pigmentation over the
buttocks and sacrum regions.
○ It results from the collection of
pigment cells or melanocytes.
○ It disappears within the first to
➢ Milia
second year or as late as school-age.
○ White or yellow pinpoint papules over
the nose, cheeks, chin, and forehead
due to the obstruction of sebaceous
glands, caused by immature
sebaceous glands or blocked
sebaceous glands.
○ This needs no treatment as it
spontaneously disappears in 2-4
weeks.
➢ Lanugo
○ Fine, downy hair on the skin
○ More on the shoulders, back,
forehead, upper arms, and cheeks
○ More in the preterm, gradually
disappears close to term. ➢ Erythema Toxicum
○ Newborn Rash
○ White or pink papular rash on the
body appearing within 24-48 hours
after birth.
25
○ Benign, disappears within a few days - In molding, a reduction of 0.5 to 1cm in
○ Harmless but must be differentiated the fetal head size or the biparietal
from rashes found in infection. diameter is normal.
○ To confirm diagnosis, a smear of - Head will return to normal in 2-3 days.
aspirate from a pustule will show - The newborn may have head injuries, so
numerous eosinophils which would the sutures and fontanelles should be
indicate infection. patted.
- The head moves from left to right, up and
down, maybe with silky hair.
- Commonly seen variations would include
caput succedaneum and
cephalhematoma.
- In the picture, you would be able to see
macrocephaly (left) and microcephaly
➢ Forceps Mark (right).
○ Brought about by forcep delivery ● Macrocephaly - having a
○ These are considered minor facial frontal-occipital circumference
injuries due to the pressure of the greater than the 90th percentile.
forceps. ● Microcephaly - having a head
○ Temporary weakness in the facial circumference of less than 31.7
muscles or facial palsy may also be cm; when the head is smaller than
evident. the chest usually due to a small
○ Baby on the right is having facial brain.
paralysis or facial palsy. ● Hydrocephaly - when the head is
■ One side will be able to make excessively large due to the
an emotion, while the other side increased amount of cerebrospinal
doesn't change. fluid (CSF)
○ Minor marks on the body or on the ● Anencephaly - the absence of
baby’s face after a forceps delivery cranial bones usually incomplete
are normal and temporary.
○ Serious infant injuries after a forceps
delivery are rare.
➢ Fontanelles
○ Posterior Fontanelle - triangle shape
○ Anterior Fontanelle - diamond shape
Assessment of the Head ○ Note that the Posterior Fontanelle
- Ideally, the head is round and closes at 2-3 months of life while the
symmetrical, and may have molding Anterior Fontanelle closes at 12-18
(shaping of the fetal head to months of life.
accommodate passage through the birth
canal)
26
○ The Fontanelle will give us a good - Bright and clear, blue or greyish, pearl
idea of the hydration status of the color appear about 3 months.
newborn. - Pupils should be equal in size, and sclera
■ If the fontanelle is sunken, it should be normally white.
may mean dehydration. - The deviation from the normal white color
■ If it is bulging, it may mean should be noted and reported.
intracranial pressure. ● If it is bluish, it could mean
congenital osteogenesis
imperfecta which affects bone
structure integrity and can cause
fracture.
● Yellowish sclera may mean
➢ Craniotabes jaundice, this means that there is
○ A demineralized area or softening of an increased serum bilirubin, and
the skull prompt intervention would be to
○ The skull bone can be indented with push fluids and perform
gentle pressure like a table tennis phototherapy.
ball. - Crying is tearless because of immature
○ When this finding is appreciated to a lacrimal structures, fully functional by two
mild degree near the suture lines in months and would result to tearing.
newborn infants, it is commonly a - Vision of the newborn with pupillary and
normal variant. blink reflexes, wherein they respond to
○ With the presence over most of the bright light placed before their eyes, the
skull, craniotabes may be associated pupillary reflexes are present after 28
with conditions in which calcification weeks gestation.
has been deficient such as - The vision of newborns is focused on
osteogenesis imperfecta or syphilis. human face. They can see the clearest at
a distance of 8-10 inches.
- Gross vision in the newborn may be
evaluated by holding the examiner’s face
8-10 inches from the newborn’s face and
determining the infant’s ability to direct his
gaze to the nurse’s face and readjust his
gaze when the nurse moves.
- Newborns can fixate and track for a short
distance the midline, with some degree of
Assessment of the Eye color and pattern discrimination.
- Eyes evenly placed on face with outer
canthus in line with the upper border of ➢ Subconjunctival Hemorrhage
the ears. ○ Characterized by having red spots on
- Best way to inspect the eyes of the the sclera due to the rupture of small
newborn is to hold the infant up and tip capillaries during delivery.
the head gently forward and backward, ○ It is just reabsorbed in about 2 weeks
rather than forcing the lids apart.
27
Assessment of the Mouth
➢ Tongue Tied
○ The newborn’s mouth ideally should
be closed and opens only when
crying
○ The lips should be equal complete
with symmetrical movement
○ Tongue should be midline,
➢ Strabismus freely-moving and NOT tongue-tied
○ Brought about by poor ○ The lingual frenulum protrudes
neuromuscular control or forward
coordination ○ The taste is present at birth but
○ This is a condition wherein there is an prefers sweet over bitter taste
occasional crossing of eyes due to ○ Palates should be intact
the normal immaturity of the eye ■ Variations include cleft
muscles. palate
○ Control is usually obtained by about ○ The saliva is scanty and increases
3-4 months. with the development of the salivary
glands at about 3 months, wherein
drooling starts by then
➢ Doll’s Eyes
○ This is moving of the eyes to the ➢ Epstein-Pearls
opposite direction as the position of ○ Small epithelial cyst/pearls on the
the newborn’s head is changed to the hard palate or gums and disappears
left and then to the right at 1 - 2 weeks
○ Present for 10 days after birth ○ An open mouth with a tongue
protruding in (quite?) states may
mean down syndromes
○ Excessive drooling in spite of frequent
suctioning is a sign of esophageal
atresia
28
➢ Natal Teeth
○ Natal and neonatal teeth rarely are
supernumerary teeth
○ They are almost always genuinely
primary lower incisors
○ Since they are immature and have
minimal length of root development,
they are greyish and are hypermobile
○ Can irritate the baby’s tongue during
sucking or the mother’s nipple during
breastfeeding
○ Pediatricians and parents may worry
that the child may aspirate these
unstable teeth Assessment of the Chest Down to the
■ Even though there are no Genitalia
reports of such accidents, - The chest should be symmetrical and
these teeth are usually have uniform chest movement
extracted - Breath sounds are clear and equal at both
sides
- HR = 120 - 160 bpm
- May have functional low pitched musical
murmurs heard just to the right of the
apex of the heart and this is common in
the first month of life
- Note that the foramen ovale and ductus
arteriosus takes 2 - 3 months to
permanently and anatomically close
➢ Oral Thrush
- Increasing murmurs and fatigue
○ White, cheese substance on the
manifested by brow sweats during
tongue may indicate oral thrush
sucking or feeding need to be referred for
○ Yeast infection that typically appears
further investigation
as white or yellow as white or yellow
● May mean acyanotic heart defect
irregular shaped patches or sores that
- Cough reflex is not present at birth and it
coats the baby’s gums and tongue
appears at about 2 - 3 days
along with the sides and roof of the
- For the female genitalia
mouth
● Labia majora should be
○ Caused by Candida albicans
symmetrical, slightly edematous,
○ While just a mild infection, it can be
covers the labia minora, and may
very uncomfortable or painful for the
have vernix caseosa between folds
newborn
○ It should be cleansed as
○ Though it shows up in the baby’s
excess vernix is a good
mouth, it probably started in the birth
culture or medium for
canal as a yeast infection
bacterial growth
■ This is where the baby
picked it up as it made its
way down the canal.
29
➢ Witch’s Milk, Pseudomenstruation
○ Breasts enlarge with milky secretions
called witch’s milk
■ Results from maternal hormones
■ Common in both sexes
■ Part of the self-limiting genital
crisis in the newborn
■ Usually occurs at the 3rd day and
may last for approximately 7 days
after delivery
○ Pseudomenstruation
■ Is a normal, occasional, and
blood-tinged vaginal discharge
due to maternal hormones part of Assessment of the Extremities
female genital crisis - There should be good muscle tone, flex,
■ Observed that the clitoris would be and resist having extremities extended
enlarged - The arms and legs should be of equal
length
● Legs are shorter than arms
- Digits should be complete 5 in each hand
and foot with nails
- Part of the assessment of the newborn is
to detect the presence of hip dysplasia.
● Use the ortolani test and/or the
barlow test to assess
➢ Cremasteric Reflex ➢ Polydactyly

○ Retractile testicles are caused by a ○ Having extra fingers or toes
normal reflex and are not the same as
undescended testicles wherein the
testicles are never felt in the scrotum
○ The testicles are connected to muscles
called cremaster muscles that can
move them in and out of the scrotum
○ When the muscles contract and draw
the testicles out of the scrotum
temporarily it is called retractile testicle
○ It is common for young boys or newborn
to have retractile testicles especially
during PEs which may trigger a reflex of
the muscle
○ This is elicited by gently stroking a finger
on the inner thigh, and the muscles will
pull the testicles upward. This is the
cremasteric reflex.
30
➢ Syndactyly - When it is positive because the hip is
○ Having webbed fingers or toes dislocated, treatment is recommended to
keep the hip in the socket until stability is
established
- How the test is done
● One side is dislocated so that
would be the ortolani positive side
when we reduced the hip
● The other side is reduced but it
can be pushed out of the socket
and is unstable (Barlow Positive
side)
1. Do not simply spread the legs
➢ Talipes Equinovarus/ “Clubfoot” 2. Lift and toggle
○ One of the congenital variations in the 3. Put your finger at the trochanter
lower extremities 4. Lift and toggle gently.
○ May be positional or true clubfoot a. There is a little bit of abduction
■ Positional and the hip pops in and out
● Feet are easily returned to b. Lift and toggle with a bit of
midline by manipulation abduction
● No treatment needed 5. PUSH IN AND SPREAD THE LEGS
OUT
Barlow Test (test for hip dysplasia)

- Identifies a loose hip that can be pushed
out of the socket with gentle pressure
- Approximately 80% of Barlow (+) hips will
resolve spontaneously in the first weeks
of life
- Early treatment may be recommended
Ortolani Test (test for hip dysplasia)
when the hip is dislocated but minor
- Identifies a dislocated hip that can be
degrees of instability can be treated with
reduced into the socket or acetabulum
multiple diapers followed by an
- Ortolani described the feeling of reduction
ultrasound study at approximately 6
as a hip flick
weeks of age
● But the translation is interpreted as
- How the test is done
a sound instead of a sensation of
1. Gently push back and then lift and
the hip moving over the edge of
toggle
the socket when relocated
a. So push out and lift it in
- After the age of 6 weeks, this sensation is
b. You can note a bit of
rarely detectable and should not be
abduction
confused with snapping that is common
c. Not wide abduction
and can occur in stable hips when
- Mostly lifting and toggling
ligament in and around the hips create
the hip into the socket
flicking noises
2. DOWN AND OUT MOTION
31
standardized graph on
weight, length, and head
circumference
- Other complications SGA infants
are at risk of developing include
● Stillbirth
● Perinatal morbidity
● Adverse effect in adulthood
● Potential for parent-infant
bonding disruption
Neuromuscular Assessment
3. LGA (Large for Gestational Age)
- ALWAYS REMEMBER!
- Birth weight above 90th percentile
- Absence of a newborn flex at birth
4. LBW (Low Birth Weight)
or persistence of a reflex past a
- Birth weight < 2500 grams
certain age may indicate a
- Independent of gestational age
problem with CNS function
assessment
- Reflexes are involuntary movements or
actions
- Some movements are
spontaneous and occur as part of
the baby’s normal activities
- Others are responses to certain
actions
- Healthcare providers check the baby’s
reflexes to determine if the brain and CNS
are working well
- Some reflexes work only in specific
periods of development
Newborn Screening
Newborn Screening (NBS)
Since part of our assessment is to weight the
- Essential public health strategy that
newborn, we use this classification to classify our
enables the early detection and
neonates:
management of several congenital
1. AGA (Appropriate for Gestational Age)
disorders which if left untreated may
- Newborn weighs between 10th -
result in mental retardation and/or death
90th percentile
- Early diagnosis and initiation of treatment
2. SGA (Small for Gestational Age)
along with appropriate long term care
- Newborns weight below 10th
help ensure normal growth and
percentile
development of the affected individual
- Similar to dysmaturity, fetal growth
- It is an integral part of the routine
restriction, or intrauterine growth
newborn care for most countries for 5
restriction
decades, either as a health directive or
- Intrauterine growth restriction
mandated by law
● Infants who at birth
- In the Philippines, this service is available
measure less than 10th
since 1996
percentile based on
32
● To obtain few products of
capillary blood from the
baby’s heel and blot on a
special absorbent filter
paper
● Drying time of blood would
take 4 hours
- NBS fee is Php 550.00 for the
regular NBS.
- Maximum allowable fee for
- Newborn screening programs in the specimen collection is Php 50.00
Philippines include screening of 6 4. Then send the specimen to the NBS
disorders. This would include laboratory
1. Phenylketonuria (PKU) - For home deliveries, babies
2. Methylmalonic Acidemia may be brought to the
3. Maple syrup urine disease (MSUD) nearest institution offering
4. Tyrosinemia NBS
5. Citrullinemia 5. Follow-up results
6. Medium chain acyl CoA - Results are available within
dehydrogenase (MCAD) deficiency 7 - 14 working days after
- The expanded screening, which is widely the NBS samples are
utilized nowadays, includes 22 more submitted to the laboratory
disorders such as hemoglobinopathies 6. We follow institution policy in
and additional metabolic disorders such communication results
as organic acid, fatty acid oxidation, and a. Negative screen
amino acid disorders. - Extremely low risk of
● The latter are included in the having any of these
standard care across the globe disorders being screened
- Newborn screening is performed after 24 b. Positive screen
hours of life but not later than 3 days from - Increased risk of having
complete delivery of the newborn one of these disorders
● Ideally done on the 48th hour being screened
● If done earlier than 24 hours, the - Immediately referred to the
baby must be screened again after nearest hospital or
2 weeks for more accurate results specialist for Confirmatory
● High risk newborns in neonatal testing and management
ICU (NICU) may be exempted from
the 3 day requirement but must be Hearing Screening
tested by 7 days - Part of the Republic Act no. 9288
- How is it done otherwise known as Newborn screening
1. Explain the procedure to the parents Act of 2004 is the Heel-Prick Method for
2. Collect the blood specimen which obtaining blood samples and the Hearing
can be done by a physician, a Screening which uses Otoacoustic
medical technologist, or after emissions (OAEs)
training by a nurse and midwife
3. Heel prick method
33
- The newborn hearing screening program ● And in continuation, as the baby is
is designed to ensure that all infants born delivered, we continue to thorough dry, by
get a hearing or a newborn hearing drying, it’s one way also of stimulating the
screening before being discharged from baby to cry
the hospital ● There is a lot to incorporate from the
- Infants who do not pass the initial and Essential Newborn Care, drying alone will
repeat screenings will be evaluated and stimulate or address the breathing and
linked to hospitals, primary healthcare the airway and then Thermoregulation as
providers, public health workers, and well.
others for appropriate treatment
- The program also provides culturally 2ND STEP: Skin to skin contact
competent support for the family ● First, we are also facilitating Bonding and
throughout the screening, diagnostic, and then the warmth and thermoregulation,
intervention changes and it also helps in the immune system of
● This would give an idea about any the baby as well, early breastfeeding,
hearing problems that could be when the baby starts to crawl and grasp
present in the early years of the the nipple, and signs of breastfeeding are
newborn addressed in the 2nd essential newborn
care
● For proper timing, cord clamping and
cutting, if you have noticed in the video,
they really used the time for that Unang
Yakap to be established
● As long as there are no signs of distress
on the side of the baby, what was seen on
the video was the standard of a normal
baby which is well-adapted and with no
Add-ons After Class (Part 1) signs of distress
Observations from the video:
1ST STEP: The immediate and thorough drying 3RD STEP: PROPERLY TIMED CORD
● We are also monitoring and make CLAMPING AND CUTTING
assessment, particularly for the breathing ● In an actual setting, the setting in the
if you place it side by side, The Principles video was from the PGH in Manila, but
of Immediate Newborn Care and this here in our hospital, the cord cutting,
essential newborn care usually the doctor does not cut right
● The first part, the immediate and thorough away.
drying, its like answering the first and ● The doctors will give enough length for
second, the Provision of the Initial Care or the cord cutting and they will continue
The Immediate Newborn Care Principles that cord cutting, the 2 inches, in the
is the maintenance and initiation of baby’s table until the essential newborn
breathing, and at the same time, the care is established, which is the Unang
second one is Thermoregulation Yakap
● So by doing the first step of Unang Yakap, ● If you have also noticed from the video,
as we all know, initial suctioning was done they give vitamins to the mother, such as
during extension, so the first part of the giving vit. K, the last thing they gave to
Immediate newborn care is addressed
34
the mother was the oxytetracycline for the clinical instructor will ask for your
eyes findings to assess if you know how
to take the Apgar Score.
➢ Practice in Velez: ● If the perfect 10 is established within 5
- We give time for the baby to do the initial minutes, we wouldn’t need to continue for
bonding and latching on another 5 minutes
- We will wait until the exact time is ● More info can be taken from the graph
established and done before we transfer ● If the mother is taking narcotics during
and do the cord cutting and giving of the labor, prepare Narcan, this will counter the
medication and the Hep. B and continue effect of the medication that the mother is
with the anthropometric measurement taking.
- Institutions have different styles, what is ● Take note of the medication that the
important is the bonding or the unang mother is receiving through health history
yakap is established.
- Raise the baby right after delivery on the Principles Of Immediate Newborn Care
mother’s abdomen and then dry, these 1. Maintain patent airway
first two are the priority ○ It is established through
Positioning and Suctioning, during
4TH STEP: Apgar Scoring the extension of the head, we
● It is the nurses role to take note or gently suction
evaluate the physical condition of the ○ Pattern should be oronasal (mouth
newborn then nose)
● This is taken from the first 1 minute, from ■ Remember that the mouth
the time that the baby was delivered of the baby has wider
● Another score is taken at 5 minutes capacity for liquid to drain,
● If the baby is still not in good Apgar so a baby has more
findings, we continue to count up to 10 or secretion compared to the
15, until the baby will complete but not nose, you need to suction
necessarily complete, as long as the the mouth first to evacuate
baby’s vital sign, particularly the heart rate all the secretions that are
and the respiratory rate is stable. present in the mouth
● If the baby is intubated, we will stop at 10 ■ Lastly is the nose because
minutes as you try to suction the
● 1st minute nose, you are also
○ Monitor appearance stimulating to cry, when
○ Monitor for the pulse they cry, they’re lungs can
○ The grimace, activity and the already accommodate air.
respiration ■ If you have plenty of
● Who will be the one to check for the secretions in the mouth
Apgar Score and the baby starts to cry,
○ Although doctors and there will be a possibility of
pediatricians give the findings for aspiration
the Apgar scores. ■ Meconium Staining can
○ The students are also required to create a problem to the
take note of the Apgar score, the baby’s lungs
35
■ The nose also has - Keep baby on mother’s abdomen can
receptors that can initiate maintain body heat (conduction)
or stimulate the baby to - Convection compared to radiation is
cry. when the baby’s temp is warmer than
■ Suctioning and positioning the environment and loses it through
is our responsibility or our the environment.
management to address f. What is an example of radiation?
respiration and initiate lung - Direct exposure
expansion - Maam’s Example is placing the baby
near the air conditioning unit
Add-ons After Class (Part 2) - Pre-warming the area is important to
Sectioning and positioning are the role of nurse combat radiation
management to address respiration and initiate g. What are characteristics that lead to heat
lung expansion. loss in the baby?
a. What is the appropriate position to address - Babies have thin skin, little
the first immediate newborn care principle? subcutaneous fat, and blood vessels
- To facilitate drainage is the Modified that are very superficial
Trendelenburg. - Babies lose heat four times more than
b. What is the mechanism of heat loss that is adults do
associated with the baby? - Babies do not shiver
- Babies have an unstable - Brown fats are metabolized to create
thermoregulating center heat energy
- Convection, conduction, evaporation,
radiation Add-ons After Class (Part 3)
c. What type of heat loss is usually exhibited by 1) What are the areas of the baby’s body
the baby with regards to wet diaper? where you could locate the brown fats?
- Conduction (transfer of body heat to ○ Chest, axilla, trachea, esophagus,
cooler object) kidneys, adrenals, mid scapula,
d. What is an example of evaporation in the abdomen, and aorta
context of a baby? 2) Brown fats develop in fetus as 26-30
- Sweat can cool down the baby as the weeks AOG and it lasts 2-5 weeks after
liquid takes away the heat energy and birth. Beyond 5 weeks, the baby’s
turns into vapor thermoregulating center is already
- Immediate and thorough drying is established
important to maintain baby’s body 3) What are the responses of the baby
heat when exposed to heat?
e. What is an example of convection? What is ○ Newborns sweat more because of
the nursing action to take to address heat the sweat glands. They have 6x
loss from convection? more compared to adults.
- The baby must be immediately ○ You would often see peripheral
wrapped after delivery to avoid vasodilation.
convection 4) What is the response of the baby when
- When baby’s head is delivered, turn exposed to cold?
off the air conditioner ○ Mottling- lacing of skin of the
baby. When they are exposed to
36
the cold, the baby's skin will look ○ Largely diaphragmatic, shallow,
blue or pale and blotchy. There and irregular
may also be a bluish marbled or ○ There are periods of apnea
weblike pattern on the baby's skin ○ Normal RR= 40-60 cycles/ min
○ Assume attitude of flexion (one 9) Benefits of breastfeeding
way of conserving their heat) ○ B - best for babies
5) Crede's prophylaxis can be delayed 1-2 ○ R - reduce incidence of allergies
hours after birth because it can alter the ○ E - economical
Bottle fed bonding process. Not well ○ A - antibodies production
established if applied early ○ S - sterile and pure
6) Taking anthropometric measurements ○ T - temperature is always ideal
○ Head circumference landmark- ○ F - fresh
just above the eyebrow to the ○ E - easy once established
occiput ○ E - emotional bonding
○ Chest circumference landmark- ○ D - digest easily (2-3 hrs)
nipple line and around the chest ○ I - immediately available
7) 3 Factors that initiates breathing or ○ N - nutritionally optional
respiration in babies ○ G - gastroenteritis reduced
○ Chemical- when the baby has 10) Gastrointestinal system
decreased O2 in their system, ○ The capacity of the GI of the baby
CO2 will increase, pH will is around 40-60 ml at birth it will
decrease. This stimulates the expand to about 90 ml in the first
chemoreceptors in the medulla few days and will empty within 2-4
that results in the forceful hours
attraction of the diaphragm ○ Feed the baby per demand
○ Thermal- changes in the ○ Know the feeding cues
temperature in the environment ○ Take note of the time the GI will
stimulates the skin of the baby. empty (2-4 hrs). After emptying,
The sensors on the skin will expect another feeding
stimulate the respiratory center ○ As the baby matures, capacity of
○ Mechanical- as the baby passes GI will also increase
through the narrowest part of the ○ Always inform mother that
mother’s pelvis, there is chest expected, after 2 hours, babies
compression. Chest compressions need to feed even if they dont cry
pushes the fluids out of the baby’s ○ Don't overfeed the baby.
lungs that triggers the chemical ○ Intestine of babies are sterile thats
factors. Upon chest compression, why artificial vitamin K should be
the pressure in the lungs becomes given to prevent bleeding
negative thus decreasing the O2 in tendencies of babies
the circulation that will cause the ○ Digestive enzyme
diaphragm to contract = ■ Lactulose - major
respiration carbohydrate in milk
8) Characteristics of neonatal respiration ■ Carbs in the breast milk are
○ Obligate nose breathers well digested
37
■ Breast Milk has lipase ■ Due to immature vascular
which helps in digestion system
and fat are in forms that ○ Jaundice
can be readily used for ■ Physiologic (after 24 hrs)
infants ■ Pathologic (within 24 hrs)
11) Meconium - first stool. ● Indicates problems
○ Consists of: in the blood like
■ Particles of amniotic fluid erythroblastosis
■ Skin cells fetalis
■ Hairs ○ Milia
■ The cells shed from the ■ Pearl like papule on the
intestinal tracts and bile face usually on the nose
○ A thick, sticky, tarry like, greenish- ○ Vernix caseosa
black accumulates in the fetal ■ Do not remove because to
intestine all throughout gestation maintain a barrier from the
and is passes within 24 hours after environment so the baby
birth can adjust and to decrease
○ Inform the mother that greenish infection
color in first stool is normal ○ Lanugo
○ If none will pass, meconium within ■ plenty lanugo is an
36-42 hours obstruction is indication of preterm birth
suspected in the GIT ○ Mongolian spots
○ Part of our assessment is to get ■ Bluish spots especially on
the temperature rectally, so aside the buttocks
from getting temp, assess if
rectum is patent Add-ons After Class (Mrs. Dotillos Version)
12) Transitional stool 1) What is the most important first thing to do
○ Greenish brown and loose in when you do immediate newborn care?
consistency ● Maintaining patent airway is the most
○ From breastmilk important.
13) Immune system ● Once the baby’s head is delivered, even
○ Ortolani’s when delivery is still at the newborn’s
■ (+) You can hear a click = chest part, we already have to do
hip dysplasia suctioning.
○ Barlow’s ● Bulb suctioning is to clean the airway of
14) The different changes of color in the skin the newborn.
of the baby 2) After maintaining patent airway, what is the
○ Acrocyanosis next important thing to do?
■ Bluish discoloration on the ● Maintaining body temperature because
extremities the baby might develop hypothermia
■ Normally seen 2-6 hours 3) In breastfeeding, what is the most important
after birth first milk that the baby should take?
■ Diminish after ● Colostrum is very important because it
thermoregulation will help the baby to have natural
○ Harlequin sign immunity.
38
● If a baby is breastfed, she does not get - From the latin word puer meaning “child”
sick easily. and parere meaning “to bring forth”
4) Once the mother starts breastfeeding, what - Refers to the 6-week period after birth
will be our nursing responsibility especially - A time of maternal changes that are both
for primigravida who have no idea what to retrogressive and progressive
do? After feeding the baby, it is important to ● Retrogressive
do what? ○ involves the returning of
● We have to burp the baby. Because if the reproductive organs
not, the baby might vomit due to the air such as the uterus and the
that has been taken in during vagina to its non-pregnant
breastfeeding. state
5) Laid back and side-lying position is usually ● Progressive
discouraged because sometimes, due to the ○ includes the production of
mother’s exhaustion, she falls asleep and the milk for lactation,
baby might fall or get crushed. restoration of the normal
6) The baby should be bathed at least 6 hours menstrual cycle, and the
after but never immediately after birth. beginning of parenting
7) Instruct the mother that while bathing, the roles
most important thing to consider is the water - Postpartum period is considered the 4th
temperature. stage of labor and this is also known as
● To check the water temperature if it is not the fourth trimester
too hot or too cold, you dip your elbow
into the basin and feel it. Three Phases of the Postpartum Period
8) Before the baby is transferred to the nursery, a) Immediate Postpartum = 1st 24 hours
never forget to put on the name after delivery
tag/identification even before the newborn is b) Early Postpartum = 1st week after
separated from the mother because delivery
abduction and/or switching babies are real c) Late Postpartum = 2-6 weeks after
issues that happened before. delivery
9) We check the temperature of the baby
rectally so as to check for an imperforate Psychological Changes during the Postpartum
anus. period
10) Bili light or bili blanket is for physiologic The changes that women undergo are crucial
jaundice. within the first 24 hours of postpartum, especially
11) Immediately after delivery, the baby should the psychological changes. These changes might
be placed under a gooseneck lamp so as to affect the women permanently if not given
maintain the temperature. appropriate attention and care.
12) Check the newborn’s temperature every 2 1) Taking-in phase: provides time for the
hours to prevent hypothermia. women to regain her physical strength and
organize her rambling thoughts about her
new role
CARE OF THE POSTPARTUM - Usually sets 2-3 days after delivery
MOTHER - The time of reflection for the women
because within 2-3 days period, women
Puerperium are passive.
39
- Dependent on the caregiver ● Allow the woman to settle in
● Women become dependent on gradually into her new role while
their healthcare provider or still at the hospital or healthcare
support person with some of the facility because making decisions
daily tasks and decision-making. about the child’s welfare is a
● This dependence is mainly due to difficult part of motherhood.
her physical discomfort from 3) Letting-go phase
hemorrhoids or after-pains, from - Recognition and adjustments of a new
the uncertainty of how she could role
care for the newborn, and also, ● The woman finally accepts her
from the extreme exhaustion and new role and gives up old roles
fatigue that she feels after like being childress or just a
childbirth. mother of one child
- Self-centered ● Readjustment to relationship is
- Reliving birth experiences needed for an easy transition on
● Women will prefer to talk about this phase
their experience during labor and - This is the phase where postpartum
birth, and also her pregnancy. depression may set in.
● Encouraging women to talk about
her experience during labor and Rooming-In
birth would greatly help her adjust - The more time the mother has to spend
and let her incorporate it in her with her baby, the sooner she will feel
new life. competent in childcare and the more she
2) Taking-hold phase will be able to form a sound mother-child
- Starts from 3-10 days relationship
- Regaining autonomy - Rooming-in is when the infant stays in the
● Women start to initiate action on room of her mother rather than in a central
their own and make decisions nursery.
without relying on others. - Mother can become better acquainted
- Women, who underwentf anesthesia, with her child and begin to feel more
reaches this phase only hours after her confident in her ability to care for him/her
delivery. after discharge.
- She starts to focus on the newborn
instead of herself and begins to actively ➢ Two types of Rooming-in
participate in newborn care. a) Complete Rooming-in
- Open to health teachings - When the mother and the child are
● Demonstrate newborn care to the together 24 hours a day
mother and watch her do the b) Partial Rooming-in
return demo of every procedure. - Infant remains in the room of the
● The woman still needs positive mother most of the time (usually
reinforcement despite the daytime) but then she will be taken to
independence she is already a small nursery near the women’s
showing because she might feel room and return to a central nursery
insecure about the care of her at night.
child
40
With both complete and partial rooming-in, the Postpartum: Maternal Concerns
father and the sibling can hold and feed the infant 1) Abandonment
when they visit. - Many mothers, if given the opportunity,
Rooming-in may also allow the couple to better admit to feeling abandoned and less
retain instructions and anticipatory guidance in important after giving birth.
the care of the newborn, especially because the - Before, they were the center of attention
nurses have demonstrated bathing, feeding, and with everybody asking about their health
changing of their own child. and wellbeing.
- During the birth of the baby, suddenly
Sibling Visitation the baby seems to be everyone’s chief
- Separation from children is as often as interest e.g. relatives ask about the baby
painful for a mother as it is for her and the gifts are all for the baby.
children. - It can make a woman feel confused by a
- Waiting at home, separated from their sensation very close to jealousy.
mother, and listening only to telephone ● You can help the woman move
reports of what their newborn past these feelings by verbalizing
brother/sister looks like, can be very very the problem or asking them how
difficult for older children. does it make them feel.
- A chance to visit the hospital and see the ● This is one way of reassuring and
new baby and their mother reduces the letting the woman know that the
feeling that their mother cares more about sensation she is experiencing,
the new baby than about them. although uncomfortable, is normal.
- It can help to relieve some of the impact - The same way with the father.
of separation and also helps to make the ● When a newborn comes home, a
baby part of the family. father may express much the
- During sibling visitation, check to be sure same feelings.
that siblings are free from contagious ● He may become resentful of the
diseases like upper respiratory tract time the mother spent with the
illnesses or recent exposure to infant.
chickenpox before they visit. ● E.G. The two used to sit at the
- Have them wash their hands, if they table after dinner and discuss their
choose to actually hold or touch the days or their future, and now, she
newborn with parental assistance. hurries away to feed the baby.
● Some hospitals require siblings to ● We need to help them accept and
wear a covered gown before understand that both motherhood
holding their new brother/sister. and fatherhood involves
- You may need to caution women that compromise in favor of the interest
opinions of a new brother/sister of the baby.
expressed by her older children may not ○ It would start during the
be complementary. However, seeing the pregnancy or early in the
baby even if his/her appearance is not postpartum period. Making
what the older children expected, it is infant care and shared
helpful in establishing strong relationships responsibility could help
and should be encouraged. alleviate these feelings and
make both partners feel
41
equally involved in the care that occurs with the delivery of the
of the baby. placenta.
2) Disappointment - For some women, it may be a response to
- Common feeling parents may dependence and low self-esteem caused
experience is disappointment in their by exhaustion, being away from home,
baby. physical discomfort, and tension due to
- During pregnancy, a couple may picture assumed new role, especially if the
a cute, chubby-cheeked, curly-haired, woman is not receiving support from her
smiling baby girl or boy and instead, partner.
they have a skinny baby without any hair - The syndrome is evidenced by
who seems to cry constantly. tearfulness, feeling of inadequacy,
- It can be difficult for parents to feel modiability, anorexia, and sleep
positive immediately about the baby disturbance.
who does not meet their expectations. - You can assure a woman that sudden
- The need to help them accept that you crying episodes are normal.
can never change the sex, size, or the - Anticipatory guidance and individual
look of their child. support from healthcare personnel are
● You can help to change the feeling important to help the parents understand
of the mother or father about their that this response is normal.
infant by handling the child warmly - It is also important to give the woman a
to show that you find the infant chance to verbalize her feelings, allowing
satisfactory or even special. her to make as many decisions as
● Comment on the child’s good possible can help give her a sense of
points such as long fingers, lovely control over life.
eyes, and a good appetite. - However, not all postpartum women cry
● During a period of crisis such as because they have baby blues. A woman
childbearing, it is possible for a sometimes has other reasons to feel sad
key person to offer support and during this time, maybe perhaps an
help them towards acceptance or overwhelming problem at home or
at least help the person involved to financial problems.
take a clearer look on her situation - Keeping the lines of communication open
and begin to cope with the new is important to help differentiate between
circumstances. problems that can be handled best with
3) Postpartal Blues discussion and concerned understanding,
- During the postpartum period, as many as and those that should be referred to the
50% of women experience a feeling of Social Service Department.
overwhelming sadness. - 30% of women experience a more serious
- They may burst into tears easily or feel let level of sadness after birth. This is termed
down or irritable. as postpartal depression.
- This temporary feeling after birth has long ● Serious depression requires formal
been known as baby blues. counselling or psychiatric care.
- This phenomenon may be caused by
hormonal changes, particularly the Postpartum: Physiologic Changes
decrease in estrogen and progesterone Several body systems are also affected after the
birth of the newborn. These changes may or may
42
not be noticed by the mother early during ○ Contains Blood, fragments, WBC,
postpartum. mucus, and bacteria
➢ Uterus ○ Lochia discharge typically continues for
○ Involution completes in 6 weeks 4-6 weeks after childbirth
■ Wherein reproductive organs return ○ Lochia starts to appear as a bloody
to their nonpregnant state discharge for the first 4 days after birth
■ Occurs more quickly in women who and is termed as lochia rubra.
are well-nourished and ambulate ■ Lochia Serosa is the brownish to
early after birth pinkish discharge that starts on the
○ The uterus returns to its nonpregnant 4th day and the amount of blood
size gradually, about 1 fingerbreadth per and tissue decreases.
day. ■ Lochia Alba appears on the 10th
○ The uterus is nonpalpable on the 10th day and the discharge decreases
day. and almost looks colorless, whitish,
○ Afterpains or yellowish. It may last until the
■ Occurs as a result of contraction of third week after birth.
the uterus
■ There are areas where the placenta
implanted is sealed off to avoid
bleeding.
■ Contraction plays a very important
role in the postpartum period for it
allows the uterus to return to its
former size quickly and also prevent
hemorrhage.
○ Monitor for Postpartum Hemorrhage!
○ Nursing Consideration: Watch out for

the lochial flow
■ Described as scanty, light,
moderate, and heavy
■ A scanty lochial flow would appear
<2 inches stain on the pad
■ For light, 4 inches stain on the pad
■ For moderate, this is smaller than 6
inches stain on the pad
■ A large or heavy lochial flow would
appear more than 6 inches stain and
is saturated in an hour.
■ A heavy lochial flow with offensive
odor would suggest retained
placental fragments
■ For puerperal sepsis, this is
➢ Lochia
described as scanty with putrid
○ Vaginal discharge after giving birth
43
odor, accompanied with fever or ○ Immediately after birth diuresis
pyrexia sets in to rid the body of the
■ A normal blood loss for NSVD is excess fluid that has accumulated
300-500 mL and for C-section is during pregnancy. On the second
800-1000 mL to fifth day after birth the urinary
output of women increases as
➢ Cervix
much as 3000mL per day.
○ Internal & External OS
● Decrease blood volume
■ The cervix is soft and malleable
○ The woman’s abdomen must be
immediately after birth but once
assessed frequently during the
contraction of the cervix takes postpartum period to prevent
place, it also returns to its damage of the bladder due to
pre-pregnant state. overdistention. Blood volume
■ At the end of 7 days, the external returns to its pre-pregnancy level
OS narrows to the size of a pencil by the first-second week of birth,
opening but appears slit-like or hematocrit level reaches normal
star-shaped compared to its round pre-pregnancy level six weeks
shape before childbirth occurred. after birth and an increase in
lymphocytes and plasma
Postpartum Progressive Changes fibrinogen occurs in the first
post-partum week as a defense
Post-partum: Retrogressive changes
mechanism against infection and
hemorrhage.
● Pain upon bowel evacuation
○ Passage of stool may still be slow
because of relaxing that is still
present in the bowels. Bowel
evacuation may still be still be
difficult because of the pain of
episiotomy
● Striae gravidarum lightens
Women Experience:
● Exhaustion
● Estrogen & progesterone drops = Increase ○ Women experience total
in FSH exhaustion as soon as birth is
○ As soon as the placenta is no completed. For several months of
longer present, pregnancy pregnancy women experience
hormones start to decrease. The difficulty of sleeping due to being
HPL and HCG are insignificant by unable to find a comfortable
24 hours and estrogen and position in bed because of fetal
progesterone returns to their activity and the presence of back
pre-pregnancy level a week after pain/ache or leg pain.
birth. FSH remains low for 12 days ○ During labor she has eaten very
and then starts to increase to little and has worked very hard
signal the start of a new menstrual with little to no sleep, now she has
cycle. sleep hunger which makes it
● Diuresis = 3000 mL/day difficult for her to cope with the
44
new experiences and stressful lasts longer than a few
situation. hours, however, infection is
● Weight loss – losing 19lbs more likely the reason.
○ At birth women lose weight ○ Puerperal infection
approximately 12 pounds, during ● Pulse
the 2nd to 5th day after birth, ○ Women’s pulse rate during
women experience rapid diuresis post-partum is usually slightly
and diaphoresis which results to slower than normal. The increased
another 5-pound weight loss. blood volume returning to the
Lochial flow causes additional 2 to heart, stroke volume increases.
3 pounds for a total weight loss of The increased stroke volume
about 19 pounds. Vital signs reduces the pulse rate to between
changes in the post-partum period 60 to 70 beats per minute. As
reflex internal adjustment that diuresis diminish the blood volume
occurs as the woman’s body and causes blood volume to fall,
returns to its pre-pregnancy state. the pulse rate increases
● Increased clotting factors accordingly. By the end of the first
● Temperature week the pulse rate will have
○ For temperature never get a rectal returned to normal. We need also
temp during puerperium because to monitor closely the pulse
of the danger of vaginal because a rapid and ___ pulse
contamination and the discomfort during this could be a sign of
involved in rectal intrusion. hemorrhage.
○ Dehydration ● BP precaution on medications
■ During the first 24 hours ○ Blood pressure should also be
after birth women may monitored carefully during the
show a slight increase in post-partum period because a
temperature due to decrease can indicate bleeding. In
dehydration. If she receives contrast to elevation above
adequate fluid during the 140mm/Hg systolic and 90mm/Hg
first 24 hours, this diastolic may indicate the
temperature elevation will development of post-partum
return to normal. Women pregnancy induced hypertension,
may experience an an usual but serious complication
increase in temperature or of the puerperium.
a febrile episode after the ○ Oxytocin is a drop frequently
first 24 hours, in such administered during the
cases a postpartum postpartum period to achieve
infection may be present. uterine contraction can cause
○ Breast engorgement contraction to all smooth muscle
■ Occasionally when a including blood vessels.
woman’s breast fill with Consequently, this drag can
milk or engorgement on the increase blood pressure. To
3rd or 4th postpartum day prevent blood pressure from rising
her temperature rises for a too high, always measure it before
period of hours because of administering the agent/drug. If
the increase in vascularity the blood pressure is greater than
in the breast. If the 140/90 mm/Hg hold the agent and
elevation in temperature notify the physician to prevent
45
hypertension and possibly inhibit this process by causing continual
cerebrovascular accident. circulation of progesterone which inhibits
○ Another complication in women prolactin and thus, milk production.
who have lost a significant amount I – 16 weeks gestation
of blood during birth is orthostatic ● Lactogenesis I or milk synthesis is the
hypotension or dizziness that process that beings around 16 weeks of
occurs due to lack of adequate gestation as the glandular luminal cells in
blood volume to retain the ___ to the breast begin secreting colostrum, a
the brain cells. If the woman thin watery pre-lactation secretion.
experiences this we need to II – Birth to 10 days PP
advise her to always change ● Lactogenesis II is triggered at first by the
position gradually like from lying delivery of the placenta when the
down to sitting, she needs to progesterone hormone and other
slowly move and dangle first her circulating pregnancy hormones suddenly
legs before attempting to walk. decrease and oxytocin sharply increases
as a result of infant sucking. Oxytocin
Lactogenesis helps the uterus shrink to its
pre-pregnancy size and some mothers will
feel uterine cramps initially when
breastfeeding until the uterus fully
involutes. Lactogenesis II is often when
mothers feel that their milk has come in or
there is breast engorgement and occurs
from birth to 5 to 10 days postpartum, this
is often termed as the transitional milk.
III – Day 10 to weaning PP
● Lactogenesis III can occur from day 10
until weaning postpartum when the
Being part of a part of the reproductive mature milk supply is now driven by the
system of a woman, the breast functions for circulating lactating hormones oxytocin
lactation or milk secretion for nourishment in and progesterone.
maternal antibodies which is the IgA and the IV – After PP until breasts involute
source of pleasurable sexual sensation. The ● Lactogenesis IV occurs after complete
arterial venous and lymphatic communicate weaning and the breast involute to their
medially with the internal mammary vessels and pre-lactation state. Other hormones are
laterally with the axillary vessels. associated with breastfeeding such as
endorphins and oxytocin and may help to
In cancer of the breast, metastasis reduce or mitigate the developing
follows the vascular supply, both medial and postpartum depression.
laterally. The early lactation process which is
driven by hormones from the hypothalamus to There are reflexes that need to be considered:
the pituitary glands in order to secrete the ● Prolactin reflex (milk secretion reflex)
lactation hormone is identified by four phases of ○ The first maternal reflex in
lactogenesis or human milk production. breastfeeding would be the
prolactin/milk secretion reflex.
Prolactin hormone is responsible for milk High prolactin levels stimulate the
production and oxytocin is responsible for the alveoli particularly the asinine cells
letdown reflex part. A retrained placenta can and milk is then produced in the
breast tubules. High levels of
46
estrogen and progesterone induce leads to a slight delay to the return
alveolar ___ growth as well as of ovulation.
stimulating milk secretion. In ● Non BF = 6-10 weeks; BF= 3-4 months
pregnancy milk is not stimulated ○ With the return of ovulation this
because of low prolactin, as a initiates the return of normal
result of high estrogen secretion menstrual cycle, the woman who
by the placenta. is not breastfeeding can expect
● Letdown reflex (drought reflex) her menstrual flow to return in 6 to
○ While the drought/letdown reflex is 10 weeks after birth but if she is
oxytocin induced, the act of breastfeeding the menstrual flow
sucking a lactating breast may not return for 3 or 4 months
stimulates the flow of milk, this or what we call the lactation
free-flowing of milk is called the amenorrhea.
letdown reflex, affected by ○ Some women, for the entire
maternal emotions. lactation period however the
● Milk ejection reflex absence of menstrual flow does
○ Milk ejection reflex controls the not guarantee that the woman will
expulsion of milk from the breast not conceive during this time,
tubules also under the influence of because she might ovulate well
oxytocin secreted by the posterior before menstruation returns.
pituitary glands. ● Lactation Amenorrhea
● Breast care
Return of Menstrual Flow ○ Breast care, for non-lactating
women to minimize or alleviate
discomfort due to engorgement
cold compress is applied to
decrease breast swelling and pain.
For lactating mothers warm
shower and bath or warm
compress can cause vasodilation
thus facilitating letdown reflex or
letdown of milk
o Cold compress: non-lactating
o Warm compress: lactating
Postpartum Hemorrhage
Postpartum hemorrhage is one of the
most important causes of maternal death
associated with childbirth. It is defined as any
● Decrease in estrogen and progesterone blood loss from the uterus greater than 500mL
○ With the delivery of the placenta within a 24-hour period or hemorrhage that
the production of placental reaches 1000mL of blood loss.
estrogen and progesterone ends ● Etiology: Uterine atony
this results in a decrease in ○ The most frequent cause of
hormonal concentration thus postpartum hemorrhage is due to
causing a rise in production of uterine atony or relaxation of the
FSH by the pituitary which then uterus. The uterus must remain in
the contracted state after birth to
47
allow the open vessels of the for possible postpartum hemorrhage because if a
placental side to peel off. mother is frequently in bed on a flat position there
● Risk factors: will be pooling of blood (see blue circle) inside
○ Polyhydramnios, macrosomia, the uterus and you will not be able to assess this
multiple gestation and grand blood because it will just pool inside uterus.
multiparity
○ Placental complications (placental Ambulation or being in an upright position
acreta, placental increta and will facilitate the drainage of this blood out of by
placental percreta) gravity and it will give us an idea of possible
○ Blood clotting problems postpartum hemorrhage.
○ Lacerations (vaginal, perineal,
cervical)
○ Medications
○ Hematoma
○ Subinvolution
Associated with retained placental

fragments is the possibility of having placental
Accreta, this is the unusually deep attachment of
the placenta to the uterine myometrium. So deep
that the placenta will not loosen and deliver.
This is what postpartum hemorrhage

looks like for a mother. Remember that we need
to monitor for any retained placental fragments.
This is the normal implantation of the

placenta however, in some cases specially the
Accreta this is a very rare case; it might go deep
within the myometrium. The Increta is already the
penetration of the placenta deep into the
This site here is where the placenta was myometrium and towards the perimetrium while
implanted. After the removal of the placenta there Percreta has already reached towards the
will be possible retained placental fragments that perimetrium. In these cases, it is associated with
promote/induce bleeding. One of the nursing previous cesarean birth and in-vitro fertilization.
considerations postpartum is to facilitate
ambulation, because through ambulation we will This can be identified through ultrasound
be able to accurately identify or give us an idea exam during pregnancy, removing such a deeply
48
imbedded placenta can lead to severe physician for the repair of lacerations or DNC for
postpartum hemorrhage. To identify the management of lacerations and retained
complications of a routine placenta, every membranes respectively.
placenta should be inspected carefully after birth
to be certain that it is complete. Maintain asepsis since hemorrhage
predisposes a mother to infection. Monitor I&O,
Retained placental fragments can also be fluid and blood replacement, and oxygen
identified by ultrasound. Attempting to remove it administration. Be alert for blood reactions.
manually may lead to extreme hemorrhage Provide psychological support, explain tests,
because of the deep attachment. Hysterectomy procedures, and situations to help ally anxiety
or the removal of the uterus or treating the and teach the need to increase iron in the diet
mother with Methotrexate to destroy the still and to adhere to follow-up care schedules.
attached tissue may be necessary.
Also, to prevent infection it is very
Nursing Management important that we start antibiotics as ordered, a
● Fundal check broad-spectrum antibiotic directed at multiple
● Lochia check/pad count organisms often are administered prophylactically
● Bladder check and vital signs monitoring for cesarean sections and prolonged rupture of
● Ice pack application membranes. Maintain the mother in bed rest and
● Breastfeeding isolate the mother from the newborn. Observe
● Administration of oxytocics standard precaution and observe careful
● Bimanual compression handwashing. Personnel with signs of infection
● Surgery should not be assigned to render direct care.
● Antibiotics
Monitor vital signs, I&O, force fluids up to
In managing complications postpartum, it 3000 to 4000mL is not contraindicated and
is important that we stay with the client and encourage frequent voiding. Promote drainage of
massage the fundus until the firm. This is the first secretions, proper positioning
nursing action for uterine atony and this is to (fowlers/semi-fowlers), perform perineal hygiene,
expel the clots. Avoid over massaging as this can provide high calorie, high protein, and high iron
tire the muscles causing relaxation. diet
Give oxytocic drugs as ordered, apply ice

Nursing Management with Episiotomy
pack on fundus and encourage regular bladder
emptying to keep the uterus contracted.
Remember that a descended bladder can
displace the uterus to the side and may
potentially cause uterine atony and bleeding.
Initiate early breastfeeding or perform

nipple stimulation to stimulate oxytocin secretion
by the posterior pituitary gland. Check vital signs
and fundus every 5 to 15 minutes. Encourage - In cases where the mother has an
voiding, the client should be able to void 4 to 6 episiotomy or laceration, we always check
hours after delivery, assess and estimate blood for its
loss frequently. It is important that we monitor the 1. Appearance
lochia and check the number of pads they
2. Tearing/Laceration
consume every hour, keep all pads and linens to
assess the volume of blood loss. Notify the
49
3. Take note for Hematoma Providing rest and sleep with early and
Formation regular ambulation
4. Hemorrhoids Diet
- In case the mother has this, we use - Provide diet that is high in protein
REEDA for assessment and calories with a caloric
Redness requirement of 2500 kcal/day for
Edema non-lactating mothers and 3000
Ecchymosis (Pinpoint lance blanching of kcal/day for lactating mothers
the skin due to bleeding) - Provide vitamins and minerals
Discharge especially Vit C and Iron
Approximation of the suture or episiotomy Monitor VS and Fundus for firmness and
- It is important to take note of early signs descent
of infection to the sites to prevent - Usually, the fundus is palpable
maternal sepsis until the 10th day
- After the delivery, the vagina may be - The uterine fundus is no longer
edematous, bruised, thin-walled due to palpable as it descends behind the
the lower estrogen levels. †here would be symphysis pubis
few rugae, may have small lacerations Monitor for the color, odor and amount of
- It is smooth for 3-4 weeks, and will the lochia
reappear at 4 weeks. There will be a
Expect for diuresis
return to pre-pregnancy state by 6-8
Note postpartal blues which may be
weeks
caused by a drop in maternal hormones in
1. Perineal care
the 4th or 5th day
- In case that the woman has an
Promote bowel & bladder function -
episiotomy or laceration,
Encourage Kegel Exercise
post-repair, we need to make sure
Provide psychological and physical
that infection should not occur.
comfort
This is why it is important that we
- Meet the mother’s needs so she
do perineal care and instruct the
can meet the infant’s needs
mother how to do this on her own
- Assist the mother in self-care and
to promote independence
baby care as indicated
2. Perilite treatment - 20 minutes at 20-inch
distance TID Promote bonding
- Dry heating to promote early - Encourage Breastfeeding
drying and healing of the wound - Start early
3. Hot sitz bath - Promote rooming in
- Especially if a client has - Verbalize positive neonatal traits
hemorrhoids and similarities to the mother and
4. Kegel Exercise father’s features
- To strengthen the pubococcygeus - Administer oxytoxic drug to
muscle after delivery promote uterine involution
Provide maternal teaching regarding
Nursing Management Strict asepsis and pericare,
- Generally during the postpartum period, observe front to back of flushing
our nursing management would include and removal of peripads
50
Hand Washing prior to after childbirth during which the mother's
breastfeeding, handling self-care, reproductive organs return to their original
and providing baby care nonpregnant condition) would be to
- The most important 1. Promote uterine involution
practice to prevent a. To promote this, we
infection and its spread in i. Promote
the hospital breastfeeding
Resumption of intercourse ii. Administer oxytocin
- The resumption of intercourse and iii. Promote proper
family planning would depend on positioning
the couple (Knee-chest or
- There is no prescribed time to Prone)
resume sexual intercourse iv. Promote normal
- Some factors to consider when anteflexion
resuming this are v. Early ambulation
1. Maternal comfort reduces the
2. Perineal swelling incidence of
3. Personal desire to have sex complications
Regular visit to the pediatrician would be secondary to
important for health maintenance prolonged bed rest
Administer prophylactic measures such such as
as RhoGam (this is for an unsensitized thrombophlebitis,
mother who is Rh- and has given birth to pneumonia, and
an infant who is Rh+, and should receive subinvolution of the
immunoglobulin within 72 hours of uterus
delivery. It is administered even when a vi. Promote regular
mother has already received RhoGam voiding as a bladder
after previous delivery or even if she displaces the
received RhoGam in the antenatal period uterus, thus
of the latest infant) & Rubella Vaccine (if delaying the normal
the mother is not immune to Rubella or involutionary
German Measles, she has to receive the process
vaccine before discharge from the - Take note of the fundic
hospital. Because of the potential height
teratogenic effects of rubella, the mother - The position of the
needs to sign an informed consent before uterus is usually
receiving the vaccine, and a recent measured in finger
instruction not to be pregnant within 28 breadths, above or
days to 3 months. Needs to be counseled below the level of
again in becoming pregnant again before the umbilicus to get
receiving rubella vaccine if she declines to accurate results
be immunized in the hospital before - Instruct the woman
discharge) to empty the
bladder first before
Also essential objectives during the
assessing
puerperium (period of about six weeks
51
- The fundus above until day 10 when it can no
the umbilicus is longer be palpated
considered + or - By this time, the
positive sign, while fundus is behind
a fundus below the the symphysis
umbilicus is pubis.
considered - or - The fundus is easily
negative sign displaced usually above
- Example, the umbilicus and to the
when the right side by a distended
fundus is 1 bladder because the broad
finger breadth and round ligaments were
below the greatly stretched during
umbilicus, we pregnancy which was then
term that as -1 followed by marked laxity
and when the after delivery
fundus is 2 2. Promote successful breastfeeding
fingerbreadths 3. Prevent common discomfort of
above the puerperium
umbilicus, we a. For breast engorgement,
term that as we manage this by
+2 applying wet compress
- Fundus at the application
level of the - Warm = Lactating
umbilicus is 0. - Cold =
Typically we Non-lactating
record this - This is indicated for
condition “as comfort
fundus is firm b. For after pain
and negative i. We explain the
precentral” possible causes to
- Also take note of the validate the
lochial discharges and normalcy of their
afterpains feelings. Explain
- Note that the normal that after pains are
involution of the uterus, is signs that the
that the fundus will be firm uterus is involuting
and is at midline and at the ii. Place an ice pack
level of the umbilicus on the fundus
- At Day 1, the fundus is a or (never hot water
about 1 fingerbreadth bag) to prevent
above the umbilicus bleeding
- Fundus descends by 1 - Give analgesics as
fingerbreadth each day ordered
c. For urinary retention
52
i. Promoting early analgesics as
ambulation 48 ordered.
hours after NSVD v. Psychological
can help prevent support and
urinary retention. explanation of the
ii. Increased fluid condition corrects
intake itself once the
iii. Stimulation to void increase in blood
may help. supply and pressure
iv. Catheterization is of pregnancy are
the last resort diminished and the
specifically, straight regular bowel
catheterization movement is
d. To prevent hemorrhoids, established
it is very important that we e. To manage constipation,
promote ambulation as i. Include roughage
well. intake
i. Treat affected areas ii. Encourage intake of
with cold packs fresh fruits as well.
right after delivery iii. Promote regular
and leave in the bowel habits,
same position, no iv. Administer glycerin
longer than 20 or bisacodyl
minutes and repeat (dulcolax) as
every 4 hours. ordered if bowels
ii. Provide moist heat do not move before
through a sitz bath the 3rd morning
with water temp at after delivery
38°C for 20 minute f. For episiotomy,
periods. i. Apply cold or ice
iii. Observe the woman packs which offer
for signs of fainting vasoconstriction
- For small effects, reduce
hemorrhoids, the edema and
mother may be discomfort, and
shown how to place also provide an
the hemorrhoid anesthetic effect
back in the which therefore
anorectal canal reduces pain.
using a lubricated ii. Dry heat or perilite
finger, cup, or can be done for 20
rubber glove. minutes with
iv. Avoid oily food, perilamp,
local heat, or positioned 20
occasional inches away from
53
the perineum. Can iii. Listening
be done 3 times a e. This is not the best time to teach
day as ordered and about baby care because the
at home 40 Watts mother wants someone to listen to
desk bulb can be her
an effective heat 2. Taking-hold Phase
lamp. a. 3 days to 2 weeks after delivery
iii. Provide moist heat b. This is the phase of striving for
with hot sitz bath independence
twice a day or more c. The mother appears to be
and anesthetic impatient to have control over her
spray ointment or own bodily functions and to learn
analgesics for relief mothering tasks, strives for
of pain can be given independence, and may have
as ordered mood swings, strong anxiety
4. Provide psychological support elements, responds to positive
- Always remember to reinforcements, and more in
provide psychological control
support to the postpartum d. Nursing Management
mother and entail an i. Provide teaching about
understanding of the baby care
normal maternal ii. Stay during this phase to
psychological adaptations provide positive
and emotional reactions reinforcement
5. Initiate contraception iii. Guard against fatigue
6. Prevent complications iv. Compliment generously for
the mother in sense of
Postpartum Phases of Maternal Role Taking doing things right
3. Letting-go Phase
a. During this time, this occurs 10
days to 2 weeks after delivery
b. This is the independence phase
c. At this time, the woman gives up
1. Taking-in Phase former role and self-concepts and
a. Heppens 1 - 3 days after delivery integrate new roles and
b. The dependent phase self-concepts as a mother
c. Mother appears to be talkative, d. She achieves independence,
verbalizes delivery experiences, accepts the baby as a separate
dependent, concerned with own being, and may have feelings of
needs, self-centered, and passive insecurity, inadequacy, and deep
d. Nursing management would loss of the separation of the baby
include from her
i. To meet or assist the e. Us nurses, we
mother in meeting physical i. Allow verbalization of new
needs roles
ii. Allow verbalization
54
ii. Provide positive nipples how to breastfeed
reinforcement as she properly.
defines her roles with her 3) What is the most common position for
support system breastfeeding mothers?
iii. Be understanding and Answer: cradle position, comfortable
supportive kaayo for mother and baby. lay-down,
and side-lying position is not encouraged
extra input because the mother may fall asleep and
1) What is the most important principle in the child may fall from her grasp.
immediate newborn care? (v important 4) In newborns, what are the different
daw) measurements to check for the
Answer: different anthropometric
● Maintain patent airway (do suctioning measurements of the newborn?
using the suction bulb immediately after Answer: weight, height,head
the birth). circumference, chest circumference,
● Second most essential: abdominal circumference.
○ maintain body temperature (rectal 5) What are you going to encourage the
temperature when newborn is infant to pass gas?
born, not at axilla because it also Answer: burp the baby, support the head
allows you to check the patency of and upper back when doing so.
the anus as well *like if they have 6) When should you bathe the newborn?
any holes that they shouldn't Answer: you should bathe the baby
have). within 24 hours (6 hours minimum). you
2) What do you call the first stool that should not bathe the baby immediately to
passes after the first 24 hours of life? prevent hypothermia.
Answer: 7) Postpartum mother’s different
● Meconium: observe for color and physiological changes (phases):
form. answer: 1) taking in: 1-3 day period
● Primigravid mother’s may have a 2) letting go: 10 days after delivery
hard time understanding how to 8) Different maternal concerns of mother
breastfeed for the first time. after delivery (v important again)
instruction should be given to the Answer: 1) abandonment: mothers have
mother so the baby can feed the feeling that they are left behind since
properly and be nutritionally the arrival of the baby (postpartum blues)
adequate. some women have 9) What is postpartum blues?
inverted nipples, which is not a Answer: sadness, fearfulness,
contraindication (this is why during inadequacy, anorexia, insomnia (s.o.
prenatal check-up, for the woman should support mother during this time, if
to massage her breast first, and untreated will become a big problem later
then gently and slowly pull the in her life).
nipple out before breastfeeding, so 10) Acrocyanosis:
the child has something to latch Answer: baby has a pink body while
onto. it is important for nurses to extremities are blue/purple. normal for the
instruct women with inverted newborn, but if prolonged could be
another problem.
55
it can be by using Standardized
Test (MMBFT). Progression
LECTURE FIVE A towards maturity (qualitative)
GROWTH AND DEVELOPMENT: ○ Maturation is a synonym for
THEORETICAL APPROACHES TO THE development.
GROWTH AND DEVELOPMENT OF ● Developmental milestone
○ Are behaviors or physical skills
CHILDREN
seen in infants as they grow and
develop (rolling over, crawling,
Growth and Development
walking and talking). The
All children pass through predictable
milestones are different for each
stages of Growth and Development as they
range. There is the normal range,
mature. Parents often ask what to expect from
in which the child can reach each
their children regarding their developmental
milestones. Major markers of
progress at health care visits, such visits provide
normal development
opportunity for new, not only to assess present
● Development task
growth and development but also to supply
○ These are the things that we need
anticipatory guidance on the topics. For these
to look into in every milestone,
reasons, including growth and development is
these includes the skill or growth
essential in the establishment of complete and
responsibility arising are a
effective nursing care plans for children.
particular time in an individuals
life.
In the next slides, the different
developmental milestones of infants, toddlers,
Division of childhoods
preschool, school-age and adolescents.
Neonate = first 28 days of life (Neonatal Period or
the Newborn Period)
The term Growth and Development are
Infant = children under or within 1 mos to 1 year
occasionally used interchangeably, but they are
Toddler = 1- 3 years
different.
Preschooler = those that are aging 3 -5 years
● Growth
School age child = 6 -12 years
○ Is generally used to note an
Adolescent = 13 – 17 years
increase in physical size
Late adolescent = 18 – 21 yrs
(quantitative change).
○ Growth in Weight is measured in =
Theoretical Foundation
pounds or kilograms
There are a number of theories that explains the
○ Growth in Height = inches or
development of humans in each age group.
centimeters
● Freudian Theory – psychosexual
● Development
development
○ Is used to indicate an increase in
○ The first one is Sigmund Freud’s
skills or the ability to function.
Psychoanalytic Theory of
Development is measured in the
Personality, and it argues that
child’s ability to perform specific
human behavior is the result of
task, such as how well a child
interaction among three (3)
picks up small objects (raisins),
components part of the mind. That
and by recording the parent’s
is the id, ego and superego.
description of a child’s progress or
56
○ This structural theory of ○ During each stage, a person
personality places great experiences a psychosocial crisis
importance on how conflicts which could have a positive or
among the parts of the mind negative outcome for personality
shape behavior and personality. development
These conflicts are mostly ○ According to the theory,
unconscious. successful completion of each
○ According to Freud, personality stage results in a healthy
develops during childhood and is personality and the acquisition of
critically shaped through a series basic virtues. Basic virtues are
of five (5) Psychosexual Stages, characteristic strength which the
which he called Psychosexual ego can -- to resolve subsequent
Theory of Development. During crisis.
each stage a child is presented ○ Failure to successfully complete a
with a conflict between biological stage can result in a reduce ability
drives and social expectations. to complete further stages, and
○ Successful navigation of these therefore a more unhealthy
internal conflicts will lead to personality and sense of self.
mastery of each developmental ○ These stages however, can be
stage and ultimately to a fully resolved successfully at a later
mature personality. time.
○ Freud’s ideas are being met with
criticism in part of it. His singular
Erickson’s Psychosocial theory
focus on sexuality as a main driver
of human personality Stage Name Psychoso Positive/negati
development. and Age cial crisis ve outcome
● Psychosexual stage
1 Infancy Trust vs P Feeling of
○ Oral - The mouth - sucking, to 1.5 mistrust trust from
swallowing etc. (EGO developes) years environmental
○ Anal - the anus-withholding or support
expelling faces N Fear and
○ Phallic - The penis or clitoris - concern
masturbation (Super ego develop) 2 Early Autonomy P Self -
○ Latent - Little or no sexual Childhoo vs Shame sufficiency
motivation present d 1.5 to & doubt N Lack of
○ Genital - The penis or vagina - 3 years independence
sexual intercourse , contrary to
● Erikson’s stage of personality self-sufficienc
y
development – Psychosocial development
○ Erickson maintained that 3 Play age Initiative P Discovery of
personality develops in a 3 to 5 vs guilt ways to
predetermined order through eight years initiate actions
(8) Stages of Psychosocial N
Guilt from
Development from infancy
actions and
thought
57
○ Kohlberg identifies three (3)
4 School Industry P
age 5 to vs Development distinct levels of moral reasoning.
12 years inferiority of sense of Each level have 2 substages.
competence ○ People can only pass through
N No sense of these levels in the order listed.
mastery Each new stage faces the
5 Adolesce Identity P Awareness reasoning typical to the earlier
nce 12 vs role of uniqueness stage
to 18 confusion of self. ○ Not everyone achieves all the
years Knowledge of stages.
roles to be
followed
N Inability to Level 3 POSTCONVE Stage 6: Self -
identity the NTIONAL selection of
appropriate Shared universal
roles of life standards principles
Right and Stage 5:
6 Young Intimacy P duties Sense of
Adult 18 vs development democracy
to 25 Isolation of loving, and relativity
sexual of rules
relationships
N Fear of Level 2 CONVENTIO Stage 4:
relationships NAL Fulfilling
with others Performing duties and
right roles upholding
7 Middle Generativi P Sense of laws
Adult 25 ty vs contribution to Stage 3:
to 65 Stagnatio continuity of Meeting
n life expectations
N Trivialization of others
of one’s
activities Level 1 PRECONVEN Stage 2:
TIONAL “Getting what
8 Late Ego P Sense of Values in you want” by
Adult integrity unity in life’s external trade-off
65+ vs accomplishme events Stage 1:
Years despair nts Punishment
N Regret over avoidance
lost
opportunities
of life ● Piaget’s theory of cognitive development
○ It explains how a child constructs
a mental model of the world. He
● Kohlberg’s theory of moral development
disagreed with the idea that
○ It identifies how a children may
intelligence was a fixed trait and
feel about an illness. It
regarded cognitive development
approximate, the Cognitive Stages
as the process which occurs due
of Development.
to biological maturation and
interaction with the environment.
58
○ Jean Piaget’s Theory of Cognitive in the rate at which children
Development suggests that progress through stages and some
children move through four (4) individuals may never attain the
stages of intellectual assessment latter stages.
which reflect the increasing
sophistication of children’s Principles of growth & development
thought. 1. G&D are continuous process from
○ His theory focuses on conception until death
understanding how children ● An example of how a rate of
acquire knowledge regarding on growth changes is a comparison
fundamental concepts such as between that of the first year and
object permanence, number, the later in life.
categorization, quantity, casuality, ● An infants birth weight and
and justice. increases height by 50% during
○ Sensorimotor the first year of life. If this
■ Birth - to ages 18 to 24 tremendous growth rate is to
months 2 years continue to a 5-year-old child
■ Understands world through ready to begin school, would
sense and actions weight 1600lbs and be 12 feet and
○ Preoperational 6 inches tall.
■ Among toddlerhood 18-24 2. G&D proceed in an orderly sequence
months through early ● Growth and height first only in one
childhood at the age of 7 2 sequence, from smaller to larger.
- 7 years Development also proceed on a
■ Understands world through predictable order. For example, a
language and mental majority of children sit before they
images creep, creep before they stand,
○ Concrete Operational stand before they walk, and walk
■ 7 - 12 years (to 11 years) before they run.
■ Understands world through ● Occasionally, a child will skip a
logical thinking and stage or pass through it so quickly
categories that a parent can’t observe that
○ Formal Operational stage.
■ 12 years onward 3. Children pass through the predictable
adolescents to adulthood stage at different rates
■ Understands world through ● All stages of development have a
hypothetical thinking and range of time rather than certain
scientific reasoning point at which they are usually
○ Each child go through the stages accomplished.
in the same order and child ● Two children may pass at a moto
development is determined by sequence at such different rates.
biological maturation and For example, that one begins
interaction with the environment walking at 9th month, another only
○ Although no stage can be missed at 14 months. Both are developing
out, there are individual differences normally and are following the
59
predictable sequence and are ● By 10 mos, the infant can
merely developing at different coordinate the arm and thumb, the
rates. index fingers sufficiently well to
4. All body systems do not develop at use a pincer like grasp or be able
the same rate to pick up an object, as fine as a
● For example, neurologic issues piece of breakfast cereal on a high
experience its peak growth during chair tray.
the first year in life, whereas 7. Development proceeds from gross to
genital tissue growth little until refined skills
puberty. ● Once children are able to control
5. Development is cephalocaudal distal body parts, such as fingers,
● Development proceeds from head they are able to perform fine motor
to tail. Newborns can lift only their skills.
head when they lie in a prone ● For example, a three year old
position. colors best with a wide crayon. A
● By age 2 months, infants can lift 12 year old can write with a fine
both the head and the chest off pen.
the bed. 8. There is an optimum time for initiation
● By 4 months, the head, chest, and of experiences or learning
part of the abdomen ● Children can not learn task until
● By 5 mos, infants have enough to their nervous system is mature
show to -- enough to allow that particular
● By 9 mos, they can control legs learning. A child cannot learn to
enough to crawl sit, for example, no matter how
● And by 1 year, children can stand much a child’s parents have
upright and perhaps walk. him/her practice until the nervous
● Motor development has system have matured enough to
proceeded in a cephalacaudal allow back control.
order, from the head to the lower 9. Neonatal reflexes must be lost before
extremities. development can proceed
6. Development proceeds from proximal ● An infant cannot grasp with skill
to distal body parts until the grasp reflexes faded nor
● Can best be illustrated by tracing stand steadily until the walking
the progress of upper extremity reflex has faded.
development. A newborn makes ● Neonatal reflexes are replaced by
little use of the arm and the hand. purposeful movements.
Any movement is to put the thumb 10. A great deal of skill and behaviors is
to the mouth is the flailing motion. learned by practice
● By age 3 or 4 mos, the infant has ● Infants practice over and over,
enough control to support the taking a first step before they
upper body weight on the accomplish this securely.
forearms and the infant can ● If children fall behind in growth
coordinate the hand to scope up and development because of
objects. illness, they are capable to catch
60
up growth to bring them equal as rapidly or develop as fully as a
again with their age group. healthy child. Depending on the
type of illness and theraphy of
Factors Affecting G&D care available to the disease.
There are a lot of factors affecting G&D ● For example, insulin was
1. Genetics discovered in 1922, so many child
● From the moment of conception with type I diabetes died in early
when the sperm and ovum fuse, childhood during those times and
the basic genetic make up of an those who leave or left physically
individual is cast (?). In addition, challenged. Currently, with good
the physical characteristics such health supervision and advanced
as eye color and height potential medicine, the effects of type I
inheritance determines other diabetes can be so minimized that
characteristics, such as learning children with diabetes can both
style and temperament. thrive and grow. Diabetes is still a
● An individual may also inherit major factor in the health of
genetic abnormality, which could children, however as more and
result in disability or illness at birth more children in developed
or later in life. country become obesed, type II
2. Gender diabetes has now begun to occur
● On average, girls are born lighter in in children as young as school
an ounce of two and shorter by an age.
inch or two than boys. Boys stand 4. Intelligence
to keep this height and weight ● Children with high intelligence
advantage until prepuberty at does not generally grow faster
which time girls surged ahead physically than other children, but
because they begin their puberty they do tend to advance faster in
growth spurt, 6 mos. to 1 year skills. Occasionally, children with
earlier than boys high intelligence fall behind in
● By the end if puberty, which is 14 physical skills because spend their
to 16 yrs old, boys tend to be taller time with books and mental
and heavier than girls. This games rather than with games that
difference in growth pattern is develop motor skills and so do not
reflected growth chart used in receive practice in these areas.
boys and girls 5. Temperament
● This chart colored in red is used ● The usual reaction pattern of the
for girls and the other one is used individual or the individuals
for boys. Since they have different characteristic manner of thinking,
pattern of growth we used behaving or reacting to stimuli in
different growth chart for these the environment.
genders. ● Unlike cognitive and moral
development, temperament is not
3. Health develop in stages but is an inborn
● A child inherits a genetically characteristics set at birth.
transmitted disease may not grow
61
● Understanding the children are not ● Approach and Withdrawal
all alike, some adapt quickly to ○ The way a child initially
new situation and others adapt responds to a new
slowly, and some react intensely stimulus, whether it be
and some passively. people, situations, places,
● Parents, its good for them to food, changes in routine or
better understand why children are other transitions.
different from each other and help ● Adaptability
them care for each child ○ The degree of ease or
constructively. Although individual difficulty in which the child
children show characteristics from could adjust or change to
all group, most children can be any situations and how well
categorized in one of the four the young one can modify
groups: his/her reactions.
a) The easy child ● Intensity of reaction
- This refers to achild who is ○ The energy level in which
rhythmic approaching, adaptable, the child responds to any
mild and positive in mood situations, whether positive
b) The intermediate child or negative.
- Having some characteristics ● Distractibility
coming from both groups that are ○ The ease which a child can
to follow. be distracted by a task in
c) The difficult child the environmental stimuli,
- Rhythmic, withdrawing, low in attention span and
adaptability, intense and negative persistence.
in mood ● Attention span and persistence
d) The slow to warm child ○ It is the ability to
- Inactive, low in approach and concentrate or stay with
adaptability, negative in mood the chat with or without
distractions.
9 Major Parts Of Temperament ● Threshold of response
Characteristics: ○ Threshold of response, the
● Activity level amount of stimulation
○ The level of physical required for the child to
activity, motion, respond. Some children
recklessness or fugitive responds to the slightest
behavior that the child stimulation and others
demonstrates in daily responds to the slightest
activity. stimulation while others
● Rhythmicity or Regularity require intense amount.
○ The presence or absence ● Mood quality
of a regular pattern for ○ The mood may be positive
basic physical function, or negative, or the degree
such as appetite, sleep and of pleasantness or
bowel habit.
62
unfriendliness in a child’s 1. Physical and biological needs
words and behavior - In order for the child to fully G&D
6. Environment physiologically, their must be
● Although children cannot grow enough sunlight, food, water,
taller than their genetically air, ventilation, and all the
programmed height potential physical need should be
allows their adult height may be attended to.
considerably less than 2. Love and affection
geneticpotential if they’re - We must be able to provide this
environment hinders their growth one, together with security, so
in some way that the child may not only grow
● For example, a child could receive physiologically but also
inadequate nutrition because of psychologically and emotionally.
their family’s low socioeconomic 3. Security
status. A parent could lack child 4. Discipline and Authority
care skills are not able to give - There should be a balance
enough attention or a child could between the sense of freedom and
have a chronic illness. discipline. So part of it is for them
● Many illneses lowers the child’s to morally grow, intellectually grow
appetite, others such as other and also for them to have a sense
endocrine disorders directly alter of discipline.
the growth rate. Having a parent 5. Dependence and independence
who abuses alcohol or other - We need to promote autonomy
substances can cause such towards them, but of course we
inconsistency in care that affects need to balance them by making
mental health. them secured, making sure that
● Individual environment is not their independence is within the
always detrimental. For example, control while promoting growth.
children with Phenylketonuria, an 6. Self esteem
inherited metabolic disease, can - They should have their own
achieve normal G&D despite of self-esteem so that they will
their genetic make-up. If their psychologically grow, they will be
diet, which is a part of their able to boost themselves, push
environment, is properly regulated. themselves to G&D.
The following are Environmental 7. Communication
influences are msot likely to affect - This will promote social growth
G&D. and social development, same
● Socioeconomic level with play.
● The parent-child relationship 8. Play
● Ordinal position in the family - Is a good avenue for children to
● Health practice their skills, their thinking,
● Nutrition and their way of socialization with
others
Needs for G&D
There are different prerequisites for G&D: Classifications of play
63
1. Social – affective play - Predominant among preschool.
- This is when infants take pleasure After children begin to invest in
in relationships with people. As situations and people with
adults talk, touch nuzzles, and in meanings and begin to attribute
various ways elicits response form significance to the world, they
the infant, the infant will learn to pretend and dramaticize almost
provoke parental emotion and everything. By acting out events in
response to such behaviors as daily life, children learn and
smiling, cooing or initiating games practice the roles and identities
and activities. modelled by members of the
2. Sense – pleasure play family and society.
- A social stimulating experience - Example, using the telephone,
that originates form without. rocking the doll, driving a car,
Objects in the environment, such pretending to be a doctor,
as light, color, taste and odor, and superhero or a police men.
texture and consistency, attracts 6. Games or the Competitive Play
children’s attention and stimulates - This is apparent in cases where a
their senses and give pleasure. sibling beat a brother in playing
3. Skill play snake and ladder, playing in local
- After infants develop the ability to soccer team, engaging in
grasps and manipulate, they competitive play and anything
persistently demonstrate and related to it. Rules and turn taking
exercise their newly acquired and functioning as a part of the
ability through skill play or team are big lessons that came
repeating an action, over and over from this type of play.
again. - It is very important that we guide
- For example, building a tower children dealing with both winning
using cups, also picking up cubes and losing.
or small cubes 7. Onlooker play
4. Unoccupied behavior - When a child simply observe other
- Refers to an activity when a child children playing and odes not
isn’t playing at all. They may be partake in the action. It is common
engage in seemingly random for younger children who are
movements with no objective. working on their developing
Despite appearances, this is vocabulary.
definitely a play and sets the stage - Children who watch what other
for future play exploration. It may children are doing, but meet no
not be playful but focusing on their attempt to enter into the play
attention momentarily on anything activity. There is an active interest
that strikes their interest and stay in observing the interaction of
focus on. Example would be other but no movements towards
daydreaming, fiddle with clothes participating.
or other objects, or walk aimlessly. - This is something not to worry, it
5. Dramatic or pretend play (Symbolic could be that the child feels shy,
Play) needs to learn the rules, or maybe
64
is the youngest and just want to identical activity but there is no
take a step back for awhile. organization, division or labor,
8. Solitary play leadership assignment or mutual
- A child plays alone goal. Each child acts according to
- This type of play is important his/her wishes and their is no
because it teaches the child how group goal. It is slightly different
to keep themselves entertained, from parallel play
and eventually setting the path to - Also features children playing
being self-sufficient. separately from one another but in
- Any child can play independently this mode of play, they are
but this type of play is the most involved with what the others are
common among younger children, doing. An example, children
among the ages, 2 or 3 or among building a city of blocks, as they
toddlerhood. At that age they are build their individual buildings,
pretty self-centered and lack good they are talking to one another and
communication skills. If the child is engaging in each other. This is an
on the shy side and doesn’t know important stage of play because it
his playmates well, they may helps little ones develop whole
prefer this type of play. hosts of skills, such as,
9. Parallel play socialization, problem solving,
- There is no group association in cooperation, and language
this kind of play. The play development. Through associative
independently but among other play, it how children begin to
children. So you put two 3 year make real friendships.
olds in a room together and this is 11. Cooperative play
what you are likely to see. The two - They all come together and
children having fun playing side by children truly play together. It i
side in their own little world. common in older preschoolers or
- It doesn’t mean that they do not in younger preschoolers who have
like each other, they are just older siblings or have been a lot of
engaging in parallel play. Despite children.
having little social contact with - Uses all the social skills that the
their playmate, children with children has been working on and
parallel play, learns quite a bit with put them into action, whether they
one another, seeking turns and are playing a puzzle together,
other social activity. Even though it playing a board game or enjoying
appears that they are not paying an outdoor group game.
attention to each other, they often Cooperative play sets the stage for
mimic the other ones behavior. future interaction as the child
- As such this kind of play is viewed matures into adult.
as an important bridge to the latter
stages of play. Function of play
10. Associative play 1. Sensorimotor development
- Children play together and are - Play is very vital in the G&D of the child,
engage in a similar or even its function is for sensory motor
65
development. Major component of play at They learn to express emotion and
all ages and its predominant form of play tension.
in infancy. Active play is essential for 7. Moral Value
muscle development and serves a useful - Knowing of moral standards of right and
purpose as a release in surplus of energy. wrong in the culture and interaction with
2. Intellectual development peers. If they are to be an expectable
- Through exploration and manipulation, member of a group, children must adhere
children learn colors, shapes, sizes, and to the codes of behavior of the culture.
textures and the significance of objects.
Books, stories, films and collections Infancy
expands knowledge and provide ● In the first year after birth, a baby is called
enjoyment. Puzzles helps with problem an infant
solving abilities. ● infancy is defined as the first year of life
3. Socialization after birth
- Learn to establish relationships. Initial ● At this time, infants are born with certain
social contact includes through play, abilities already developed
establishing social relationships and ○ For example, they have a
problems associated with this well-developed sense of smell
relationship. They learn to give and take. ○ They can also communicate their
4. Creativity needs by crying when they are
- Children can experiment and try out their hungry, uncomfortable, bored or
ideas in play through every medium at lonely
their disposal. Primarily a product of ● During the first year, they develop many
solitary activity, yet creative thinking is abilities such as the ability to smile, make
often enhance to improve settings where vocal sounds, spend time mumbling, sit,
listening to other’s ideas stimulates further and crawl until they are able to stand and
exploration of one’s own ideas. walk
Experiment and try out new ideas. ● Trust vs mistrust, oral stage
5. Self-awareness ○ Based on the theories of child
- Children learn who they are and their development, infants belong to
place in the world. The process of TRUST VS MISTRUST
developing a self-identity is facilitated development
through play activity. They become ■ When an infant is hungry, a
increasingly able to regulate their own parent feeds and makes
behavior to learn what their abilities are the infant comfortable
and to compare their abilities to those of again
others. ■ When an infant is wet, a
- Fast abilities to assume and try out parent changes his/her
various roles and to learn the effect of diaper and the infant is dry
their behavior as on others. again
6. Therapeutic value ■ When an infant is cold, a
- Important in any age. Can express parent holds the baby
emotions and release unexpectable closely
impulses in a socially acceptable passion. ■ By these simple processes,
infants learn to trust that
66
when they have needs or immunizations and health
are in distress, a parent will assessments
come and meet that need ○ They are also important for
■ If care is inconsistent, parents because they provide an
inadequate, or rejecting, opportunity for parents to ask
infants will mistrust questions about their child’s
■ They become full and growth pattern and development
suspicious of people in the progress
world ○ They provide opportunities for
■ Fortunately, because not all healthcare providers to assess for
children achieve the potential problems as they first
development task readily, appear
each task need not be ● Aspiration’s prevention
resolved once and for all ○ Aspiration is the chief
the first time it arises injury threat to infants
■ The problem of trust vs throughout the first year
mistrust for example is not ○ Round, cylindrical objects
resolved forever during the are more dangerous than
first year of life but arises square or flexible objects
again at such successive in this regard
stages of development ○ A 1-inch or 3.2 cm
■ It is important that we cylinder such as a carrot
emphasize the importance or hotdog is particularly
of having a constant dangerous because it can
caregiver, or the mother totally obstruct an infant’s
should be there most of the airway
time to promote trust for ○ A deflated balloon can be
the infants sucked into the mouth,
○ According to Freud, an infant obstructing the airway in
belongs to the ORAL STAGE the same way
wherein the child explores the ○ Educate parents who feed
world using their mouth their infant formula to not
■ It is important that we prop bottles. By doing
provide oral stimulation by this, they are
giving pacifiers and do not overestimating their
discourage thumb sucking infant’s ability to push the
● Health care visits: 2 weeks, 2 months, 4 bottle away
months, 6 months, 9 months, and 12 ○ Sit up, turn the head to
months the side, cough, and clear
○ A standard schedule for health the airway if milk should
care visits is for 2 week, 2 months, flow too rapidly into the
4 months, 6 months, 9 months, mouth, allowing an infant
and 12 month visits to aspirate
○ These visits are important for the ● Fall prevention
infant because it provides time for
67
○ Also, we promote ○ And towards the end of
prevention of falls pregnancy, parents need
○ Instruct the parents to to prepare for their baby’s
never leave an infant in an arrival by childproofing the
unprotected surface such house
as the bed or couch even ○ This is the use of different
if the infant is in an infant gadgets or different tools
seat to prevent any injury for
○ Place the gate at the top the child to occur
and bottom of stairways ○ This is an example of
and do not allow the infant propping a bottle. It is
to walk with a sharp important to instruct
object in the hands or parents not to do this
mouth because we might not
○ Raise the security rails know that the bottle is
and make sure that opened fast towards the
○ And it is important not to infant and may cause
leave the child unattended aspiration
in a high chair, and avoid ○ It is very important that
using an infant walker the caregiver should look
near a stairway into the infant while it is
● Safety with siblings feeding on a bottle
○ Infants become more fond ○ Side-rails are used and
to play with at about 3 should not be too wide.
months of age The platform should be at
○ Older brothers and sisters the low level to have a
grow more interested in higher level of rails
interacting with them ○ Also bassinet, which we
○ It is important to remind usually use in the hospital
parents of children under for the newborns, is good
about 5 years of age as for up to 2 months only
the group are not because the baby tends to
responsible enough or roll over and they might
knowledgeable about fall
infants to be left ○ All infants and toddlers
unattended with them should ride in a rear-facing
○ They might introduce an seat until they have
unsafe toy or engage in reached the highest
play that is too rough for weight or height allowed
an infant by their car’s safety seat
○ Some preschoolers may manufacturer
be jealous of a new baby ○ Most convertible seats
and they will physically have limits that will allow
harm an infant if alone children rear-facing for
● Child proofing two years or more
68
○ Normal wiggling can easily
cause the baby to slip
down under the water
○ This applied to a hospital
setting as well
○ Being able to swim
momentarily may also
● In the first year, caring for an infant cause children to l ose their
such as feeding, bathing, and so intrinsic fear of water so
forth, occupies what may seem being more danger when
like all of the parent’s waking around water than children
hours who are still naturally more
○ All of these basic care cautious
related activities, provide ○ Such progress may also
important opportunities for cause hypothermia and
parents and infants to get spread microorganisms
to know one another and to because infants this age
become used to each are still not toilet-trained
other’s personalities and ○ Exposure to chlorinated
factors can damage lung
○ When it comes to bathing, epithelium that may be
it is very important to never precursor to childhood
leave the baby unattended asthma
on baths
○ Check the temperature of
bath water for comfort and
to prevent chilling
○ Except in very hot weather,

an infant does not need a
bath everyday
○ As babies begin to develop ○ If a parent is tired and
good back support, many would not enjoy bath time
parents begin to bathe or in some days is just too
them in an adult tub rushed, a complete bath
○ Caution parents to never can be omitted with only an
leave an infant unattended infant’s face, hands, and
in a tub, even when diaper area washed
propped up out of the ○ Some infants do need their
water or sitting in a bath head and scalp washed
ring or bath seat frequently may it be
69
everyday or every other they could easily slip under
day to prevent seborrhea the water
○ Seborrhea is a scaly scalp
condition often called
CRADLE CAP
○ If seborrheic lesions do
develop, they adhere to the
scalp in yellow crusty
patches
○ The skin beneath them
may be slightly
○ Parents should be on the
erythematous
lookout for potential
○ The patches can be
sources of injury
softened by oiling the scalp
○ Accd to the CDC, most
with mineral oil or
accidents occur where
petroleum jelly, and leaving
1. There is water such
it on overnight
in the bathroom,
○ The crust can then be
kitchen, swimming
removed by shampooing
pool or hot tubs
the hair the next morning
2. Heat or flame in the
○ A soft toothbrush or a fine
kitchen, fireplace, or
toothed comb can be used
barbecue grill
to help remove the crust
3. Toxic substances
○ Bath time should be fun for
under the kitchen
an infant and can serve
sink, in the
many functions other than
medicine cabinet,
just the obvious cleanliness
garage or garden
○ Especially during the 2nd
shed, or any other
half of the first year, an
place where
infant enjoys poking at
medication place is
soap bubbles on the
stored
surface of the water and
4. There are potentials
playing with bath toys
for a fall on stairs,
○ Bath time also help some
high windows or
infant learn different
from furniture
textures and sensations,
■ This is why
and provides an
childproofing is very
opportunity to exercise and
important
kick, as well as a good
○ When infants begin
opportunity for parents to
teething at 5-6 months,
touch and communicate
they chew any objects
with the child
within reach to lessen gum
○ Teach parents to not leave
line pain
the infant alone in tubs as
○ Remind parents to check
for possible sources of lead
70
paints such as wander unto ○ Nub covers which snap
an elevator, out of the over door knobs to prevent
hospital, or into a young children from turning
laboratory area, or fall them
down a flight of stairs if not ○ Cordless window coverings
supervised to prevent strangulation
○ It is important to instruct could also be of use
parents to teach them to
keep guns out of reach,
keep coin lithium batteries,
or button batteries, or any
batteries that contain them
out of reach since they can
be fatal if swallowed
○ Keep choking hazards,
● Nutrition
toxic substances, hot, and
○ The entire first year of life is one of
sharp items out of reach
extremely rapid growth, so a
○ Have your child use safety
high-protein, high-calorie intake is
glasses if they are involved
necessary
in activities such as
○ Both commercial formulas and
woodworking, science
breast milk contain 20 calories per
experiments involving
ounce
chemicals, racket ball,
○ Calorie allowances can be
paintball, or other
gradually reduced during the 1st yr
enterprises with flying
from a level of 120/kg body weight
debris
at birth to approx 100/kg body
○ Never leave young kids
weight at the end of the first yr to
unattended in baths
prevent babies from becoming
○ Safe latches or locks in
overweight
cabinets or drawers to help
○ From a nutritional standpoint, a
prevent poisoning and
normal full term infant can thrive
other injuries
on breastmilk or a commercial
○ Outlet covers could also be
iron-fortified formula without the
used in these area of the
addition of solid food until 4-6
wall
months
○ Anchors to prevent
○ Delaying solid food until this time
furniture, TVs, and ranges
help prevent overwhelming an
from tipping over and
infant’s kidneys with a heavy
crushing children
solute load that can occur when
○ Corner and edge bumpers
protein is ingested
to prevent injuries from falls
○ Although difficult to document, it
against sharp edges of
also may delay the development of
walls, furniture, and
food allergies in susceptible
fireplaces
infants and be another way to help
prevent future obesity
71
○ Weaning at 6 months formula feeding, the infant
■ The transition from breast still needs vitamin C for
milk or iron-fortified that, iron and fluoride
formula to solid food is supplementation
what we call as weaning ■ Breastfeeding should still
which we usually do at 6 be encouraged every 2-3
months of life hrs or per demand
■ Teach parents to offer new ■ And if not through
foods one at a time and breastfeeding, we can
teach the child to eat that administer milk through
item for about 1 week cup feeding to prevent
before introducing another nipple confusion
new food ■ It is best for the 1st solid
● This system helps food feeding if an infant is
parents to detect held in the parent’s arms as
possible food if for bottle feeding or
allergies breastfeeding which
● For example, if they reduces the newness of the
start egg yolk on experience and minimize
monday and by the stress associated with
tuesday evening, it
the child is ○ High protein and high calorie
breathing noisily or ○ Breast feeding every 2-3 hours or
has rash, they can per demand, cup – feeding
suspect the child is ○ Allergy – precaution
allergic to eggs ● Diaper-area care
● If two new foods ○ The most effective means of
have been started promoting good diaper hygiene is
on monday, it to change diapers frequently about
would be hard to every 2-4 hours
know which one ○ However it is rarely good practice
was the suspect to interrupt the child’s sleep to
■ Introducing foods one at a change diapers
time also establish a sense ○ If an infant develops a rash from
of trust in infants because sleeping in wet diapers, air drying
it minimizes the number of or sleeping without a diaper may
new experiences in any 1 be a solution
day ○ At each diaper change the parents
■ Take note for the important should wash the skin with clear
nutrients taken by the water or a commercial alcohol-free
infants diaper wipe, then pat or allow to
○ Cow’s milk needs vit. C, iron, and air dry
fluoride supplementation ○ Routinely use an ointment such as
■ Note that the cow’s milk Desitin or A&D ointment to keep
which we usually use for
72
urine and feces away from an ■ Changing the brand or type
infant’s skin is a good prophylaxis of diaper, or washing
○ Parents do not need to use baby solution usually alleviates
powder the problem
■ If they choose to, advise ○ If a diaper area is covered with
them to sprinkle the lesions that are bright red, with or
powder on their hands first without oozing, lasts longer than 3
and then apply to the days, and appear as red pinpoint
infant’s skin lesions, suspect a Fungal or
■ Caution them to not shake Candida infection
the powder on the infant to
reduce the possibility of
aspiration
■ Place the container out of
the infant’s reach after
applying it
○ Parents should always watch
carefully while infants or toddlers
are in the tub as well
○ Some infants have such sensitive
skin that diaper dermatitis or rash
is a problem from the first days of
life
■ It occurs for several
reasons
1. Frequent diaper ● Dental care
changing ○ It is well-accepted that exposing
2. Exposing the diaper developing to fluoride is one of the
■ Exposing the diaper to air most effective ways to promote
may relieve the problem healthy tooth formation and
■ Some infants may have to prevent tooth decay
sleep without a diaper to ○ The most important time for
control the problem children to receive fluoride is
■ Whenever the entire diaper between 6 months and 12 yrs of
area is erythematous or age
irritated so that the outline ○ A water level of 0.6 ppm fluoride is
of diaper can be identified, recommended because this is the
one must suspect an level that protects tooth enamel
allergy to the material in the yet does not lead to staining of
diaper or the laundry teeth
diaper products if a ○ In communities where the water
commercial washed or supply does not provide enough
home-washed diaper is fluoride, the use of oral fluoride
being used supplements beginning at 6
months or the use of fluoride
73
toothpaste or rinses after tooth chewing for a day or two
eruption is recommended and become cranky
○ Teach parents to ask about because they are a little
presence of fluoride in the drinking hungry from not eating as
water in the community to help much as usual
them determine if supplementation ○ High fever, seizures, vomiting,
is necessary diarrhea, or earache are NEVER
○ Breast fed infants do not receive a normal signs of teething
great deal of fluoride from breast ■ An infant with any of these
milk so it may be recommended to S/S has an underlying
receive fluoride drops once a day infection or disease
○ Teach parents to begin brushing process requiring further
even before teeth erupts by evaluation
rubbing off a wash cloth, a soft
wash cloth over the gum pads.
This eliminates plaques and the
presence of bacteria creating a
clean environment for the arrival of
the first tooth
○ Once teeth erupt, all surfaces
should be brushed with a soft
brush or wash cloth once or twice
a day
○ Children lack the coordination to
brush effectively until they are
school-aged. So parents are
responsible for this activity past
infancy
○ Toothpaste is not necessary
because it is the scrubbing that
removes the plaque
○ The initial dental checkup should
○ Many OTC medications are sold
be made by 1 yr of age
for teething pains
■ Checkups should continue
○ As a rule, their use should be
at 6 month intervals until
discouraged if they contain
adulthood
benzocaine, a topical anesthetic
○ During teething, some appear to
because if applied too far back in
be in distress
the throat, this can interfere with
■ To relieve gums or sore and
the gag reflex
tender before a new tooth
○ Teething rings that can be placed
breaks the surface
in the refrigerator provide soothing
■ As soon as the tooth is
coolness against the tender gums
through the surface
○ An infant who is teething will place
■ Because of the pain, the
almost any object in the mouth so
infant can be resistant to
parents must screen articles within
74
the baby’s reach whether they are
edible or safe to chew
● Sleep
○ 10 – 12 hours of sleep
○ Sleep needs and habits vary
greatly among infants
○ Most require 10-12 hours of sleep
at night and one or several naps
during the day
○ Parents are usually advised to let a
baby sleep in a separate space
rather than in your bed so that
your parents do not awaken in
every toss and squeak
■ Doing so allows the infants
to learn to quiet themselves
and go back to sleep
should they briefly awaken
■ This can help prevent night
● Dressing walking in the future
○ Clothes for infants should be easy ○ Some parents prefer to have
to launder and simply constructed infants sleep with them in the bed
so dressing and undressing are ■ They believe this practice
not a struggle promotes a feeling of
○ Infants enjoy kicking and making security
gross body movements so their ■ Bed-sharing also promotes
clothing should not be binding breastfeeding but also has
○ When they begin to creep, they the danger of accidental
need long pants to protect their suffocation
knees ● Caution parents to not place
○ Until they begin to walk, they need pillows on an infant’s bed to avoid
only soled shoes or merely socks suffocation
or booties to keep their feet warm ● Place the infant on their back to
○ Even when they begin walking, the sleep because this position
soles of their shoes need only be markley prevents the incidence of
firm enough to protect their feet Sudden Infant Death Syndrome
against rough surfaces (SIDS)
○ Extremely hard soles and ○ Use of pacifier while an
high-ankle sides are unnecessary infant sleep may further
reduce the risk
75
feel about them and their
infant’s needs
■ Benefits include
1. Appear to be
comforting
2. Aid in pain relief
3. Decrease incidence
of SIDS
● Thumb sucking
■ An infant who completes a
○ Sucking is surprisingly a strong
feeding and still feels
need in early infancy
restless and discontent,
○ Many infants begin to suck a
who actively searches for
thumb or finger at about three
something to suck may
months of age and continue the
need a pacifier
habit through the 1st yr of life
■ Risks include:
○ The sucking reflex peaks at about
1. Increased incidence
10-12 whereas thumbsucking
of otitis media
peaks at about 18 months
2. Negative impact on
○ Parents can be assured that
breastfeeding
sucking does not deform the jaw
3. Dental malocclusion
in infancy, it does not cause baby
if used for more
talk, or any other speech concerns
than 2-3 yrs old
associated with it
■ Theoretically, a child
○ Children who continue the habit
whose sucking needs are
into school-age age however, can
met in infancy will not
have changes in their dental arch
crave as much oral
that can lead to asymmetric
stimulation in life, and is
concerns such as cross bite
less likely to be a pencil
■ The best approach for
chewer, nail biter, or
parents is to ensure that
cigarette smoker
infants have adequate
■ A major drawback for use
sucking pleasure and then
of pacifiers is cleanliness
to ignore thumb sucking,
● They tend to fall on
making an issue of it rarely
the floor or sidewalk
cause a child to stop. If
and are then put
anything it may intensify or
back into the
prolong it
infant’s mouth
○ Increased incidence of otitis media
● If not
○ Negative impact on breastfeeding
well-constructed, it
○ Dental malocclusion (2 to 3 years
may come apart
old)
and the nipple part
○ Pacifier use
may be aspirated
■ Whether to use pacifiers is
● Hanging a pacifier
a question that parents
on a string around
must settle for themselves
the infant’s neck
depending on how they
76
could cause that this is a normal mechanism
strangulation for relief of tension in children of
■ Parents should try to wean this age
infants from their pacifier ○ No therapy is necessary excessive
any time after 3 months of banging done to the exclusion of
age, and certainly during normal development or activity
the time that sucking reflex ○ Head-banging past the preschool
is fading at 3-9 months period or if associated with other
● Meaning after this symptoms can be of pathological
age, it is difficult basis
because a pacifier ■ A child may need referral
becomes a comfort for further evaluation
mechanism like a ● Bowel Pattern
warm blanket or ○ Constipation
fuzzy toy that a ■ May occur in formula-fed
child may continue infants if the diet is
to cling deficient in fluid
● Head banging ■ Can be corrected simply
○ Starts at the 2nd half of infancy with the addition of more
until preschool fluid
○ Assoc. with naptime or bedtime ■ Some parents misinterpret
○ For 15 mins the normal pushing
○ Begins during 2nd half of first yr of movements of the newborn
life and continuing through to be constipation
preschool ■ When infants defecate,
○ Associated with naptime or their infants do turn red,
bedtime and lasting for 15 minutes and they grimace and grunt
can be considered normal ■ As long as stools are not
○ Children do this to relax and fall hard and contain no
asleep evidence of fresh blood, as
○ Investigating stress patterns might occur in rectal
operating in the house may be fissure, this is normal infant
helpful behavior
○ If some of the stress can be ■ If it persists beyond 5 or 6
relieved such as a parent’s over months of age, advise
assumption, a child’s parents to check with their
development, marital discord, healthcare provider about
illness in another family member, measures to relieve this
the head-banging may be ■ Adding foods with bulk
decreased or it may already be such as fruits or
such an ingrained habit that it will vegetables, and adding
persist for months or years fluid intake generally
○ Advice parents to pad the rails of relieves the problem
cribs so infants cannot hurt ○ Loose bowel
themselves and reassure them
77
■ Many new parents are also vomiting, loss of appetite,
unsure of the consistency decrease of voiding and
and color of normal weight loss should be
newborn stools examined by their
■ So they may report normal healthcare provider
stooling as diarrhea because these suggest an
■ Stools of breastfed infants infectious process
are generally softer than ● Dehydration occurs rapidly
formula-fed infants in a small infant who is not
■ If a mother takes a laxative eating and is losing body
while breastfeeding, an fluid through loose stools
infant's stool may be very ● Colic
loose ○ Paroxysmal abdominal pain on
■ Formula-fed infants can infants under 3 months
have loose stools if the ○ Marked by loud, intense crying
formula is not diluted and the infant
properly ● Pull legs up against abd.
■ Occasionally, loose stools ● Face is red and flushed
may begin with the ● Fists clench
introduction of solid food ● Tensed abdomen
such as fruits ● If offered a bottle, an infant
■ When talking to a parent sucks on it vigorously for a
about loose stools, ask for few minutes as if starved,
the then stop as another wave
1. Duration of abdominal pain occurs
2. Number of stools ● For 3 hours, 3x/day
per day ● No changes in bowel
3. Color ● Cause is unclear
4. Consistency ● May occur in susceptible infants
5. Presence of mucus from overfeeding or swallowing
or blood too much air from feeding
6. Presence of ● Formula-fed infants are more likely
associated fever or to have colic than breastfed
cramping babies possibly because they
7. If the infant swallow more air when drinking or
continues to eat because formula is harder to
well digest
8. Does the infant ● Although infants continue to thrive
appear well despite colic, the condition should
9. Does the infant not be dismissed as unimportant
seem to be thriving ● It is a disturbing and frightening
10. Wetting at least 6 problem for parents not only
diapers daily because an infant appears to be in
● Infants with assoc S/S acute pain, but the distress occurs
such as fever, cramping, for a few hours, usually into the
78
middle of night so no one gets ○ Parents who did not handle their
adequate rest infants much in the healthcare
● Us nurses help in determining the facility where the child was born
baby’s feeding pattern may discover spitting up after they
○ If bottle fed, ask about the take the baby home
1. Type of formula fed ○ They may interpret this as vomiting
2. If they are holding or a sign of infection
the baby upright so ○ Ask them what they mean by
air bubbles can rise spitting up, how long, how
3. Burp the infant frequently, and the appearance of
adequate after the spit up milk
feeding ○ Almost all milk that is spit up has a
○ If breastfed, a change in maternal faintly sour smell but should not
diet such as avoiding gassy foods contain blood or bile
such as cabbage may help reduce ○ A baby that spits up a mouthful of
colic periods. milk rolling down the chin 2-3
○ It may be helpful to recommend times a day or sometimes after
that both breast and formula fed every meal is experiencing normal
infants receive small frequent infant spitting up
feedings to prevent distention and ○ Associated signs such as diarrhea,
discomfort abdominal cramps, fever, cramp,
○ Offering a pacifier may be cold, or loss of activity suggest
comforting illness
○ Some parents place a hot water ○ If an infant is spitting up so
bottle on the baby’s stomach for forcefully that milk is projected 3
comfort but this should be or 4 ft away, it may be indicating
discouraged pyloric stenosis or the abnormal
■ A basic rule for any type valve between the stomach
abdominal discomfort is to and duodenum which requires
avoid heat in case surgical intervention
appendicitis is developing ○ Burping the baby after meals often
■ This is highly unlikely in limits spitting up
young infants but parents ○ Parents may try to sit the baby in
may remember that they an infant chair for half an hour
used heat and may use it after feeding
again when child is holder ○ Changing formulas is of little value
■ Hot water bottles or bags ○ Reassure parents that spitting up
may also burn the delicate decreases in amount as the baby
infant skin becomes better at coordinating
● Spitting up swallowing and digestive process
○ Rolls down the chin ○ In the meantime, a bib protects
○ Almost all infants spit up although baby’s clothing and parents
formula fed infants do so more ○ After a few months, the baby will
than breastfed babies stay in an upright position longer
79
and gravity will help to correct the the front teeth and lower back
problem teeth
● Miliaria ○ The problem is called Baby Bottle
○ Prickly heat rash most often in Syndrome
warm weather or if babies are ○ This occurs because the CHO in
overly stressed or sleep in the solution ferments to organic
overheated rooms acids that demineralize the tooth’s
○ Cluster of pinpoint reddened enamel until it decays
papules with occasional vesicles ○ To prevent this problem, advice
and pustules surrounded by the parents to never put their baby
erythema usually appear on the to bed with a bottle
neck first and may spread upward ○ If parents insist a bottle is
to the ears and the face and down necessary for the baby to fall
unto the trunk asleep, advice them to fill it with
○ Bathing an infant BID during hot water, and use a nipple with a
weather particularly if a small smaller hole to prevent the baby
amount of baking soda is added to from receiving a large amount of
the bath water may improve the fluid
rash ○ If the baby refuses to drink
○ Eliminate sweating by reducing the anything other than milk, the
amount of clothing on an infant or parents may dilute the milk with
lowering the room temperature water more and more until the
should bring immediate bottle is down to water only
improvement and prevent further
eruption
Toddler
● During the toddler period the age span
● Baby bottle tooth decay from 1 to 3 years enormous changes take
○ Putting an infant to bed with a place in a child and consequently in a
bottle of formula, breastmilk, family during this period children
orange juice, or glucose water can accomplish a wide array of developmental
cause aspiration tasks and change from largely immobile
○ It can also lead to decay of all the and preverbal infants who are dependent
upper teeth and the lower on caregivers for the fulfillment of most
posterior teeth needs to walking, talking young children
○ Decay occurs because while an with a growing sense of autonomy or
infant sleeps, liquid from the independence.
propped bottle continuously soaks ● To match this growth, parents must also
change during this period, if a parent
80
enjoyed being the parent to an infant ○ Examine toys for small parts that
because time could be spent rocking or could be aspirated
singing to the child they may not enjoy ○ Remove toys that appear
being the parent of a toddler as now their dangerous
task is to support their child’s growing ○ Do not feed toddler popcorn
independence with patience and peanuts etc.
sensitivity and to learn methods for ○ And urge children not to eat while
handling child's frustrations that arise running and do not leave toddler
from the quest for autonomy. alone with a balloon
● The developmental task of a toddler years ○ Maintain the child in the car seat.
according to Erik Erickson is the Do not be distracted from safe
development of a sense of autonomy driving by a child in a car.
versus shame or doubt. Children who ○ Do not allow child to play outside
have learned to trust themselves and unsupervised
others during the infant year are better ○ Do not allow child to operate
prepared to do this than those who electric garage doors
cannot trust themselves or others. ○ Supervise toddler who is too
● To develop a sense of autonomy is to young to be left alone on a tricycle
develop a sense of independence. ○ Kitchen safety with pedaling toys
● Interventions: ○ Look before crossing driveways
○ Never present medication as and do not cross streets
candy, buy medications with ○ But do not expect that a toddler
childproof cups.Put way will obey these rules at all times. In
immediately after use. other words, it is important that a
○ Never take medication in front of provider should stay close by.
the child, place all medication and ○ Note that some children are more
poisons in locked cabinets or active, curious, and impulsive and
overhead shelves where the child therefore more vulnerable to an
cannot reach them. intentional injury than others
○ Never leave medication in the ● Autonomy vs. Isolation
parents' purse or pocket where ● Poisoning
the child can reach it. ● Aspiration
○ Always store food or substances ● MVA
in their original containers. ● Playground injuries
○ Know the names of houseplants
and find out if they’re poisonous
_____ or set them on high surfaces
beyond toddler’s grasp.
○ Be certain that small batteries or
magnets are out of reach.
○ Post the telephone number of the
nearest poison control center by ● The best baby proofing solution to
the telephone. prevent the child climbing the stairs is a
○ Inspect toys to be certain they are baby gate or fence.
free of lead ____ paint. ○ A baby gate will prevent the child
from going anywhere near the
81
staircase, a properly installed baby ● Never drink hot beverages when the child
gate will hamper the curious is sitting on the lap or playing within
child’s access even when the reach.
guardian is not watching. ● Buy flame retardant clothing.
● It is important that we teach the parents ● Do not allow toddlers to blow out
to keep the house windows closed or matches.
keep secure screens in place. ● Store matches out of reach and keep
● Place gates at top and bottom of stairs, electric wires and cords out of toddler’s
supervise at playgrounds. reach, so cover electric outlets with safety
● Do not allow the child to walk with a sharp plugs.
object in hand or in the mouth and raise ● Also do not allow the toddler to approach
crib rails and check to make sure they are strange dogs. Supervise child's play with
locked before walking away from the crib. family pets.
Nutrition
● Since they love to cruise around the

house, they might wander around the
kitchen and touch hot pots and cause
burns.
○ It is important that we teach the
● Toddlers' appetite has decreased over
parents to cook on the back
time, so food consumption will be less.
burners of the stove if possible.
● Always remember that the recommended
○ Turn handles of pots toward the
calorie intake for toddlers would be 1000
back of the stove to prevent the
kcal per day for toddlers with a
toddler from reaching up and
sedentary lifestyle.
pulling them down.
● While, 1400 kcal per day for hyperactive
● If a vaporizer is used, use a cold mist type
toddlers.
rather than steam vaporizer so the child
● Because the ample amount of food eaten
cannot be scalded.
daily varies from one child to another, it is
● Keep the screen in front of the fireplace or
important that we teach parents to place
heater.
a small amount of food on a plate and
● Monitor toddlers carefully when they are
allow the child to eat it and ask for more
near lit candles.
rather than serving a large portion the
● Do not leave toddlers unsupervised near
child cannot finish.
hot water faucets.
● Allow self feeding which is a major way to
● Check the temperature setting for hot
strengthen independence in a toddler.
water and heater, so the thermostat is not
● Offer finger foods and allow a choice
over 125 degrees fahrenheit.
between two types of food helps promote
● Do not leave coffee or tea pots on the
table where the child can reach them.
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independence, while exposing children to statement such as “you did a great job” before
varied foods. making the switch.
○ Nutritious finger foods that
toddlers enjoy include pieces of As soon as children are off on their feet
chicken, slices of banana, pieces and walking they need shoe soles that are firm
of cheese and crackers. enough to provide protection from rough
○ Most toddlers insist on feeding surfaces, however, toddlers do not need
themselves and generally will extremely firm or ankle-high shoes because of
resist eating if a parent insists on toddlers’ arches are still developing it is better for
feeding them. their arches to provide foot support rather
○ An individual child may react after than having it provided by shoes. Sneakers are
repeated attempts at being fed by an ideal toddler shoe because the soles are hard
refusing to eat at all. enough for tough or for rough surfaces and arch
● Many toddlers prefer to eat the same type support is limited
of food over and over because of the
sense of security this offers. Sleep
● Frequently, they eat all of one item before
going on to another, they often prefer
brightly colored foods to bland colors.
● Finger – food
● Provide options
● 1, 00kcal/day – sedentary lifestyle
● 1,400 kcal/day – active lifestyle
● The amount of sleep children need
Dressing gradually decreases as they grow older,
they may begin the toddler period
napping twice a day and sleeping 12
hours each night and end it with one
nap a day and only 8 hours of sleep at
night.
● Parents who are not aware that the need
Parents may be reluctant to encourage for sleep declines at this time may view a
toddlers to dress themselves because it is easier child's disinterest in sleeping as a
and quicker for a parent to do so. Also, a toddler problem.
who is dressed by parents will usually be wearing ● If a child has difficulties falling asleep at
clothes in the correct way. night it may be time to omit or shorten an
afternoon nap.
When toddlers dress themselves seeing ● If a child is so short tempered that ____ is
variably put shoes on the wrong feet and shirt impossible, perhaps the child needs two
and pants on backward. Encourage parents to naps a day.
give up perfection for the benefit of the child's ● Some others begin having night terrors or
developing sense of autonomy. awake crying from a bad dream and so
may receive little sleep because they are
If they feel they must change the child's reluctant to fall back asleep.
clothes, urge them to begin with a positive ● Other toddlers receive nap time as part of
their developing negativism, parents may
83
minimize this by including a nap as part of
lunch time routine, not as a separate Bathing
activity.
● Example: the child always goes from the
table directly to bed as if the two things
are connected, the parent can state
simply “it's nap time now” and give a
secondary choice “Do you want to sleep
with your teddy bear or your ragdoll”
toward the end of the toddler period when
children are ready to omit their afternoon
When it comes to bathing, remind parents
naps, they may still be agreeable to a
that although toddlers can sit well in a bathtub it
shoes-off or quiet play period until they
is still not safe to leave them unsupervised. They
begin to attend school full time.
might slip and get their head under water or
● Although toddlers need to be independent
reach and turn on the hot water faucet and scald
they also need a feeling of security.
themselves. Parents shouldn't add bubble bath
● Just as adults like to know there are guard
to the water because its use is associated with
rails along steep mountain roads, toddlers
vulvovaginitis and possibly urinary tract infection
like to see parents as firm, consistent
especially in girls.
people who can be counted on to be
reliable over and over especially when
Dental Care
they're tired.
● Many toddlers are ready to be moved out
of a crib into a youth bed or regular bed
with protective side rails or a chair
strategically placed beside it by the end of
toddler period.
● Remind parents to stress that sleeping in
a regular bed does not give children the
right to get in and out of bed as they
choose. ● To prevent dental caries from frequent
● Some toddlers do well if they are allowed snacking, encourage parents to offer fruit
to sleep in a regular bed and a folding or protein foods for snacks rather than
gate is placed across the door to the high-carbohydrate items such as cookies
room. This arrangement gives them a to limit exposure of the child's teeth to
feeling of independence but still keeps carbohydrates.
them safe. ● Calcium is especially important for the
● When first moved to a bed without side development of strong teeth and is good
rails many children are found sleeping on for snack foods.
the floor of the room in the morning. There ● In addition, children should continue to
is no harm in this unless it is cold or drink chlorinated water or if not
drafty. available, receive fluoride supplements
● Dressing the child in warm pajamas or so all new teeth form with cavity resistant
putting a blanket on the floor might be enamel.
solutions to help parents adapt this.
84
● Remind parents not to put a child to bed must have reached three important
with a bottle of milk or juice to help developmental levels, one physiologic and the
prevent the development of caries. other two cognitive.
● Toddlers need a toothbrush they 1. They must have control of rectal and
recognize as their own. urethral sphincters, usually achieved at
● Toward the end of the toddler period they the time they walk well.
can begin to do the brushing themselves 2. They must have a cognitive
under supervision. Almost all children understanding of what it means to hold
need some supervision until about age 8 urine and stools until they can release
years. them at a certain place and time
● Remind parents that it is better for a child 3. They must have a desire to delay
to brush thoroughly once a day, probably immediate gratification for a more socially
at bedtime, than to do it poorly many accepted action
times a day.
● After brushing, parents can use dental
floss to clean between their child's teeth
and remove plaque.
● Urge parents to schedule a first dental
visit with a dentist skilled in pediatric
dental care by 12 months of age.
○ Screening and assessment of
dentition can begin as early as 6
months of age but should occur
no longer than 24 months of age.
Some toddlers smear or play with feces
○ Dental services can begin by age 3
often at about the same time that toilet training
years.
has started. This occurs because they have
○ Parents can prepare their child for
become fully aware of body excretions but
this first visit and subsequent visits
have no adult values towards them.
by reading a story about a dentist
visit.
Stools seem little different from the
○ Because children rarely have
modeling clay they play with. This activity can be
cavities this early, this visit is
minimized by providing toddlers with play
usually painless and sets a
substances of similar texture and by changing
positive stage for future dental
diapers immediately after defecation, teach
supervision visits.
parents to accept this behavior for what it is:
enjoyment of the body and of the self and the
discovery of new substances. After a child is fully
Toilet Training
toilet trained this activity rarely persists.
Toilet training is one of the biggest tasks a
toddler tries to achieve. It is important that we
Negativism
explain to parents that toilet training is an
individualized task for each child. It should begin
and be completed according to a child's ability to
accomplish it, not according to a set schedule.
Before children can begin toilet training, they
85
Discipline
As part of establishing their identities as

separate individuals, toddlers typically grow
through a period of extreme negativism. They
do not want to do anything a parent wants them
to do. Their reply to every request is a very
definite no.
A toddler’s no can be vastly reduced by
limiting the number of questions asked of the
child. A father does not really mean, for example,
“Are you ready for dinner?” he means come to Discipline means setting rules or road
the table it's dinner time. A mother asked “Will signs so children know what is expected of them.
you come take a bath now?” She means it's time Punishment is a consequence that results from a
for your bath. breakdown in discipline or the child's disregard
of the rules that were learned. Enforcing most
Making a statement instead of asking a limits of this type arises out of the day-to-day
question in this way can avoid a great many interactions with a child and out of the rhythm of
negative responses. Another is that a toddler childcare, not out of a set procedures, such as
needs experience in making choices, however, to “today i'm going to teach and discipline”
provide the opportunity to do this a parent could
give a secondary choice. No is not allowed for Two general rules to follow would include
the major task so the parent states “it's bath time parents need to be consistent. Rules are learned
now” but then says “Do you want to take your best if correct behavior is praised rather than
duck or your toy boat into the tub with you?” wrong behavior is punished. A timeout is a
Another example is “It's lunch time, do you want technique to help children learn that actions have
to use a big or little plate?” or “It's time to go consequences. To use a timeout effectively,
shopping, do you want to wear your jacket or parents first need to be certain their child
your sweater?” understands the rule they're trying to enforce.
Parents should give one warning, if the

child repeats the behavior, parents select an area
that is non-stimulating such as a corner of a
room or a hallway, the child is directed to go
immediately to timeout space. The child then sits
there for a specific specified period of time, if the
child cries or shows any other disruptive
behavior, the timeout period doesn't begin until
there is quiet. When a specified time has passed,
86
the child can return to the family, a guide as to she’ll put you to bed, when you wake up in the
how long children should remain in their timeout morning, mommy and daddy will be here again”.
chair is 1 minute per year of age. Example, for a
two-year-old would stay in the corner for 2 No matter how well prepared toddlers are
minutes using a timer that rings when time is up they may cry when the babysitter actually
is an effective way to let children when they can appears or may greet the babysitter warmly only
return to the family. to cry when the parents reach for their coats. It
1. Parent need to be consistent helps if parents say goodbye firmly, repeat the
2. Rules are learned best if correct explanation they will be there when the child
behavior is praised rather than wrong wakes in the morning and then leave.
behavior punished
a. Time out – 1 minute = 1 yr of Prolonged goodbyes only lead to more
age crying. Sneaking out prevents crying and may
ease the parent’s guilt but it can strengthen a
Separation anxiety child’s fear of abandonment and so should be
discouraged. This applies to leaving after hospital
visits as well.
Temper Tantrums
Fear of being separated from parents

begins at about 6 months of age and persists
throughout the preschool period. This universal
fear in this age group is known as separation
anxiety. ` Almost every toddler has a temper
tantrum at one time or another. The child may
Toddlers who have separation anxiety kick, scream, stomp feet, shout, flail arms and
have difficulty accepting being separated from legs, bite or bang his or her head against the
their primary caregiver to spend the day at a floor.
daycare center or if they are or their primary Temper tantrums occur at the natural
caregiver is hospitalized. consequences of a toddler's development. They
occur because toddlers are independent enough
Most toddlers react best to separation if a to know what they want but they do not have the
regular babysitter is employed or if the daycare vocabulary or the wisdom to express their
center has consistent caregivers, it helps if feelings in a more socially acceptable way. A
toddlers have fair warning they will have a tantrum may also be a response to difficulty
babysitter. For example, they could be told making choices or decisions or to pressure from
“Mommy is fixing dinner early because mommy ____ Such children need to express feelings in
and daddy are going to visit some friends tonight. some way and do so with temper tantrums.
Marcia is going to come and babysit for you,
87
Some children hold their breath as part of difficulty interacting with
a temper tantrum until they become cyanotic, playmates.
this occurs when a child is provoked. The child ○ Preferring instead to watch a
develops a distended chest, often has air-filled spinning toy, water swirling down
cheeks and shows increasing stress as the body the toilet, or repeating the same
registers oxygen want. song repetitive phrases.
● Children need to be screened for autism
Ignoring the child will make it an symptoms by 12 months of age and
ineffective technique for expressing frustrations again at 18 and 24 months of age by
_____ holding an unprovoked neurologic problem observation and parent report.
in which children under stress appear to forget to - Does not speak any words
breathe in or hold breathing usually at the peak of - Does not make any eye contact
anger. They become so short of breath they - Has difficulty interacting with
slump to the floor. playmates
- Prefers staring on other friends
True breath-holding needs follow-up to
separate it from temper tantrums. The best
approach is for parents to simply tell a child that Questioning
they disapprove of the tantrum and then ignore it.
They might say “i'll be in the bedroom when
you're done kicking, you come into the bedroom
too”.
Children who are left alone in a kitchen
this way will usually not continue a tantrum but
will stop after 1 or 2 minutes and rejoin their
parents. Parents should then accept the child
warmly and proceed as if the tantrum had not
occurred; this same approach works well for
nurses caring for hospitalized toddlers.
Autism Spectrum Disorder

● ASD or Autism Spectrum Disorder
○ A complex range of
neurodevelopment disorder
characterized by imitation
difficulties, poor social interaction,
and frequent repetitive and
stereotyped movement.
● Symptoms begin to appear slightly in
infancy but are usually obvious enough
during the toddler years for parents to
become concerned.
○ Because their child tends not to
speak any words, does not make
eye contact with others, and has
88
Preschool running to a designated neighbour
The preschool period traditionally includes if outside or dialling 911 if near a
the age 3, 4, and 5. Although physical growth phone
slows considerably during this period, personality ○ Describe what police officers look
and cognitive growth continues at a rapid rate. like and explain that police can
Therefore this is also an important period for help in an emergency situation
parents because they may be unsure how much ○ Explain that if children or adults
independence and responsibility for self care they ask them to keep secrets about
should allow the rapidly maturing child anything that has made them
Promoting Preschool Safety uncomfortable, they should tell
● Safety precaution in harmful objects at their parents or another trusted
home adult even if they had promised to
○ By age 4 years, children may keep the secret
project an attitude of ● Bullying
independence and the ability to ○ Explaining that bullying behaviour
take care of their own needs. from other children is not to be
However, they still need tolerated and should be reported
supervision to be certain they do so they can receive health
not injure themselves or other managing needs
children while rough housing and
to ensure they do not stray too far
from home
○ Their interest in learning adult roles
may lead them to exploring the
blades of a lawn mower, electric
saw, or a neighbor’s pool
○ Because they imitate an adult’s
role so well, they may imitate ● Because of front seat airbags,
taking medicine if they see family preschoolers need to be buckled into car
members doing so seats or booster seats in the back seat
○ It is also not too early to think ● Urge parents to stress the important role
about gun safety or being certain of seat belts in preventing injury and to
that any gun in the home is locked make the rule that the car does not move
away, separate from its until seatbelts are fastened
ammunition ● Many preschoolers outgrow their car
● It is important to educate children about seats during this period. A need to
the potential threat of harm from strangers graduate to a booster type of seat
or how to address bullying behaviour at ● Remind parents to check the position of
preschool or at play the shoulder harness in both types of
● Safety from strangers seats so the belt doesn’t cross a child’s
○ We caution a child never to talk face or throat
with or accept a ride from a ● Preschool is also the right age to promote
stranger bike safety because falls of bike are major
○ Teach a child how to call for help cause of severe head injuries in this group
in an emergency by yelling or
89
● To prevent such injuries, preschoolers ● Preschoolers prefer bright colors or prints
need a safety helmet approved for and so may select items that are
children their age and size appealing in color rather than matching
● Encourage parents who ride bicycles to ● As with other preschoolers, mismatching
demonstrate safe biking habits by wearing is common. However, children need the
helmets as well. Seeing a parent continue experience of choosing their own clothes
wearing a helmet may be the most ○ One way for parents to solve the
compelling reason for a preschooler to problem of mismatching is to fold
wear one together matching shirts and
slacks so a child sees them as a
set rather than individual pieces
○ If children insist on wearing
mismatched clothing, urge parents
to make no apologies for their
appearance
● Preschoolers may not eat a great deal of

meat because it can be hard to chew.
Many parents ask whether their
preschooler needs to talk supplementary ○
vitamins to make up for this ● On some occasion, even though they may
○ As long as a preschooler is eating be tired, children of this age group may
foods from all type of food groups refuse to go asleep because of fear of the
and meets the criteria for healthy dark and may wake up at night terrified of
child such as being alert and a bad dream
active with height and weight ○ This means that a preschooler
within normal averages, additional may need to sleep with a night
vitamins are probably unnecessary light turned on although they did
○ If parents do give vitamins, remind not need one before
them that a child will undoubtedly ○ A helpful tool for parents to use is
eat a vitamin as a candy rather to screen out frightening stories or
than medicine because of the tv watching just prior to bedtime
attractive shapes and colors of and to be certain when the light in
preschool vitamins so they must their bedroom is dim. It has a
be stored out of reach soothing atmosphere, no score
○ Caution parents not to give more teddy bears or evil smiling dolls
vitamins than the recommended ● Rough housing helps relieve tension and
daily amount or poisoning from should be allowed as long as it does not
high doses of fat-soluble vitamins become destructive.
or iron can result ○ In addition, preschoolers love
● Many 3 year old and most 5 year olds can time-honored games such as
dress themselves except for difficult “Ring around the Rosie”, “London
bodice although conflict may occur over
what a child will wear
90
Bridge” or other structured games surfaces have been cleaned, they should
they were not ready for as toddlers also floss their child’s teeth because this
○ Promoting these type of games is a skill beyond a preschooler’s motor
and reducing tv watching can be ability
steps to help children develop ○ Preschoolers should continue
motor skills and prevent childhood fluoridated water or receive
obesity prescribed oral fluoride
supplement if fluoride is not
provided in the water supply
● Encouraging children to eat apples,
carrots, chicken, or cheese for snack
rather than candies or sweets is yet
another way to prevent tooth decay
○ If a child is allowed to chew gum,
● Preschoolers can watch and dry their it should be sugar-free
hands adequately if the process is ● A first visit to the dentist should be
regulated for them arranged no later than 2 years of age for
○ Make sure that the water is not too an evaluation of tooth formation because
hot for them deciduous teeth must be preserved to
○ Although preschoolers certainly protect the dental arch
seat well in bathtubs, they should ● Dental services must be performed at 3
not be left unsupervised in years of age
bathtubs at bath time in case they ● Teeth grinding/Bruxism may begin at
decide to add more hot water or to this age as a way of letting go similar to
practice swimming and be unable body rocking which children do for a short
to get their head out of the water time each night before falling asleep
again ○ Children who grind their teeth
○ Some girls develop vulvar irritation extensively may have greater than
and perhaps bladder infection average anxiety
from exposure to bubble baths so ○ If grinding is extensive, the crowns
parents should not add much of the teeth can actually become
product into the water abraded
○ Preschoolers cannot clean their ○ The condition can advance to
fingernails or ears well. Either so, such an extent that tooth nerves
these areas often need touching become exposed and painful
up by a parent or older sibling ○ If damage is evident, refer the
○ Using a non-irritating shampoo family to a paediatric dentist so
and hanging a mobile over a tub that the teeth can be evaluated,
so they have a reason to look repaired, and conserved
while their hair are being rinsed
helps make hair washing a fun
procedure
● In taking care of the teeth, many
preschooler’s do well brushing their own
teeth. Parents must check that all tooth
91
○
● Common preschool health problems
● Encouraging creativity is encouraging include colds and ear infections
vocabulary building ○ Children who attend childcare or
○ One way for parent to do this is to preschool programs also have
read aloud to their child increased incidence of GI
○ Another way is to answer disturbances such as vomiting and
questions so that the child sees diarrhea, and URTIs from exposure
language as an organised system to other children unless frequent
of communication handwashing is stressed at the
● However, questions of preschoolers are setting
frequently philosophical and not backed ○ It is important that we emphasize
by findings such as “Why is grass green?” to the parents the importance of
○ A child may listen to an health maintenance check-ups,
explanation of chlorophyll but then bringing their child to clinics for
repeat the question regardless of immunization, and teaching the
the clarity of the explanation parents anticipatory guidance to
because the parent look into when it comes to children
underestimated the depth of the health problems
question. ● Many preschoolers continue to have
○ The child did not want to know occasional enuresis at night until
WHAT makes the grass green but school-age
WHY PHILOSOPHICALLY it is ○ If other symptoms are present
NOT red, blue, or yellow. such as pain, low-grade fever,
○ The obvious answer to that is IDK restlessness, a child should have a
● There are also times wherein the opinion urine culture because persistent
of the preschooler may bring them in bed-wetting can indicate a
opposition with the parents. low-grade UTI
○ So a major parental responsibility ● Preschool age is also the time for vision
when this happens is to guide the and hearing assessment because for the
child through these struggles while first time, a child is able to be tested by a
not discouraging a child’s right to standard chart or by audiometry test
have an opinion ● UTIs tend to occur with high frequency in
● A time out is a useful technique for preschool girls
parents to correct behavior throughout ● A language assessment should be done if
the preschool years just like toddlers. the child is not able to make wants known
○ Time-out period should be as by complete articulated sentences by age
many minutes as long as a child is 3 years
old (3-5 minutes for preschoolers)
92
● Preschoolers’ imagination is so active that ○

it may lead them to several fears such as ● Fear of Mutilation
fear of the dark, mutilation, and ○ It is also significant during the
separation or abandonment preschool age as revealed by the
● First is fear of the dark intense reaction to even a simple
○ This is a tendency to fear the dark injury such as falling and scraping
as an example of fear heightened a knee, or having a needle inserted
by a child’s vivid imagination for immunization
○ A stuffed toy by daylight becomes ○ A child cries afterward not only
a threatening monster at night from the pain but also from the
○ Children awaken screaming intrusiveness of the injury or
because of nightmares procedure
○ They may be reluctant to sleep or ○ According to Freud, boys develop
go back to sleep by themselves a fear of castration because
unless a light is left turned on or a developmentally, they are more in
parent sits nearby tune with their body parts and are
○ Leaving on a dim night light can starting to identify with the same
solve problems and cost only sex parent as they go through the
pennies audiple phase
○ Children who awake terrified and ○ Preschoolers can be worried that if
screaming need reassurance they some blood is taken out of their
are safe and whatever was bodies, all of their blood will leak
chasing them was a dream and is out
not in the room ○ They often life a bandage to peak
○ Most preschoolers do not at an incision or cut to see if their
remember in the morning that they body is still intact underneath
had such a dream. However, they ○ They dislike procedures such as
remember for a lifetime that they needlesticks, rectal temperature
received comfort when they assessment, otoscopic
needed it examinations or having an NGT
○ Giving sleep medication to tube passed through their
counteract sleep disturbances stomach. They need explanations
does not solve the basic problem of how limited medical procedures
so this is rarely recommended are such as clarifying a tympanic
○ thermometer does not hurt or a
93
finger-prick feels quickly as well as phenomenon frequently
distraction techniques in order to encountered in preschool
feel safe ■ For example, after a trip to
the zoo, if you ask a
preschooler what
happened today, a child
presumes that you want
something exciting to have
happened. They may
answer “A bear jumped out
of their cage and ate the
boy next to me.” This is
NOT lying and is merely
supplying expected
answers.
■ Caution them not to
encourage this kind of
● Fear of Separation/Abandonment
story-telling but instead
○ It is yet another major concern
help them separate fact
○ Their sense of time is still so
from fiction by saying
distorted that they cannot be
“That’s a good story but no
comforted by reassurances such
tell me what really
as “Mommy will pick you up from
happened”
preschool at 12.”
○ Imaginary friends
○ Their sense of distance is also
■ Many preschoolers have an
limited so making a statement
imaginary friend who plays
such as “I work only a block away”
with them
is not reassuring
■ Although imaginary friends
○ Making time and space into
are a normal creative part
something a child knows better
of preschool years and can
such as meals, television, shows,
be invented by children
or a friend’s house is more
who are surrounded by real
effective. For example, “Mommy
playmates as well as those
will pick you up from school after
with few, parents may find
you have had your snack” is more
them concerning so let
comforting than “Mommy will pick
them know that as long as
you up at 3 pm”
they have exposure to real
● Behavior Variations
playmates and imaginary
○ A combination of keen imagination
playmates do not take
and immature reasoning results in
center stage in the
a number of other common
children’s life or prevent
behavior variations in preschool
them from socializing from
○ Telling tall tales
other children, they should
■ Stretching stories to make
not pose a problem and
them more interesting is a
94
should leave as quickly as which objects belong to
they came which category
■ Parents can help their ○ Regression
preschooler separate fact ■ Some preschoolers
from fantasy about their generally in relation to
imaginary friend such as by stress revert to behavior
saying “I know Eric is they previously outgrew
imaginary and is not real such as thumb sucking,
but if you want to pretend, negativism, loss of bladder
I’ll set a place for him.” This control, and inability to
response helps the child separate from their parents
see what is real and what ■ These are commonly
fantasy is without termed as regression
restricting imagination or ■ As nurses, we help parents
creativity understand that regression
○ Difficulty sharing in these circumstances is
■ Sharing is a concept that normal, and a child’s
first comes to be thumb-sucking is an
understood at age 3 instance that is normal and
■ Before this, children is of little difference to a
engage in parallel play parent’s reaction to stress
wherein 2 children = 2 toys so it is easier for them to
= 2 places because they accept and understands
cannot share ■ Obviously removing the
■ Around 3 years of age, stress is the best way to
children begin to help the child discontinue
understand some things this behavior
are theirs, some belong to ■ The stress/stressors
others, some can belong to mentioned are ones that
both are not easily controlled
■ Assure parents that sharing ○ Sibling rivalry
is a difficult concept to ■ Jealousy of a brother or
grasp, and as with most sister may first become
skills, preschoolers need evident during preschooler
practice to understand and because this is the first
learn it time children have enough
■ Parents may need to help vocabulary to express how
the child learn property they feel, and partly
rights as part of learning to because preschoolers are
share more aware of family roles
■ Defining limits and and how responsibilities at
exposing children to these home are divided
3 categories (Mine, Yours, ■ For many children, this is
Ours) help them determine also the time wherein a
95
new brother or sister is help relieve this type of
born separation anxiety as well
■ To help raise preschoolers when a mother gets
feel secure and feel hospitalized for the delivery
self-esteem during this of a sibling
time, reminding them that ● Sex education
there are things that they ○ Line of communication
can do that the younger ■ During the preschool age,
sibling is not allowed to do, children become acutely
providing them with a aware of the difference
private drawer or box for between boys and girls
their things that parents or ■ Preschoolers question
other children do not touch about genital organs are
can be helpful simply in fact-finding
■ A private box serves as a ■ It is important that parents
defense against younger do not convey are never to
children who do not yet be talked about so they
appreciate property rights leave an open line of
■ If children are to start communication for
preschool or childcare, it is questions
also best if they can do so ■
before the new baby is ○ Masturbation
born or 2-3 months ■ It is also common for
afterwards, that way preschoolers to engage in
children can perceive masturbation while
starting school as a result watching tv or before they
of maturity and not being fall asleep at night
pushed out of the house by ■ The frequency may
the new child increase under stress as
■ Also, help parents not to does thumb-sucking
underestimate the ■ If observing a child doing
significance of a bed to a this bothers parents,
preschool child because it suggest it playing certain
is security, consistency, things are done in certain
and home if their places but not in others
preschooler is sleeping in ■ Children can relate to this
the crib that will be used kind of direction without
for the new baby feeling inhibited just as
■ It is usually best if the they can accept the fact,
preschooler can be moved they use a bathroom in
to a bed about 3 months in private or eat only at the
advance of the birth table
■ Remember, about sibling ■ Calling unnecessary
visitation, allowing the child attention to the act can
to visit in the hospital can increase in anxiety and
96
cause increased and not ○ Trying to make children complete
decreased activity fine motor tasks for which they are
not developmentally prepared
does not instill that concept
● Broken Fluency or Secondary stuttering
○ A child may begin to repeat words
or syllables, saying “I want a
ne-new, spo-spoon.”
○ This is called broken fluency
■ Prolongation and repetition
of sounds, syllabus, and
words
● At the end of the preschool period, ■ it is often referred to as
children begin a formal school experience secondary stuttering
as they enter kindergarten because the child began to
● Because school involves a great deal of speak without this problem
children’s time and influences their future and then during preschool
greatly, it is important for parents to take develops it
time preschoolers not only physically by ○ Children are unaware that they are
being certain their immunizations are up not being fluent unless it is called
to date but also emotionally to their attention
● If a child was not attending preschool, ○ Remind parents that this is a
some parents may have to change their normal part of normal
child’s daily routine a few months in development and if accepted,
advance of beginning school to accustom such will past
the child to walking or waking earlier or ○ It is resolved most quickly parents
going to bed earlier follow if using simple rules
○ If a child will be required to take a including
lunch at school, a parent can ■ Do not discuss in the
introduce this new experience by child’s presence that
preparing a bagged lunch at home he/she is having difficulty
○ If a child is to purchase lunch at with speech because this
school, the parent can play can make the child
cafeteria at home by serving a conscious of speech
buffet style meal and letting the patterns and compound
child practice walking from one the problem
dish to another to select their food ■ Listen with patience rather
● A better contribution for parents to make than interrupt the child to
toward their children’s achievement in ask the child to speak more
school is to instill in their children the slowly or to start over,
concept that learning is fun and that their these actions make a child
child may not always be able to do all the aware speech is repetitious
things other children can do, but trying to and broken fluency
do one’s best is what is important increases
97
■ Always talk to a child in a ○ The correcting is no different from
calm and simple way to that involved when a child uses
role model slow speech poor grammar
■ If adults talk quickly, a ○ If the parents become emotional, a
child imitates this pattern child realizes the value of such a
and makes it difficult to word and may continue using it for
speak clearly the attention it creates
■ Protects space for the child
to talk if there are other School Age
children in the family
■ Rushing to say something Promoting school-age safety
before a second child School-age children span from 6-12 years
interrupts is the same as Typically slow physical growth during this period
rushing to conform to adult of time, cognitive development grows at rapid
speech rates.
■ Do no force a child to
speak if he or she does not 7 and 10 year old children have different
want to needs compared to 11 and 12 year olds. All
■ Do not ask preschoolers to children should be treated uniquely as individuals
recite or sing for strangers to understand the particular development needs
■ Do not reward a child for for each child.
fluent speech or punish for
non-fluent speech
■ Broken fluency is a
developmental stage in
language formation not an
indication of regression or
a chronic speech pattern
● Bathroom language
○ Preschooler imitate the
vocabularies of their parents or
older children in their family so ● School-age children are ready for time on
well during this time so they make their own without direct parent
incorporate swear words if they supervision. School-age is not too early to
hear this used observe the children’s backpack effect on
○ Parents may have to be reminded the child’s posture. More than 10% of the
that children do not necessarily child’s body weight is enough for the child
what the word they are using to lean to bear the weight. This can lead
means to chronic back pain.
○ They have simply heard it just as ● To promote safety (especially in bike
they have heard hundreds of other riding). Teaching bicycle safety is
words and have decided to use it important at this age. I.E.: wearing a
○ It is important that correction helmet and not give rides to strangers.
should be done unemotionally Warn children not to go to remote places
such as graveyards, silos, and alleyways.
98
Parents can establish a code word for the
child in order to prevent a stranger from
picking them up.
● Also teach the child consent, to prevent
strangers from touching them if they do
not wish to be touched. This includes
family members (most sexual abuse and
harassment comes from within the family)
● Teach children to avoid meeting strangers
from the internet in person.
● It is important to avoid recreational drugs,

tobacco, and firearm use.
● School-age children should keep adults
informed with where they are and what
they are doing. A cell phone is useful in
these situations.
● Children are more prone to unintentional
injuries when parents are less attentive.
● Special precautions must be taken at this
time as children are more curious and
bold in their ventures. More vulnerable to
unintentional injuries than others.
● For older school age children, teach them
● Adolescence is the right age to teach the
about safe sex. This will benefit them, as
importance for caring for one's own
they will know what to do years ahead of
belongings.
their first sexual encounter.
● Adolescents will dress, have the same
● Teach children about fire and knife safety.
interests, and be interested in the sports
Implement safety when cooking and
that their friends are also interested in.
swimming.
(instead of their parent’s interests)
● Include microwave safety and avoid using
● It is important to note if a child wears
metals when microwaving.
something other than what the others are
● Teach to wear sunblock during swimming
wearing, it is possible that they may
and other outdoor activities
become the object of exclusion from a
● Teach child not to climb on electric posts.
school club of group.
● It is best for them to learn how to swim,
roughhousing is not appropriate during
the learning process.
● Pressure to swim beyond physical
capabilities is also not appropriate.
● These children require 10 to 12 hours of

sleep each night
● Older children require 8 to 10 hours.
99
● Nighttime terrors may increase during the lower jaw, or genetic traits from
first school years of a adolescents life as malocclusion.
the child reacts to beginning school. ● May also stem from mouth breathing or
● At 9 years when friends become abnormal tongue position.
important, children give up night-time ● Thumb sucking is another possibility of
talks with the parent and instead may text irregular tooth position (especially during
or phone a friend. 6 to 10 years when adult teeth erupt).
● Children with electronic devices have less ● The time to begin adjustment depends on
sleep time and are more likely to be the malocclusion and jaw size.
obese. ● Braces are painful when first applied, and
during adjustments to ensure
Pedodontist straightening.
● Specialize in children’s teeth, and ● Some children develop canker sores on
understand the development level of the the buccal membrane.
child. ● Rubbing dental wax on top of the surface
● The parents of children with caries may of the braces can give relief.
be encouraged to visit a pedodontist if ● Oral gel, rubbed on the ulcerations may
one is available and affordable. also give relief.
● School-age children must be reminded to ● Children with braces must be accessed
brush their teeth daily. They must use a periodically to see if they are brushing
tooth-brush, floss, and gargle. properly.
● Snacks must be healthy such as chicken ● They should use dental floss to remove
or cheese rather than candy. plaque from the wires.
● Carries are destructive lesions and ○ Soft-bristled toothbrush
decalcification of the enamel and dentin ○ Fluoridated-based
of the tooth. toothpaste
● pH level of the tooth surface drops 5.6 or ○ Dental floss
below, which when children consume
fermented carbohydrates such as table
sugar.
● Plaque develops and destroy the teeth
● When dental carries are found it must be
treated immediately.
● If carries are found the child’s oral hygiene
must be reevaluated and re-taught.
● Children must believe that they contribute
to the health of their teeth and practice
self-care with parental support rather than
parental demand
● Dental visits are required every 6 months
with the eruption of new teeth.
● Sealants can be applied to lessen the
decay of the tooth.
● Many six year olds will quote their
● Tooth position from the normal position
teachers as the final authority on all
may come from a cleft palate, a small
subjects.
100
● This may be the first time the parent may nephritis and rheumatic fever from
see the child accept another authority developing.
other than themselves (may be painful). ● Girls must be examined for scoliosis or
● Children can also cite their friends for curvature of the spine. Parents detect this
behavior. (this is a normal consequence if skirt hangs unevenly or bra straps are
exposed to other people) uneven.
● Everyday duties must be practiced in ● Vomiting or headache in the morning may
order to be accomplished well. The way be a symptom of school phobia.
parents correct children will influence the ● Physical examination must be an order for
way the child views themselves. school phobia because it is a symptom of
other pre-existing conditions.
● Absent seizures can be misinterpreted as
developmental problems if examination is
not thorough.
● Attention deficit disorder can lead to
behavior or inattention disorders.
○ Articulation
○ Anxiety r/t beginning school
○ Homeschooling
Eye Vision ○ Latchkey child
● Streptococcal sore throats ○ Sex education
● Scoliosis ○ Stealing
● School phobia ○ Bullying
● Absent seizures
● There are certain childhood diseases that

take place during school-age
● Squinting, rubbing the eyes, and pain may
be a sign of vision problems.
● Those with sore throats may be examined
by a physician to prevent (throat?)
101
● Diarreah or headache, or abdominal pain
on school days are symptoms of school
refusal.
● Treatment for this can prevent peer
ridicule
● Children may benefit from this by walking
to school but not going in. Then going to
school for one hour until they are able to
stay in the whole day.
● Problems in articulation may occur, ● Homeschooling is important if the parents
broken fluency is common in preschool plan to teach their children from home. It
years. is important if the child is happier in
● Problem in school age children is experiences in communities such as clubs
articulation (s, z, th, l, r, and w are hard and sports with other children.
vowels to sound out.) ● Ask if children are exposed to other
● This is most noticeable in 1st and 2nd children, ethnicities, and adults different
grade, if persists to 3rd grade is also from themselves rather than encountering
normal. them in college.
● Many 1st graders are capable of mature ● Latchkey child has two parents who work
action at school but appear less mature away from home and leave the child alone
when they come home. for a good part of the day.
● Some develop baby-talk, ticks, ● Major concern of latchkey children of
thumb-sucking, and other immature staying home alone, may in turn cause,
behavior. delinquency, poor school performance,
● Wrinkling the forehead, rapidly blinking, and increased unintentional injury due to
and other movements. May occur during lack of parental control.
the day, but disappear at bedtime. ● Children who are responsible and feel
● May be a symptom of anxiety. safe in the community, a short period of
● Scolding, threatening, or spanking does independence promotes problem solving
not stop ticks or nail biting and makes and self care
problems worse. ● Nurses are in a position about such
● Using bad tasting nail polish, and services, so their children feel safe and
restraining child’s hands are not effective. stimulated (after school programs).
● These behaviors when underlying stress is ● Sex Education is incorporated in health
discovered and elevated. classes appropriate to the age of the
● Allow parent bonding time after school to child.
allow child to feel as a part of the family ● Both pre-adolescent boys and girls can
even they are away at school. be introduced to the functions of bodily
● If behavior persists, the family may benefit organs and their mechanisms.
from counseling, therapy, and ● Sexual characteristics and functioning,
pharmacologic aid. pregnancy, and reproductivity can be
● School refusal or phobia: fear of attending introduced at this age.
school, similar to agoraphobia or anxiety ● It is important to urge parents and
disorder. educators to watch films and read
102
booklets with children in order for them to ○ For preschoolers, since this is a
know that there are resources available. very active time in their life, they
● During early school-age a child will go are imaginative, they love to
through a period of stealing loose-change explore, they are slowly leaving the
from parents. (7 years of age). When they house to explore the outdoors and
discover the importance of money. other environments. This would
● Stealing occurs when the child discovers mean that they have pseudo
the importance of money, but it is not independence - the child may
balanced by strong moral principles or the project an attitude of
knowledge of ownership. independence and ability to take
● This is best handled if the parent tells the care of their own needs but of
child the money is missing. The course they still need their parental
importance of property rights can be supervision because they are still
reviewed. very young and they could get into
● Shoplifting occurs with the school-age some accidents especially if they
child, but this problem arises with are left unsupervised
preadolescents. ○ Safety measures should focus on
● If one parent takes money from the other possible accidents that might
without permission neither should be happen during this time of their
surprised if their child does the same. lives for example, they should
● Alert parents that internet and texting have car seats because motor
bullying does occur and that it does not vehicular accidents (MVA) are
always need to be face to face to be considered a big hazard during
harmful. this time
● Bullies may have advanced physical size ○ Falls, drowning, animal bites,
and strength for their age and aggressive burns, poisoning, and strangers
temperament. Parents may be permissive also have to be taken into
to their child, and may resort to physical consideration (at this time, parents
punishment. should teach children to be
● Bullying can be done through social cautious around strangers)
media, f2f, and texting. ○ Nursing considerations for safety
● Supervising closely during school (for of preschoolers:
teachers) insist if behavior does not stop ■ Repeatedly reminding the
both the school and the parents will guardian of automobile
become involved. safety
● Allow child to discuss bullying with ■ Stress proper medication
parents to help them know it should be administration especially in
reported very young children.
● Parents should monitor their child's social Always practice proper
media interactions. storage of medications and
never take medications in
Add ons: front of a child. If you
1. Safety issues and considerations for very administer medicine, check
young children. with the physician first
103
especially when it is an ○ Small children are not well
OTC drug equipped with knowing what to
■ Teach the child to never feed themselves so it is the job of
accept bribes, never talk to the guardian, the food handler, the
strangers, or accept parent to:
anything from them. The (Preschoolers):
guardian must always ■ provide nutritious snacks
know the whereabouts of and meals
the child. The child also ■ make mealtimes enjoyable
must be informed that if and happy
someone tells them a ■ encourage the child to eat
secret which makes them properly by offering small
uncomfortable, they should servings so they will be
tell someone who they can given an opportunity to not
trust about it. feel so overwhelmed and
■ It is also important to they will also feel a sense
remind the parents that the of accomplishment when
frequency of accidents will they are able to finish a
increase in conjunction to plate of food.
the stress of the parents. ■ Them being picky with
So if the parent are very food is usually carried on
stressed, there is a high from toddlerhood to
risk for accidents during preschool age. Parents are
that time encouraged to make food
○ Nursing considerations for safety presentations lively and
of School age children: creative. Make vibrant
■ School age children are colors and textures
ready for a time of their available for the child so
own so more accidents will they can explore the food
occur if the child is under they enjoy and so that they
stress and if the parent is will be encouraged to eat
under stress more.
■ MVA are still a common ■ Allow the child to help in
cause of accidents so the kitchen
these children still have (School age):
booster seats. They can ■ Make mealtimes happy and
graduate to regular seats enjoyable
but endure seatbelts ■ Usually these children will
■ Sexual abuse is a common leave the table because
and unfortunate known all they would rather do
too well hazard. Start sex something else so it is
education and awareness important to help keep
when it comes to this them focused on their
2. Nutrition: meals
104
■ More daily dietary ■ Encourage the parent to
allowances. Especially learn whether the child is
calories and especially for scared of the dark that is
boys because why they refuse to sleep
physiologically they need ■ Offer night light or sleep
more calories. Encourage with the child, comfort
them to always have them and reduce stress
proper meals and snacks before bedtime
because they are very ■ When nightmares occur,
active they have to accept the
■ Let the child plan meals dream as a real fear. They
because they love eating could sit with the child and
meals they have prepared comfort them so the child
and planned will be reassured and have
3. ADL a sense of security
○ Preschoolers still need supervision ○ For younger school agers their
but it is also good to give them average time of sleep is lesser and
more opportunities to choose lessens as they get older ( 8-9 1/2
things for themselves for example, hrs a night). Night terrors may
letting them choose their own continue but not so prevalent
clothes because it can help 5. Bathing
develop their independence and ○ Preschoolers need supervision
autonomy. They prefer bright especially risk of scalding
colors and prints that is also a themselves because they dont
signature in preschoolers. If the know how to regulate temperature
parent want to narrow down their in the shower. Falls and slips are
choices but also give them a also a risk
chance to decide, they could ○ School agers can regulate bath
create sets of clothes and from water. They are capable of bathing
there, the preschooler can choose themselves. Towards the end of
○ School age can take care of their the school age, they will be more
own clothes and belongings. They interested in the upkeep of their
would base their styles on their own hygiene
friends. They have full 6. Exercise
independence on clothing choices ○ Preschoolers and school age
4. Sleep children are very active
○ For preschoolers, because of their ○ Especially preschoolers they love
active imaginations, they would playing traditional games (london
probably get nightmares, sleep bridge, ring around the rosie)
talk, or sleep walk. This is a normal ○ Roughhousing especially when
part of development. This could they have siblings is normal. This
also be a parental concern but is a good way to release tension
reassure the parent that this is a ○ School age children would be
normal part of development of a involved in structured games and
preschooler activities and organized sports
105
7. Dental care they used to be the center of
○ Preschoolers would start attention
independent toothbrushing but it 10. Parental concerns for school age:
is still good to supervise them. ○ Fear of lack of belongingness
They would also experience 11. Sex education
bruxism like grinding because it is ○ It is a crucial time especially in
a way to release tension preschool age it can start here.
○ School age children since they are Parents dont have to wait for the
starting to have permanent teeth, school to start it. Teaching starts
it is important to have proper at home. Health teachings and
dental care. Encourage them to what to expect, changes in the
visit the dentist at least 2x a year body, precautions etc. by this time
and brush teeth daily. The preschoolers will ask “where did i
frequency is not as important as come from”
the quality 12. Behavior variations
8. To encourage healthy family functioning, ○ School age children tend to lie,
discipline must be established. The cheat, and steal especially the
parents have to serve as good role younger age group
models to both of these age groups ○ May lie because they may have a
because this is critical for the formation of difficulty separating fantasy from
their values reality. They cheat especially if
9. Parental concerns for preschoolers: they see it in their surroundings
○ Fear of the dark they would imitate so parents
○ Fear of mutilation should serve as examples of
○ Fear of separation/ abandonment honesty. Stealing because children
○ Prone to telling tall tales- stretch don't really know property rights
stories to make it seem more vey well. A consideration for this is
interesting. Acknowledge this but to encourage the child to respect
also bring them back to reality by the property rights of others and
saying “thats a good story but tell respect the child’s personal rights
me what really happened” as well. If caught stealing,
○ Imaginary friends as long as it is encourage them to return the item
not harming the child or taking and say sorry
center stage in their socialization ○ Bullying, obesity, and drug use
preventing them from socializing could be rampant in school age
to other people then it is not a children
problem
○ Difficulty sharing. They would
regress. A preschooler who is not Adolescent
thumbsucking may thumbsuck Adolescence is generally defined as a
especially if they are stressed period between ages 13 and up to 20 years. A
○ Sibling rivalry. It is natural for an time that serves as a transition between
older child to feel jealousy or childhood and becoming a late adolescent.
resentment towards a new It can be divided into:
member of the family especially if 1. Early period: 13 to 14 years
106
2. Middle period: 15 to 16 years - Take graduated driver programs seriously
3. Late period: 17 to 20 years so the child learns safe driving habits for
both two wheel and four wheeled
During all periods adolescents are defined vehicles.
not so much by chronological age but by
physiologic, psychological and sociological For sports, it is important to use
changes. The drastic change in physical protective equipment such as face masks for
appearance and the change in expectations of hockey, and pads and helmet for football. Do
others especially parents that occur during the not attempt to participate beyond physical limits.
period can lead to both emotional and physical Keep well hydrated by drinking fluid before and
health concerns. after play. Careful preparation for sports through
training is essential to safety and recognize and
set one's own limit for sports participation.
Other common causes of death in

adolescents are homicide and self-harm or
suicide. These are related to easy accessibility of
guns when added to depression, binge drinking,
Intentional (?) injuries most commonly and impulsivity. Gang violence and the desire to
those involving motor vehicles, are the leading protect themselves are additional factors.
cause of death among adolescents. Although
teenagers are at the peak of physical and Nutrition
sensory motor functioning, their need to rebel Adolescents experience such rapid
against authority or to gain attention through growth that they may always feel hungry. If their
risk-taking leads them to take careless actions eating habits are ____ unsupervised because of
such as speeding or driving while intoxicated. peer pressure and when in a hurry to get to other
Some adolescents dismiss seatbelts as childish activities, they tend to eat fadish or quick snack
and so need extra instruction that is why to use foods rather than more nutritional sound ones.
every safety precaution available when in a motor
vehicle. So instruct them to: Adolescents who are slightly obese
- Always use a seatbelt whether a driver or because of prepubertal changes may begin low
a passenger. calorie or starvation diets during adolescence to
- Never use a cellphone or text while lose weight. Some diets are so excessively, they
driving. develop eating disorders such as bulimia or
- Do not drink alcohol while driving and anorexia nervosa.
always refuse to ride with anyone who has
been drinking. Anorexia often stems from a distorted
- It is important to name a designated body image which may result from an emotional
driver or arrange with the parents to be trauma, depression, or anxiety. Some people may
picked up or provide money for a taxi. view extreme dieting or weight loss as a way to
- Wear a helmet and long trousers as driver regain control in their lives. There are many
or passenger on a motorcycle. different emotional behavioral and physical
- Accept theres has no place in safe symptoms that can signal anorexia.
driving.
107
While someone with bulimia may develop
an unhealthy relationship to food overtime, they
may get caught up in damaging cycles of binge
eating and then panic about the calories they
have consumed. This may lead to extreme
behaviors to prevent weight gain.
A weight loss diet is appropriate during

adolescence but it must be supervised to ensure
the adolescent is consuming sufficient calories
and nutrients for growth. For example, many
adolescents entirely omit breads and cereals to
lose weight, rather than just reducing the
amounts they eat. Diets such as can be deficient
in vitamin b, thiamine, and b2 riboflavin which are
necessary for growth. Health Problems
● Hypertension
Sometimes adolescents may be unaware ○ Hypertension is present if the
that their food intake is excessive because they blood pressure reaches above for
have been told they need excess nutrients for two consecutive readings in
healthy and adolescent growth and everyone in different settings:
their family eats large portions. Health teaching ■ 127/81 mmHg for 16 year
with these adolescents may need to begin with a old girls
discussion of a normal weight and standard food ■ 131/81 mmHg for 16 year
portions because they do not begin to own this old boys
problem as adolescents they run a high risk of ○ All children older than 3 years of
becoming obese adults. age should have their blood
pressure routinely taken at all
The general measures to help adolescents health assessments to detect this.
decrease overeating include: ○ This is particularly important for
1. Making a detailed vlog of the amount they adolescents because new
eat, the time and the circumstances and medications plus education can
then changing those circumstances help to greatly reduce the
2. Always eating in one place like the kitchen incidence of cardiovascular
table instead of while walking home from disease as they reach adulthood.
school or watching television ● Poor posture
3. Slowing the process of eating by counting ○ Urge children of both sexes to use
mouthfuls and putting the fork down good posture during these rapid
between bites, or growth years
4. Being served food on small plates so the ○ Assess posture at all adolescent
helping looks larger. health appraisals to detect the
● Anorexia difference between simple poor
● Bulimia posture and a beginning of spinal
● Obesity dysplasia or scoliosis.
● Body piercing & tattoo
108
○ Body piercing and tattoos are a infections in adolescence, such as
strong mark of adolescence. infectious mononucleosis.
○ Body piercings and tattoos have ○ Chronic fatigue syndrome
become a way for adolescents to although not seen as often in this
make a statement of who they are age group as in adults may also
and that they are different from need to be ruled out.
their parents. ● Menstrual irregularities
○ Be certain they know the ○ The most common menstrual
symptoms of infection at a irregularities would be acne.
piercing or tattoo site such as:
■ Redness
■ Warmness
■ Draining
■ Swelling
■ Mild pain
○ To report these symptoms to their
healthcare provider if they occur
because serious staphylococcal
or streptococcal infections can
occur at piercing sites.
○ It is important to caution
adolescents that sharing needles
for piercing or tattooing carries the
same risk for contracting a blood
borne disease as sharing needles
for intravenous drug use.
● Fatigue
○ Because so many adolescents
comment that they feel fatigue to
some degree it can be considered
normal for the age group.
○ However, fatigue may also be a
beginning symptom of disease so Acne
it is important that it is not ● Due to increase androgen levels and
underestimated as a concern. active sebaceous glands
○ Always assess diet, sleep ● Acne is a self-limiting inflammatory
patterns, and activity schedules of disease that involves the sebaceous
fatigued adolescents. glands which empty into hair shafts.
○ Be aware that if fatigue begins as ● It is the most common skin disorder of
a short period of extreme tiredness adolescents and it is more frequently
it suggests disease more so than a occurring in boys than girls.
long ill-defined report of always ● Change is associated with puberty that
feeling tired. causes acne to develop include the
○ Blood tests may be indicated to increase in androgen level in both sexes
rule out anemia and common and sebaceous glands become active.
109
● The output of sebum which is largely
composed of lipids, mainly triglycerides,
increases.
● Trapped sebum causes whiteheads or
closed comedones.
● As trapped sebum darkens from
accumulation of melanin and oxidation of
the fatty acid components on exposure to
air, blackheads or open comedones
form.
● Leakage of fatty acids causes a dermal
inflammatory reaction. Bacteria lodge
and thrive in the retained secretions and
ducts. Sexuality
Acne is categorised as mild, moderate,

and severe:
1. Mild – comedones
- Mild is made up of comedones or
blocked hair follicles.
2. Moderate – Papules and pustules
present
3. Severe – cyst present
Risk Factors:
● Emotional Stress Stalking refers to repetitive, intrusive, and
● Menstrual periods unwanted actions such as constant threatening,
● Make-up and hair products pursuing directed at an individual to gain the
individual’s attention, or to evoke fear. Electronic
Treatment (The goal): media can be used for cyber stalking, internet
● Decrease sebum formation harassment, and internet bullying to embarrass,
● Prevent comedones harass, or threaten adolescents.
● Control bacterial proliferation
● There are systemic medications and This is one of the concerns regarding
external medications that could be sexuality and sexual activity that can threaten
applied as ordered by the doctor. especially female adolescents. To avoid stalking,
adolescents should be aware of and avoid
situations where they will be vulnerable to being
alone with the stalker and with assistance, report
talking to law enforcement.
110
adolescent joins, and what
the requirements for
membership are.
○ Help adolescents make
sound decisions about
what type of hazing their
organization advocates for
by asking them about the
subject at health
assessments.
● Substance use disorder
○ Substance use disorder, formally
referred to as substance abuse
disorder
■ Refers to the use of
chemicals to improve a
● Hazing & Bullying mental state or induced
➢ Bullying euphoria.
○ Bullying which began ○ This is so common among
during school-age can adolescents that as many as 50%
easily continue into of high school seniors report
adolescence and actually having experimented with some
becomes more serious form of drug according to CDC in
because this can be the 2012.
time the bullied child has ○ One of the many abused
the ability to retaliate substances would include:
through self-destructive ■ Prescription and
behavior or school over-the-counter drugs
violence. ■ Alcohol
➢ Hazing ■ Tobacco
○ is a form of organised ■ Steroids
bullying, and refers to ■ Marijuana
demeaning or humiliating ■ Amphetamines
rituals that prospective ■ Cocaine
members have to undergo ■ Hallucinogens
joint sororities, fraternities, ■ Opiates.
adolescent gangs or sports ○ It is important to promote
teams. therapeutic communities or 24
● To help prevent this from hour facilities in which adolescents
happening or the dangers of can live while they recover from
bullying and hazing to happen to chemical dependency, which may
the child: be necessary for some
○ Urge parents to be aware adolescents.
of what clubs or ■ The aim for all these
organisations their programs is to increase
111
adolescents’ sense of self one or both parents or
esteem, improve problem reveal how little support
solving ability, and realign the adolescent receives at
them. home.
■ Adolescents should be ■ School friends may often
encouraged to seek care be the one who are first
for themselves or others aware that an adolescent is
whenever an overdose contemplating suicide.
situation is apparent as ■ Caution parents not to
prompt treatment can be discount reports from their
life-saving. child’s friends who tell
● Depression & Self – injury them they are concerned.
○ Self-injury ■ ____ chosen from suicide,
■ Includes a range of some adolescents
self-destructive actions demonstrate characteristic
from cutting to suicide, the behaviors that show they
planned intent to end one's are making preparations to
life. end their life.
■ Cutting ■ Teach family and friends
● found more these typical danger signs,
frequently in girls when caring for a child
than boys and can after a suicide attempt, ask
begin as early as enough questions and a
grade school. health history so you can
○ Suicide help to analyze whether an
■ Successful suicide occurs adolescent made a
more frequently in males detailed suicide plan.
than in females although
more females apparently Metro Manila Developmental Screening Tool
attempt suicide than males. (MMDST)
■ Adolescent suicides tend - Screening is a presumptive identification
to be attempted most often of unrecognized disease or defect.
in the spring or in the fall, - It is used for early detection and tests
reflecting school stress at child with problem.
this time of the year and - It facilitates early referral and treatment,
between 3:00 p.m. and and detects developmental disabilities.
midnight, reflecting - MMDST is indicated for children 6 ½
depression that increases years old and below.
with the dark. - The MMDST is a simple and clinical useful
■ Because suicide usually tool.
reflect problem in the - It is used to determine early serious
family, a family assessment developmental delays.
is helpful. - It is organized by Dr. William K.
■ A thorough family history Frankenberg and modified and
may reveal conflict with standardized by Dr. Phoebe
112
Dauz-Williams, RN, Ph.D. from DDST ○ Small clear glass/bottle with 5/8
(Denver Developmental Screening Tool) to inch opening
MMDST ○ Small bell with 2 ½ inch – diameter
- It is developed for health professionals mouth
such as doctors, nurses, and etc. ○ Rubber ball 12 ½ inches in
- It is not an intelligence test. It is a circumference
screening instrument to determine if a ○ Cheese curls
child's development is within normal. ○ Pencil
- Patterned on DDST ○ Mat
Objectives: ➢ GUIDELINES
● Measures developmental delays 1. Children less than 6 months should be
● Evaluates 4 aspects of placed on the lap of the provider or by
development: the examiner.
○ Gross – Motor Adaptive 2. Associative play is introduced during
■ This includes tasks the whole test.
which indicate the 3. Identify the age of a child based on
child’s ability to sit, the date of examination; and consider
walk, and jump. prematurity if the child is 2 years old
○ Fine – Motor Adaptive and below.
■ Covers tasks which 4. Start on tasks below the child’s age
indicate the child’s level.
ability to see and 5. Allow 3 trials per task.
use his hands to
pick up objects and This is the test form:
to draw.
○ Language
■ This covers tasks
which indicate the
child’s ability to
hear, follow
directions, and to
speak.
○ Personal – Social
■ Covers tasks which
indicates the child’s
ability to get along
with people and
- Across the top and bottom of the form are
take care of himself.
age scales. Age is marked in months from
➢ MATERIALS
1 to 24, and from years in 2 ½ to 6 years.
○ Bright red yarn pom – pom
- Each item is represented in a test form by
○ Rattle with narrow handle
a bar. The bar is placed along the age
○ Eight 1 – inch colored wooden
scales to show when 25%, 50%, 75%,
blocks (red, yellow, blue, green)
and 90% of the normal children are able
to pass the item.
113
➢ HOW TO USE THIS TOOL? the test to the child,
1) First, we need to determine the however, per provider’s
age of the child based on the date testimony, the child is able
of examination. to do that in some
● E.G. The child is currently 6 instances.
months to be exact. So, we “N.O.” – No opportunity
draw a line across 6
months (the red line ➢ SPECIAL CONSIDERATIONS
presented in the picture), ○ Manner in which the test is
from the top 6 months to administered must be exactly the
the bottom 6 months. same as what is stated in the
2) Then, we looked into the tasks manual. Words/directions may not
passed over or crossed over by be changed.
the line. ○ If the child is premature, subtract
● Based on this line, we are the number of weeks of
to administer the tasks prematurity.
three boxes to the left. ○ If the child is more than 2 years of
● It is expected that the tasks age during the test, subtracting
on the left are easy or may not be necessary.
passable for the child. ○ If the child is shy or uncooperative,
However those tests the caregiver may be asked to
towards the right may be administer the test, provided that
too advanced and it is the examiner instructs the
expected that the child caregiver to administer it exactly
may fail. as directed in the manual.
3) We start from the third task from ○ If the child is very shy or
the left and go towards the right to uncooperative, the test may be
see if the child may have an deferred.
advancement.
MMDST FROM THE VIDEO
➢ SCORING & POINT SYSTEM - Metro Manila Developmental Screening
“P” – Pass Test is a simple, clinically useful tool and
“F” – Failure an early detection model that applies to
● Failure of an item that is the detection of developmental disabilities
completely to the left of the in children.
child’s age is considered a - It is a modification that is standardized by
developmental delay, Dr. Phoebe D. Williams from the original
whereas failure of an item Denver Developmental Screening Test or
that is completely to the DDST by Dr. William K. Frankenburg.
right of the child’s age line - The MMDST is designed to detect
is acceptable and not a developmental delays in children 2 weeks
delay. to 6 ½ years of age.
“R” – Refusal/Pass by report
● This is for instances ➢ Demographic Data
wherein we cannot elicit ○ Child’s Name: Lexie Brazz Linaga
114
○ Birthday: November 6, 2016 gud na siya sa iya mga kaduwa.” -
○ Address: Brgy. Ipil, Ormoc City, Leyte Reported by her Father
○ Father’s Name: Nelson Linaga Jr. ➢ Gross Motor
○ Mother’s Name: Apple Linaga ○ Throwing Ball Overhead - PASSED
○ Birth History: Normal ○ Balance on One Foot in 1 Second
○ Birth Order: 2nd - PASSED
○ Breastfeeding History: Since birth till ○ Pedals Tricycle - “Naa siya’y bike
6th month kanang tulo gaming ang ligid (usa
sa atubangan tapos duha sa likod)
pero dili pa siya kaabot sa pedal.” -
Reported by her Father
○ Broad Jump - PASSED
➢ Results
○ Personal-Social: No Delays
○ Fine motor adaptive: 1 Failed
(Imitate Vertical Line)
○ Language: No Delays
➢ Personal-Social
○ Gross Motor: 1 Failed (Pedals
○ Plays Interactive Games - PASSED
Tricycle)
○ Uses Spoon Spilling Little -
PASSED
ADD-ONS:
○ Puts On Clothing - PASSED
● Some of the Key Concepts when it comes
○ Washes and Dries Hands -
to adolescents, we already know that
PASSED
there are so many changes in all aspects
○ Separates from Father Easily -
of an adolescent’s development.
PASSED
● They are all grown-up but not quite an
○ Removes Garments - PASSED
adult yet. All stages of adolescents, from
➢ Fine Motor Adaptive
early, middle, to late adolescents.
○ Imitates Bridge - PASSED
● We become mature, physically, mentally,
○ Tower of 8 Cubes - PASSED
psychological, socially, emotionally, all
○ Imitates Vertical Line - FAILED
aspects of our well-being.
○ Dumps Cheese Curls from Bottle
○ Early adolescence is the stage
Spontaneously - PASSED
where we can clearly see that the
➢ Language
age group is still considered
○ “Mustorya mana siya tabian man
awkward.
ganing na, pero nauwaw lang na
○ They’re still trying to figure out the
siya karon kay wala paman siya
transition, from childhood to
kaila ninyo.” - Reported by her
adolescents and eventually to
Father
adulthood later on in life.
○ Points to one named body part -
● Safety Issues
PASSED
○ Leading cause of death is still
○ Name 1 picture - PASSED
motor vehicular accidents
○ Follows Directions - PASSED
■ Top risk for all age group
○ Uses Plurals - “Nah! Tabian mana
○ Drowning
siya, naay time usahay na mutabi
115
○ Homicide ○ They are very conscientious and
○ Gang violence very afraid of developing bad
○ Athletic injuries for morbidities breath
● Nutrition ● Sleep
○ Adolescents tend to eat fat diets, ○ Fatigue may be present, probably
they tend to eat quick snack foods because of responsibilities,
○ Most of them are always on the go activities and so on.
○ Finding an identity would lead to ● Exercise
rebellion, they refuse to eat what ○ It is important to stress that this is
the parents, or whoever the adult part of our health promotion
is, that usually prepares or preps ○ This can be an outlet for tension
their meals. ● Promotion of Healthy Family
○ They refuse to eat what parents Functioning
think are good for them, it is a ○ Always acknowledge how
normal reaction, a normal way of challenging it is to be a teenager
finding your own independence. ○ A parent may approach you
○ So a consideration for this, is to because of rising tensions
provide an opportunity for the between them and their child at
adolescent to plan meals for home. Remind parent that, yes,
themselves, give them you are struggling with dealing
responsibility when it comes to with a teenager but also
diet and nutrition. Remind the acknowledge that its hard being a
parents about the food groups and teenager also.
that they should be eating a ○ Patience is a virtue during this
variety of food groups. time.
○ They are not picky, but they are ● Towards Later Adolescence, slowly they
conscious of what goes in their will begin to realize things that they can
body. express and they have the opportunity to
○ Eating disorders usually comes express their feelings, opinions,
out during these times. This is frustrations.
something to consider when ○ They would develop healthy ways
dealing adolescents. of coping with that and
● ADL’s communicating with the significant
They are capable of Total Self-care: people in their life.
○ They are body aware ○ They would eventually mature, it is
○ Very overly conscious of their good to reassure the parent since
appearance during this time, parent-child
○ Personal hygiene friction would increase.
○ When it comes to style, they’re ● Common Health Problems In
acutely aware of what their peers Adolescents
are wearing, who they like. Not all ○ Eating problems could
of them want to stand out, some sometimes develop into eating
of them would prefer to go with disorders.
the flow.
● Dental Care
116
■ These are mental health
concerns already, anorexia
for example.
■ In the presence of the
Mental Health Revolution,
people are opening up
leading to a reduced
stigma when it comes to
mental health.
○ Hypertension, obesity and acne
are some physical, normal and
common problems.
○ Poor posture could become
apparent during this time.
○ Fatigue
○ Sexuality concerns
■ For girls, they will have
menstrual irregularities.
■ STIs can be the focus of
health teachings and health
promotion.
■ Rape prevention
○ Body modification
■ Not necessarily body, but
some traditional families
may not approve of this
■ It is important to talk to
them about it, let them
voice out their concerns
■ If ever their child does have
any body modification
tattoos or piercing, or the
like, it is important to
educate the child on the
proper care of those body
modifications.
● MMDST
○ You can check out some
resources for that.
○ The featured video shows the little
girl performing the activities
instructed by the people around
her.
117
LECTURE FIVE B
GROWTH AND DEVELOPMENT:
NURSING PROCESSES FOR THE
PROMOTION OF GROWTH AND
DEVELOPMENT
LECTURE FIVE B
GROWTH AND DEVELOPMENT:
HEALTH PROMOTION AND DISEASE
PREVENTION IN DIFFERENT STAGES
OF GROWTH DEVELOPMENT

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FIRST SEMESTER A.Y.

LESSON ONE - MCH nurses educate, through this we are

Male Reproductive System

Parts of the Perineum

Uterine Blood Supply

Main Follicle Oocyte Corpus Uterus

Hormones FSH LH LH Estradiol

GNRH- MAIN REGULATOR AND INITIATOR

Menstrual Cycle - Hormonal Regulation (Video)

- Variation in Length, Flow, and Discharge

2. Ability of sperm to reach

- An important part of embryonic

- Another abnormality is the low-lying

Functions of the Placenta

Image of Ductus Arteriosus (in red) and Foramen

Image of Ductus Arteriosus

Immune system Musculoskeletal System

Endocrine System Fetal Development month by month

- Aside from the subjective factors

-This is another protocol when counting

(Doppler ultrasound velocimetry)

Signs of Pregnancy 2. Nausea and vomiting

3. Fetal Movement by Examiner

● Cervix = becomes thicker, shorter, and

Nursing Responsibility when doctor performs

8. Diaphoresis – increased cavity of the

This is how a Candida Inspection looks like, this

This is Chlamydia, caused by Chlamydia

So these is an example of correct way of wearing

16. Ankle edema is normal during the

FDA Pregnancy Categories

A Controlled studies of pregnant women show no

B Animal studies show no risk, or animals show

C Animal studies show risk, caution is advised,

D Evidence of risk to human fetus, beneﬁts may

○ Is the most important exercise for

Add-ons After Class

- Mucus plug is expelled, blood is from

True Labor vs. False Labor diameter. (Cephalopelvic disproportion:

Felt ﬁrst in lower back Felt ﬁrst abd and

Continue regardless Disappears with

The anterior and posterior this is wider

● Fetal lie it is a relationship of the long axis

Another example now M refers to

Fetal presentation is the part of the fetus

The measurements of the diameters of the fetal

image of the maternal pelvis

4 Basic Types of Pelvis

The soft tissues of the passageway

Once a cervix has completely dilated, the

With ﬁrst time pregnancies, the body

- This is early deceleration, or you will see

- These are the decelerations that are a

In the choice of position for labor, consider the

Pregnant women psychological response to

- Latent or preparatory phase starts - In an active phase of labor cervical

Bear down only during contractions. Mother will

Primigravida: 10cm with bulging with

Peri-care: front to back motion, wash with ➔ Types of Delivery

LECTURE FOUR C Unang Yakap

image of a radiant warmer

heart rate or the pulse. Respiration Absent Slow, Vigorous cry |