RLE107MCF BREAST CARE

➔ The aseptic cleaning of the breast in

CARE OF THE MOTHER, CHILD, AND
preparation for breast feeding.
FAMILY

ASSESSMENT:
BREAST AND PERINEAL CARE
1. Review general assessment data about
ANATOMY OF THE FEMALE BREAST: patient.
2. Observe for sign of abnormalities.
1. Breasts
3. Assess patient’s ability to perform breast
➢ are paired mammary glands (also
care.
described as accessory organs)
4. Assess patient’s learning needs related to
that lie over the muscles of the
breast.
anterior chest wall.
➢ Composed of glandular and fatty OBJECTIVES:
tissue
➔ To clean breast and soften the nipple in
➢ Composed of 15-20 lobes (have
preparation for breastfeeding.
smaller structures called lobules
where milk is produced) by the GENERAL CONSIDERATIONS:
alveoli wall.
✓ For mothers who are breastfeeding, do not
2. Ducts
apply soap or cotton balls with soapsuds on
➢ tiny tubules where milk travels
the nipple.
3. Nipple
✓ For mothers whose nipples has milk crust,
➢ small projection which mammary
use NSS.
ducts of female from which milk
can be secreted EQUIPMENTS:
4. Areola
✓ Sterile OS
➢ dark colored skin on the breast at
✓ Clean towel
surrounds the nipple.
✓ Kidney basin
✓ Extra sterile forceps
✓ Sterile cotton balls
✓ Clean diaper
✓ Sterile water/ NSS
✓ Soap suds
PROCEDURE:
❖ Patient should be in a semi-fowler’s position
❖ Expose the farther breast first and wrap a
rolled towel around it.
❖ clean breast from nipple going outward in
rotating motion
❖ rinse the breast from nipple going outward in
rotating motion until soap solution is all
washed out
❖ dry breasts using dry cotton ball starting from
the areola, NOT on the nipple. Pat dry.
❖ Apply sterile OS or Clean diaper over the
OBJECTIVES:
nipple.
EVALUATION:
✓ Breast care has been comfortably and
effectively provided.
✓ Patient’s breast appears free of complicating
conditions.
✓ Patient understands the importance and
GENERAL CONSIDERATIONS:
technique for proper breast care.
PERINEAL CARE
EQUIPMENTS:
➢ The aseptic cleansing of the vulva and
perineum.
ASSESSMENT:
✓ Review general assessment data about
patient.
✓ Observe for signs of perineal itching, burning
on urination, or skin irritation. Ask patient if
he or she experiences any of these problems.
✓ Assess patient's ability to bathe him or herself
and to perform perineal care.
✓ Reassess patient's learning needs related to
perineal care, while providing privacy, assess
the perineal/genital area for abnormalities.
✓ To keep the vulva and perineum clean.
✓ To promote healing of perineal wound.
✓ To prevent infection.
✓ To prevent disagreeable odor.
✓ To remove secretions.
✓ To provide comfort.
✓ Flushing water should be at right
temperatures
✓ Observe special care when the patient has
the perineal wound or stitches
✓ if the patient has defecated or voided, the
bedpan first before giving the perineal first
✓ Discard used perineal balls into the waste
receptacles, not in the bedpan
✓ Towel
✓ Kidney basin
✓ Straight & curved forceps
✓ Ointment
✓ Cidex solution
✓ Liquid soap
 ➢ The essential intrapartum and newborn care
✓ Paper towel protocol tackles thtime-boundnd sequence of
✓ Rubber draw sheet actions that will ensure the safe care of both
✓ Perineal bedpan the mother and the newborn during birth and
✓ Waste receptacle beyond. It focuses on the care of the newborn
during the period immediately after birth.
➢ The detailed procedure as well as the ratio le
PROCEDURE TO CONSIDER: for each of the four core steps step are
discussed.
✓ Screen the patient for privacy
➢ In addition, unnecessary and or potentially
✓ Wash hands and wear gloves
harmful practices that should be avoided are
✓ Place rubber protector and bed pan under
likewise examined.
patient’s buttocks
✓ Water should be sterile and warm (check using
elbows)
PREPARATION FOR DELIVERY:
✓ Sequence:
a. Center of vulva
1. Perforations in the workplace.
b. Farther labia minora
✓ Make sure all necessary
c. Nearer labia minora
shipments and supplies are
d. Farther labia majora
available
e. Nearer labia majora
✓ Staffing and schedules are in
f. Center of vulva down to the anus
order
g. Mons veneris/mons pubis ( zigzag motion)
✓ Proper documentation
h. Farther thigh (sunshine motion)
i. Nearer thigh (sunshine motion). Use a new or
2. Maintaining the ideal room
clean perineal ball for each stroke
temperature at 25 to 28°C to prevent
j. Repeat sequence of cleansing as necessary.
cold stressed and hypothermia in the
baby.
✓ Check room temperature using
EVALUATION:
a room thermometer
1. Perineal care has been comfortably and ✓ Close windows draw curtains,
effectively provided. turn off electric fans to eliminate
2. Perineal area is clean, odor-free. air drafts.
✓ Turn off the air-conditioning unit
at the time of delivery
ESSENTIAL INTRAPARTUM AND NEWBORN
CARE (EINC) ✓ If air-conditioning is centralized,
adjust the thermostat prior to
Pregnancy Childbirth Postpartum and Newborn Care
the delivery
(PCPNC)

3. Repair necessary equipment
✓ Delivery instruments
✓ Hand washing implements
✓ Sterile gloves two sets if solitary
healthcare
✓ Warm towels or linens
✓ A bonnet
✓ Sterile plastic cord clamp or cord tie
✓ Sterile instrument clamp
✓ Sterile pair of scissors (separate
from that use for episiotomy, if
done)
✓ Oxytocin 10 IU and sterile syringe
for IM injection
✓ Receptacle for placenta container
we are 0.5% chlorine for
instruments
✓ Newborn Care Interventions/
Supplies after the first breastfeed,
approximate 1 to 2 hours after birth
✓ Eye prophylaxis erythromycin or
tetracycline ointment
✓ Vitamin K ampule, cotton balls,
FOUR CORE STEPS OF IMMEDIATE NEWBORN
sterile Syringe for IM injection.
✓ Anti- hepatitis B vaccine, cotton
balls, sterile syringe for IM injection
✓ BCG vaccine, cotton balls, sterile
syringe for ID injection
3. Perform hand hygiene
➢ Protect health workers and their
patients from risk of infection.
4. Wearing of sterile gloves
➢ Sterile gloves are worn routinely for
each delivery to protect the mother,
her baby and health workers from
exposure to diseases spread by
blood and other body fluids.
IMMEDIATE NEWBORN CARE OF THE EINC
PROTOCOL:
❖ What happens to a mother and her baby
during labor, delivery and in the first hours
after birth has a major influence on their
survival future health and well-being.
❖ Health workers have an important role at this
time.
➢ The care they give is critical and helping
to prevent complications and
maintaining normality.
➢ Health workers are giving care which is
based on many years of research
evidence, and which is known to save
the lines of mothers and their newborn
babies.
➢ Give emphasis on essential newborn
care for the first 90 minutes.
CARE OF THE
1. (First core step) Immediate and thorough
drying with in the first 30 Seconds
2. (Second core step) Skin to skin contact
3. (Third Core Step) Properly- timed Cord
clamping, within 1 to 3 minutes
4. (Fourth Core Step) Non separation of the
newborn from the mother for early initiation
of breast-feeding, Wait in the first 1- 2 hours
after birth
1. (First core step) Immediate and
thorough drying with in the first 30
Seconds
➢ Drying is the first score step in the essential
newborn care protocol. It stimulates the
babies breathing And provides warmth to the
 apnea vagal induced bradycardia, slower rise
in oxygen saturations and mucosal trauma
newborn to prevent hypothermia.
with possibly an increased risk for infection if
Hypothermia can result in infection
inexpertly performed.
coagulation defects acidosis delayed fetal to
newborn circulatory adjustment, hyaline
✓ Do not ventilate within the first 30
membrane disease and brain hemorrhage.
seconds unless the baby has both
The family is the procedure after delivery of a
flappy lips and not breathing. Only a
baby.
small number of all babies born facilities
➢ Call out the time of birth
need some form of resuscitation. In any
➢ Place the baby on the mothers abdomen.
depressed newborns drying
Baby should be in prone position with the
provide sufficient stimulation.
head turned to the side or in a side Lying
✓ Do not slap, shake or rub the baby.
position. Baby should be placed vertically on
✓ Do not hang the baby upside down
the mothers abdomen with the head close
✓ Do not squeeze the babies chest
to the mothers chest. If this is not possible put
✓ 1.2.6. Do not wipe off the white greasy
the newborn on a clean, warm safe place
substance covering the newborn’s body
close to the mother.
(vernix). This helps to protect the
➢ Use a clean dry cloth to thoroughly dry the
newborn skin and gets reabsorbed very
newborn by wiping The eyes, face, head,
quickly.
scalp, front and back arms and legs. Wipe
away any blood or meconium. Remember to
discard the wet cloth afterwards.
2. (Second core step) Skin to skin
➢ Assess the newborns breathing while drying
contact
the baby.
✓ Skin to skin contact facilitates bonding
➢ If after 30 seconds newborn is breathing or
between the mother and her newborn. It also
crying normally, do skin to skin contact
provides warmth, prevents hypothermia and
➢ However if after 30 seconds the newborn is
it’s complication. It provides protection From
not briefing or Is gasping, clamp and cut the
infection by exposing the baby to the good
umbilical cord, call for help and start basic
bacteria of the mother and it increases the
resuscitation.
blood sugar of the baby more importantly it
REMINDERS: aids in the initiation of breast-feeding with
colostrum and facilitates successful breast-
✓ Do not routinely suction the mouth and nose
feeding.
of the vigorous newborn unless the mouth/
✓ Remove the mothers gown then place thE
nose is blocked by secretions. Routine
newborn prone on the mother’s chest, skin to
suctioning has no proven benefit if amniotic
skin with the head turned to one side to
fluid is clear and especially with the newborns
facilitate drainage of any secretions from the
cry and breathe immediately after birth.
mouth and nose.
Unnecessary suctioning in a baby who Is
crying and breathing normally Can cause
 ✓ Cover the newborn’s back with a dry blanket
and head with a bonnet.
✓ Place the identification band on the ankle.
✓ Make sure that the room temperature is
properly maintained at 25 to 28°C and the
babies temperature is between 36.5 to
37.5°C.
REMINDERS:
✓ Do not separate the newborn from the mother
if the newborn does not exhibit severe chest
in drawing gasping or apnea and the mother
does not need urgent medical or surgical
management (e.g. emergency hysterectomy)
✓ Do not put the newborn on a cold or wet
surface.
✓ Do not do foot printing. It is an inadequate
technique for newborn identification
purposes. DNA genotyping and human
leukocyte antigen test are better method of
identification.
✓ Check for multiple birth as soon as the
newborn is securely positioned on the mother.
Palpate the mothers abdomen to check for a
second baby or for multiple births. If there is
no second baby give 10 IU of oxytocin
intramuscularly to the mother with in one (1)
minute of babies birth. If there is another baby
(or more) call for help deliver the second baby
and manage like the first baby.
✓ The first skin to skin contact should last
uninterrupted for at least one hour after birth
or until after the first full breast-feed.
✓ Skin to skin contact can restart at anytime if
the mother in the newborn have to be parted
for a minute of treatment or care procedures.
If they are separated, wrap baby with warm
covers and place in a cot in a
warm room. A radiant warmer maybe use if the room
is not warm or if the newborn is small.
3. (Third Core Step) Properly- timed
Cord clamping, within 1 to 3 minutes
✓ The placenta transfuses blood to the newborn
after delivery, providing oxygen, nutrients and
additional blood volume through the pulsating
cord. Once this transfusion is completed cord
pulsations will stop and the cord will flatten.
Placental transfusion can provide the infant
with more blood volume and additional red
blood cells resulting in less anemia in both
term and preterm babies. In preterm, it
reduces the need for blood transfusion in the
first 4 to 6 weeks of life and the occurrence of
intraventricular hemorrhage and late onset
sepsis.
✓ Remove the first set of gloves immediately
prior to cord clumping
✓ Palpate the umbilical cord and wait for the
cord pulsation to stop (typically at 1-3
minutes)
✓ After cord pulsations have stopped and the
cord has flattened, clamp and cut the cord as
follows:
✓ Place the first plastic clamp/tie 2cm from
umbilical cord base and the second
instrument clamp/tie at 5cm from the base.
✓ Cut the cord near the plastic clamp/first tie.
✓ Observe for oozing of blood. If there is, place
asecond tie near the plastic clamp.
REMINDERS:
✓ Do not milk the cord towards the newborn.
✓ Do not Clamp the cord earlier than one (1)
minute after birth in both term and preterm

babies who do not require positive pressure
ventilation
✓ Do not use binder/“bigkis” or bandage the
stamp. When the binder gets soiled and if
unchange it may harbor germs that will cause
infection. It also prevents aerationwhich will
facilitate the drying process. The binder may
also rub against the fresh cord and cause
irritation.
4. (Fourth Core Step) Non-separation of
the newborn from the mother for early
initiation of breast-feeding, Wait in the
first 1- 2 hours after birth
✓ Keeping the newborn and mother together
facilitates the newborn’s early initiation to
breastfeeding in the transfer of colostrum.
Early initiation of breastfeeding reduces the
number of newborn death by decreasing the
ingestions of infectious organism. Breast milk
also provides many anti-infective substances
like immunoglobulins and lymphocytes that
may stimulate and enhance the baby’s
immune system. Studies have shown that
breast-feeding reduces death due mainly to
diarrhea and lowers respiratory tract
infections.
✓ Leave the newborn on the mother’s chest for
continuous skin to skin contact.
✓ Do not leave the mother and baby alone
during the first hour after delivery. Monitor the
mother and the baby every 15 minutes in the
first hour, every 30 minutes in the second
hour, and regularly thereafter to prevent
accidents such as fall and accidental
suffocation from occurring.
✓ Monitor the babies breathing and take note of
the presence of grunting, chest indrawing, or
fast breathing. Check to see if the babies feet
are cold to touch.
✓ Observe the newborn. The baby may want to
rest for 20 to 30 minutes and even up to 120
minutes before showing signs of readiness to
feed.
✓ Advise the mother to start feeding the
newbornones the baby shows the feeding
cues (e.g., opening of mouth, tonguing,
licking, rooting). Make verbal suggestions to
the mother to encourage her newborn to
move towards the breast.
✓ . When the new one is already advise the
mother to position in the touch her newborn
counsel on positioning and attachment if
needed.
✓ Look for signs of good attachment and
sucking if that attachment or sake is not good
or is not successful try again then reassess.
✓ A small amount of breast milk maybe express
before starting the breast-feeding to soften
the nipple area so that it is easier for the new
one to attach.
✓ Administering erythromycin or tetracycline
ointment, Or 2.5% Povidone iodine drops To
the newborns eyes with inone hour after birth.
Do not wash away the eye antimicrobial. Eye
care is given to protect the baby’s eyes from
infections such as gonorrhea which can be
passed on to the baby during the birthing
process and can eventually result in
blindness.
5. Newborn procedures can be done at bedside
after the initial breastfeeding.
✓ proceed to the physical examination and
weighing of the newborn.
 ✓ Let the baby suck for as long as he she wants
✓ This should be followed by injections with
on both breasts.
vitamin K ( IM), Hepatitis B vaccine (IM) and
✓ Postpone washing until after six hours. Early
BCG (ID)
boxing removes the vertex which is a
✓ maternal procedures can be done with a
protective barrier to E. coli and group B strep.
newborn in skin to skin contact with the
It also hinders the crawling reflex and leads to
mother unless the treatment requires for
hypothermia.
sedation.
✓ If the mother is HIV positive.
✓ Standard precautions should be followed as
6. If problems I encountered in the first breastfeed.
with any other delivery and after care.
✓ Immediate skin to skin contact can still be ✓ For newborns who do not breastfeed within
done as with any other mother and baby. one hour examine the baby. If healthy, leave
✓ Give a special counseling to the mother the newborn with the mother to try
regarding choice of feeding. breastfeeding later. Assess in three hours or
✓ If mother chooses replacement feeding sooner if the newborn is small.
explain the risk of diarrhea and malnutrition ✓ For mothers who are ill and cannot breast-
and how to avoid them. feed help the mother to express her breast
✓ Teach the mother how to feed baby by cup. milk and give the breastmilk to the baby by
✓ Check for other conditions for which breast- cup. On day one expressed breastmilk onto a
feeding is no longer contraindicated. spoon and feed by spoon.
✓ 6.3. For mothers who cannot breast-feed at all
give the newborn donated heat treated
Reminders:
breastmilk if available Raw donor breastmilk
✓ Do not touch the newborn unless there is a is the next best option followed by artificial
medical indication. formula as the last resort.
✓ Do not throw away colostrum it is equivalent
to the baby’s first immunization.
✓ Do not give sugar water formula or other pre-
lacteal. This will delay the infestation of
breast-feeding which increases the risk of the
newborn dying from serious infection.
✓ Do not give bottles or pacifiers. If these are
introduce the new one may develop a learn
preference for the battle leading to nipple
confusion’s especially if this are used before
the newborn isoffered the mothers breast this
contributes to a vicious cycle of poor
attachment sore nipples and milk
insufficiency, Which will undermine the
chances of successful breastfeeding.
 RLE107MCF EQUIPMENTS:

✓
CARE OF THE MOTHER, CHILD, AND Thermometer
✓ Mild soap
FAMILY
✓ Baby’s brush
✓ Diapers
✓ Baby’s shampoo
INFANT’S BATH
✓ Baby’s dress

➢ Washing of infant with soap and water. ✓ Baby’s layette/ towel

✓ Baby’s tub
✓ Water

ASSESSMENT:
PROCEDURE TO CONSIDER:
✓ Review general assessment data about the 1. Check the temp of the baby (normal 37.5)
baby 2. Wrap baby in a mummy restraint
✓ Observe for any signs of abnormalities 3. Hold the baby in a football hold
4. Fold the outer ears
5. Sequence of washing:
OBJECTIVES: a. Head

✓ To clean and refresh the infant b. Face

✓ To stimulate circulation c. Farther arm

✓ To promote comfort d. Chest

✓ To develop sense of security e. Abdomen (entire anterior portion)

✓ To remove secretion and excretions f. Back

✓ To allow inspection of the body and skin g. Nape

breakdown h. Entire posterior aspect

i. Lower extremity
GENERAL CONSIDERATIONS: j. Buttocks and genital areas (swipe to the
back, not towards genitalia)
1. Prolonged exposure of the body can cause
rapid cooling because infant’s temperature
control mechanism is immature
2. The infant’s skin is thin and sensitive that UMBILICAL CORD CARE
requires gentle handling. Soap and other
substances applied to the skin should not be ➢ Is cleaning the umbilical cord using sterile
harsh or abrasive water (refined/ 70% alcohol optional)
3. Powder is not indicated after bath that it may
be irritating to the infant’s delicate respiratory
tract.
OBJECTIVES: 1. Provides all the energy and essential nutrients from
birth up to 6 months of life
✓ To promote drying and healing of the cord.
✓ To prevent infection 2. The first few drops of breastmilk called colostrum
✓ To provide comfort contains antibodies that protects babies against
✓ To prevent foul odor infectious diarrhea and pneumonia

EQUIPMENTS: 3. It strengthen the bond between the mother and child

✓ Sterile water 4. Tt reduces the risk of ovarian and breast cancer of

✓ Alcohol the mother
✓ Sterile cotton pledget
5. It helps space pregnancies due to the hormonal
✓ Medicine dropper
effect which often induces cessation of menstruation
✓ Kidney basin

PROCEDURE TO CONSIDER:
10 STEPS TO SUCCESSFUL BREASTFEEDING
✓ Cover the genitalia/ circumcision stump If
present Every facility providing maternity services and
✓ Clean the umbilicus at the base from inner to care for newborn infants should:
outer in circular motion to include the umbilical
1. Have a written breastfeeding policy that is routinely
stump. Repeat the procedure until the cord is
thoroughly clean, then discard. 2. Train the healthcare staff in skills necessary to
✓ Drop sterile water/ alcohol to the umbilicus, implement this policy on breastfeeding within the first 6
make sure to avoid dripping the solution to the months upon entry to the hospital
genitalia or circumcision stump.
3. Inform the pregnant women about the benefits and
✓ Let it dry by open dressing
management of breastfeeding during prenatal
✓ Remove cord clamp after 48hrs. Do after
consultations. After delivery reiterate breastfeeding
care.
benefits in the wards during post partum period

4. Help mothers initiate breastfeeding within half –an

hour of birth by placing the newborn on skin-to-skin

BREASTFEEDING 5. Show mother how to breastfeed and how to maintain

lactation even if they should be separated from their
➢ Is the best way in providing ideal food for a healthy infants
growth and development of babies
6. Do not give newborn infants food or drink other than
breastmilk, unless medically indicated. Educate
mothers on the importance of exclusive breastfeeding
Benefits of Breastmilk and Breastfeeding:
7. Practice rooming-in. That is, allow mothers and
infants to remain together 24 hours a day
8. Encourage breastfeeding on demand
9. do not give artificial teats or pacifiers (also called
dummies or soothers) to breastfeeding infant
10. Foster the establishment of breastfeeding support
groups and refer mothers to them upon discharge from
the hospital or clinic
Complimentary Feeding
Giving other foods in addition to milk after 4
months of age:
✓ Feed slowly and patiently; encourage the
baby to eat but do not force
✓ Practice food hygiene and proper food
handling
✓ Start 6 months with small amounts of food and
increase gradually as the child gets older
✓ Feed variety of nutritious foods
✓ Continue breastfeeding on demand until 2
years old and beyond
substitutes and other related products ( including
bottles and teats It prohibits the use of health
facilities and health workers in the promotion of
their marketing of the products covered by the
code.
2. Republic Act N0. 7600 The Rooming In and
Breastfeeding Act of 1992 (later amended
as RA 10028)
➢ Rooming – in shall be observed within 30 minutes
after birth. For normal Deliveries, The Phil. Infant
and young Child Feeding (IYCF) Policy as adopted
from WHO and UNICEF
➢ The “2002 Global strategy on Infant and Young
Child feeding calls for a renewed and accelerated
action toward the promotion of appropriate IYCF
practices.
3. PHIC Circular No. 26 s 2005: The Mother-
Baby Friendly Hospital Initiative
➢ As part of its accreditation requirements for all
hospitals, this initiative encourages support , and
promotes breastfeeding in the primary, secondary
and tertiary levels of tertiary hospital facilities,
recognizing that breastfeeding is essential for
health and well-being of the infant and the mother

LAWS THAT PROTECTS AND SUPPORT

4. DOH Administrative Order No. 2005-0023
BREASTFEEDING
Formula One for health as the Implementing
Mechanism for health Sector Reforms
1. EO 51- National Code of Marketing of
➢ Breastfeeding Program as one of the priorities for
Breastmilk Substitutes
Public Health Program Development
➢ this code calls for intensifying dissemination of
information on breastfeeding and proper nutrition.
It also calls for regulation and advertising
marketing and distribution of breastmilk
 OBJECTIVES:
FACILITATING BREASTFEEDING ✓ To supply infant’s nourishment and fluid to meet
the baby’s total needs.
✓ Position mother comfortable on bed or chair
✓ Wash hands thoroughly with soap and water. EQUIPMENTS:
✓ Confirm the infant's name on the wristlet /anklet
✓ Feeding bottle
with the mother
✓ Bottle cap
✓ Pick up baby and position her /him horizontally
✓ Alcohol
facing the mother
GENERAL CONSIDERATIONS:
✓ Let the baby’s head rest on the mother’s forearm,
NOTE:
while supporting her/ his back with the same
✓ Nipple with holes of sufficient size to suit the
forearm and holding his bottom with the same
individual child should be checked for patency.
hand
✓ Holes that are too small may cause fatigue.
✓ Assist mother in facilitating mother’s nipple into
✓ Holes that are too large may cause choking.
infant's mouth
✓ Unused portion of formula should immediately
✓ Instruct the mother to make sure that the baby’s
discarded.
lower arm doesn’t get in the way and to support
the nursing breast with the other hand while PROCEDURE CONSIDERATIONS:
feeding
1. Check the name of the infant and at the
✓ Encourage the mother to maintain her eyes on the
bottle before giving the infant his feeding
baby most of the time
2. Wrap the infant warmly and hold him in a
slight fowler’s position.
3. Place the entire nipple in the infant’s mouth.
1989 United nation Convention on the Rights of the
4. Fill the entire nipple area with formula.
Child:
5. Place an extra diaper on your lap (under the
❖ This article emphasizes the children’s right to the infant’s buttocks).
highest attainable level of healthcare services and 6. Burp the infant.
guarantees the provision of access to adequate
nutrition for all infants and young Children HOW TO BURP THE INFANT:

1. Sitting position:
FEEDING AND BURPING ✓ Position the baby sitting on
your/mothers lap with chest
Bottle Feeding
supported by the base of the
➢ Is supplying nourishment to an infant through hand
feeding bottle ✓ Cup chin with thumb and index
finger
✓ Gently pat or rub the baby’s back.
2. Upright Position:
✓ Place a small towel over the shoulder
✓ Hold the baby upright against the shoulder
supporting the head
✓ Gently pats or rubs baby’s back

3. Prone Position:
✓ Lay baby across the lap
✓ Belly rests on the thigh
✓ Hold head higher than the Chest

CHARTING

✓ Time when given

✓ Amount taken
✓ Sucking reflex
✓ Condition of the baby
✓ Signature
 • Bloody show – vaginal discharge that occurs
RLE107MCF
at the end of pregnancy or during labor
CARE OF THE MOTHER, CHILD, AND • TPAL - Term, Premature, Abortion, Live
FAMILY (describes the outcomes of pregnancies)

TERMINOLOGIES ASSESSING OB HISTORY

• Gravida – refers to the number of times a
woman has been pregnant ANTENATAL CARE:

• Para/Parity – is the number the woman has ➢ Regular and periodic care of a pregnant

given birth to a fetus with gestational age of woman and her unborn baby throughout

more than 24 weeks whether the child was pregnancy.

born live or was stillborn ➢ Regular visits to a skilled health professional.

• Primigravida – has been pregnant for the first

time FACILITIES TO VISIT:

• Primipara – has been given birth to one child ✓ OB-OPD

• Multigravida – has pregnancy previously or ✓ Clinic

been pregnant 2 or more times ✓ BHC

✓ Puericulture center
• Multipara – has carried 2 or more
✓ Lying in
pregnancies to viability
• Grand multipara – carried 5 or more
OBJECTIVES OF ANTENATAL CARE:
pregnancies to viability
✓ To identify danger signs of pregnancy and
• Nulligravida – has never been and is not
manage health problems that have an
currently pregnant
unfavorable outcome on pregnancy.
• Abortion – termination of pregnancy before
✓ To prevent occurrence of serious
the fetus attained viability
complications.
• Abortus – expelled from the uterus during the
✓ To educate and counsel women for a health
first half of gestation (20 weeks or less), or
pregnancy, childbirth and postnatal recovery
weighing less than 500 gms
including care of newborn, promotion of early
• Stillbirth - infant died in the womb after 20
breastfeeding initiation and exclusive
weeks gestation (earlier regarded as
breastfeeding and family planning.
abortion). Sometimes called as fetal demise (
IUFD –fetal death)
FOCUSED ANTENATAL CARE:
• Stillborn – death or loss of the baby before or
In normal, uncomplicated pregnancies, at least 4
during delivery
antenatal visits with a skilled health provider:
• Term – pregnancy with AOG of 38-42 weeks
• Premature – born before 38 weeks
1st visit: within 3 months
2nd visit: 6 months
3rd visit: 8 months
4th visit: 9 months – return if undelivered within 2
weeks after the EDC
NOTE: Pregnant women who do not come for
prenatal care should be visited at home
STEPS TO FOLLOW IN ANTENATAL CARE
1. QUICK CHECK for emergency signs
✓ Unconscious/convulsing
✓ Vaginal bleeding
✓ Severe abdominal pain
✓ Looks very ill
✓ Severe headache with visual disturbance
✓ Severe difficulty in breathing
✓ Dangerous fever (looks very weak)
✓ Severe vomiting
2. Make the woman comfortable.
✓ Greet her, make sure she is comfortable and
ask how she is feeling.
✓ At first visit, register the woman and issue a
mother and child book (antenatal record form)
3. Assess the pregnant woman
✓ At FIRST visit: do a complete history
✓ Name and Age
✓ Past medical history/alcohol/drug/substance
abuse?
✓ Family History?
✓ Obstetric history: gravidity? LMP? AOG?
GRAVIDITY
Obstetric History may be summarized by series of 4
digits using the abbreviation TPAL; or By a series of 6
digits using the abbreviation GTPALM.
• G – GRAVIDA (woman who is or has been
pregnant, regardless of pregnancy outcome,
regardless of the number of fetuses.)
• P– PARA refers to number of past
pregnancies that have reached viability
whether infants born or alive or not.
EXAMPLE:
G1P0 – a woman pregnant for the first time
(primigravida)
G2P1 – a woman who is pregnant for the second time
and has delivered one fetus carried to the period of
viability.
Take Note: VIABILITY – AFTER 20 WEEKS
TERM/FULL TERM deliveries; 37
T completed weeks or more.
PRETERM deliveries; 20 to less than 37
P complete weeks
ABORTIONs; elective or spontaneous
A loss of a pregnancy before the period of
viability (less than 20 weeks)
Living children a woman has delivered
L regardless of whether they were live
births.
Multiple gestations and births (not the
M number of neonates delivered; Twins
counted as 1)
EXAMPLE:
Jane is pregnant for the third time. She had twins at 36
weeks and a son at 38 weeks gestation.
ANS: G3T1P1A0L3

Do At FIRST visit: do a complete history

Ask Ask about or check record for prior
about or pregnancies for general danger signs
check
Do Do a complete physical examination:
Vital signs, height, weight

BMI CALCULATION
DESIRABLE WEIGHT GAIN

On a trimester basis in Desirable weight gain:

a woman with normal
pre-pregnancy weight: 11.2-15.9 kg (25-35 lbs)

1st trimester (3 lbs.) 0.4 kg or 1 lb./ mo.

2nd trimester (12 lbs.) 0.4 kg or 1 lb./week

3rd trimester (12 lbs.) 0.4 kg or 1 lb./week Pre- Recommended Weight Gain
Pregnancy Weight

If a woman is high risk for nutritional deficit, more

Underweight ( BMI 28 to 40 lbs. (about 13 to 18
precise estimation of weight gain can be calculated.
under 18.5) kg)
This is done by computing the body mass index:

Normal weight ( BMI 25 to 35 lbs. (about 11 to 16

18.5 to 24.9) kg)

Overweight ( BMI 25 to
15 to 25 lbs. (about 7 to 11 kg)
29.9)

Obesity ( BMI 30 or
11 to 20 lbs. (about 5 to 9 kg)
more)
Note:
✓ BP decreases slightly during 2nd trimester KEY MESSAGES:
because of peripheral resistance to • Mother and her family should prepare a birth
circulation, and is lowered as the placenta plan for birth preparedness and complication
expands rapidly. readiness together with the health care
✓ During 3rd trimester, bp rises again. Increase attendant.
BP and sudden weight gain are danger signs • Counsel the woman to deliver in a health
of PIH facility with a skilled health worker as the birth
✓ Heart rate increases by 10 beats /min . attendant.
✓ Early in pregnancy temperature increases
slightly and decreases to normal at about 16
weeks. AOG COMPUTATION & FUNDAL HEIGHT
✓ Slight increase in RR (2 breaths/min) DETERMINATION
✓ Increase in HR and RR suggest bleeding.
1. AOG ( Age Of Gestation ) Or Gestational
On All Visits: Age
✓ Check duration of pregnancy (AOG) ➢ Refers to the length of pregnancy measured
✓ Ask for occurrence of any danger signs during from the 1st day of the last menstrual period.
this pregnancy ➢ Sometimes measured in lunar months (10
✓ Check record for previous treatments months, 40 weeks or 280 days) or in
received during this pregnancy ➢ TRIMESTER (3 months period)
✓ Prepare birth and emergency plan
✓ Ask patient if she has other concerns • 1ST TRIMESTER - 1 TO 12 WEEKS (1-3
✓ Educate and counsel on family planning and MOS.)
breastfeeding • 2ND TRIMESTER - 13 TO 24 WEEKS (4-6
On the third trimester, do also: MOS.)
✓ Leopold’s examination • 3RD TRIMESTER - 25 TO 38 WEEKS (7-10
✓ Check fetal heartbeat MOS.)

Advise on danger signs of pregnancy and where COMPUTATION FOR AOG DETERMINATION
to go during emergency

Data Given: LMP (Last Menstrual Period)

✓ Severe headache
✓ Blurring of vision • 1st Day Of The LMP
✓ Fever • Date Of Check Up/ Prenatal Visit
✓ Fast or difficult breathing
✓ Severe abdominal pain
✓ Vaginal bleeding
✓ Convulsions
 LMP FORMULA SAMPLE
EXAMPLE: LMP : January 6, 2021
LMP: JUNE 25, 2021 (6 – 25 – 2021)
Date Of Check Up: June 7, 2021
LMP Falls From April – December -- - 3 + 7 +

JANUARY 31 – 6 = 25 DAYS (31 DAYS OF JANUARY 1

MINUS 6 WHICH IS THE DATE OF LMP) 6 – 25 – 21 (LMP)

-3+7+ 1
3 – 32 – 22
JANUARY 25
FEBRUARY 28
Days In March: -31
MARCH 31
EDC: 4 - 1 - 22
APRIL 30
MAY 31
NOTE: ONLY 31 DAYS IN MARCH, 1 DAY IS
JUNE 7 ( DATE OF CHECK UP)
FORWARDED TO APRIL
152 DAYS

SOLVING FOR THE AOG BASED ON THE

152 DAYS__ = 21 WEEKS
7 DAYS ULTRASOUND
21 X 7 = 147 DAYS
152 – 147 = 5 DAYS
➢ counting the days after the date of the previous
AOG: 21 Weeks & 5 Days Or
ultrasound then divided by 7, and add to the AOG
21 Weeks 5/7 Days
as revealed by the ultrasound.

DETERMINATION OF EDC Example:

Date of ultrasound is June 25, 2021 with AOG of 13
weeks
( Expected Date Of Confinement, Estimated Date Of
Birth Or Expected Date Of Delivery )
Solution:

NAEGELE’S RULE
Ask the woman to state the 1st day of the LMP (Last June 30 – no. of days

Menstrual Period) (subtract) June 25 – date of ultrasound

_______
LMP Falls From January – March -- + 9 + 7 June 05
LMP Falls From April – December -- - 3 + 7 + 1 (add) July 31
(add) Aug. 23 (date today)
LMP FORMULA SAMPLE _______
LMP: JANUARY 1, 2021 (1 – 1- 2021) 59 divided by 7 = 8.42 or 8
LMP Falls From January – March -- + 9 + 7
8 x 7 = 56
1 – 1 – 2021 (LMP) (subtract) ________
+ 9+7
__________ 3
EDC: 10 – 8 – 2021 ( OCTOBER 8, 2021)
 AOG = 8 3/7 1. Explain the procedure
(add) 13 ------ AOG by ultrasound 2. Instruct client to empty her bladder.
____________ 3. Help the woman into a supine position and drape her
AOG = 21 2/7 weeks appropriately to provide privacy; expose her abdomen.
4. Position one end of the tape measure at the notch of
the symphysis pubis (a little below the hairline).
5. Pull the tape measure up and over the abdomen to
BARTHOLOMEW’S RULE the top of the fundus, being careful not to tip the corpus
of the fundus back.
➢ To determine the AOG based on the location of 6. Measure the distance in centimeter.
fundus in the abdominal cavity.

WEEKS CM LANDMARK
Measurement Of The Fundus:
• 3 mos. (12 wks.) – Just above the symphysis 16 WEEKS 12 – 16cm Above symphysis pubis
pubis
20 WEEKS 17 – 20cm Below umbilicus
• 4 mos. (16wks.) – Midway between the
symphysis pubis and the umbilicus 24 WEEKS 21 – 24cm Level of umbilicus

• 5 mos. (20-22wks.) – At the level of the 28 WEEKS 25 – 28cm Above umbilicus

umbilicus
32 WEEKS 29 – 32cm Between Umbilicus
• 9 MOS. (36wks.) – Just below the xiphoid & Xiphoid Process
process
• 10 mos. (40wks.) – Same level in 8-9mos. Or
MCDONALD’S RULE
4cm. Below xiphoid process due to lightening

➢ Uses fundal height to determine the duration of a

pregnancy.
➢ Using a tape measure and recording the distance
from the superior aspect of the symphysis pubis to
the uterine fundus in cm. as the woman lies
supine.

As a rule of thumb your

fundal height (in cm) is
equal to the weeks of
FUNDAL HEIGHT DETERMINATION gestation (valid between
20th and 32nd weeks of
➢ To measure fundal height use pliable but not pregnancy).
stretchable tape measure and follow these steps:
 2. PRESENTATION:
FH LARGER THAN FH SMALLER THAN
EXPECTED EXPECTED

Thicker uterus Baby prematurely descending

into the pelvis

Full Bladder 1. PHALIC/ VERTEX PRESENTATION

Taller or slim stature baby Short stature baby

Twins 2. BREECH PRESENTATION

Well-conditioned abdominal Loose abdominal muscles

muscles

Miscalculated due date Miscalculated due date

CEPHALIC PRESENTATIONS:

LEOPOLD’S MANEUVER 1. Occiput/vertex

2. Brow
3. Face

1 2 3

➢ Four maneuvers for assessing fetal position,

presentation, degree of descent and fetal attitude
by external palpation of the mother's abdomen. BREECH PRESENTATIONS:

1. FETAL POSITION:
➢ Describes the location of a
fixed reference point on the
presenting part in relation to the
Frank full breech footling breech
four quadrants of the maternal
Breech
pelvis

➢ LOA, LOP, ROA, ROP,

RSA, LMP
 What fetal part is in
3. ATTITUDE: 1ST Fundal grip fundus
MANEUVER (breech or vertex)
Palpate for the back
2ND Umbilical grip and FHB
MANEUVER
Palpate for
3RD Pawlick’s engagement of
FLEXED EXTENSION
MANEUVER grip presenting part
✓ FLEXION IS NORMAL (engaged or not)
Palpate position of
4TH Pelvic grip head – determine
MANEUVER descent and flexion
4. LIE:
➢ the relationship of the long axis of the fetus to the
long axis of the woman
1. Identify fetal part that occupies the fundus. The head
feels round, firm, freely movable and palpable by

transverse lie – Uncommon ballottement; the breech feels less regular and softer.

2. Using palmar surface of one hand, locate and palpate

the smooth convex contour of the fetal back and the
irregularities that identify the small parts (feet, hands,
elbows).

OBJECTIVES:
3. With the right hand, determine which fetal part is
To identify number of fetuses
presenting over the inlet to the true pelvis. Gently
✓ To determine fetal presentation, lie,
grasp the lower pole of the uterus between the thumb
presenting part, degree of descent, and fetal
and fingers, pressing in slightly. If the head is
attitude
presenting and not engaged, determine the attitude of
✓ To identify point of maximum intensity (PMI)
the head.
of fetal heart rate (FHR) in relation to the
woman’s abdomen 4. Turn to face gravida’s or client’s feet. Using two (2)
✓ To monitor the descent and internal rotation hands, outline the fetal head with palmar surface of
of the fetus fingertips

FACTORS AFFECTING THE PERFORMANCE OF

MANEUVER
✓ Difficult to perform in obese women
✓ Women with hydramios
✓ Women with full bladder
 MONITORING LABOR STRAIGHT CATHETERIZATION

Uterine contraction – tightening and shortening of CATHETERIZATION

cervix resulting in effacement and dilatation of cervix • Assisting in the introduction of a catheter
into the bladder through the urethra for
Phases of uterine contraction: the relief of urinary retention or for
emptying the bladder
1. Increment – intensity increases
CATHETER
2. Acme – contraction is at peak • is a thin, clean hollow tube which is
usually made of soft plastic or rubber.
3. Decrement – intensity decreases

4. Duration – length of uterine contraction from

the beginning of uterine contraction to the
end of the same uterine contraction.

5. Frequency – time when contractions begin

to the beginning of the next uterine
contraction.

6. Interval – time from the end of uterine

contraction to the beginning of uterine
contraction (resting period of uterine
contraction). ASSESSMENT

1. Determine the most appropriate method of

catheterization based on the purpose and
indication specified in the order such as total
amount of urine to be removed or size and type of
catheter to be used
2. Assess the client’s overall condition e.g., mobility
and physical limitations, ability to cooperate in
positioning.
3. Determine if the client is able to cooperate during
the procedure and if the client can be positioned
supine with head relatively flat.
4. Determine when the client last voided or 7. To facilitate accurate measurement of urinary
catheterized. output for critically ill client whose output
5. Palpate the bladder to check for fullness or needs to be monitored hourly
distention. 8. To prevent urine from contacting an incision
6. Assess presence of pathological condition that after perineal surgery
may impair passage of catheter from the urethra 9. To manage incontinence
into the bladder.
7. Determine the purpose of catheterization. GENERAL CONSIDERATIONS
• Use a straight catheter if only a spot urine
specimen is needed, if amount of ✓ Identify status of patient for appropriate
residual urine is being measured, or if preparation of catheter size.
temporary decompression/ emptying of ✓ Follow proper hand washing techniques.
the bladder is required ✓ Do not allow the spigot on the drainage bag to
8. Use an indwelling/retention catheter if the bladder touch a contaminated surface.
must remain empty or continuous urine ✓ Do not open the drainage system at connection
measurement/collection is needed. points to obtain specimens or measure urine.
9. Determine if client is allergic to antiseptic, tape or ✓ If the drainage tubing becomes disconnected, do
rubber not touch the ends of the catheter or tubing.
10. Assess need for perineal care before Wipe the ends of the tube with antiseptic solution
catheterization before reconnecting.
11. When possible, complete a bladder scan to assess ✓ Prevent pooling of urine and reflux of urine into
the amount of urine present in the bladder before the bladder.
performing a urethral catheterization ✓ Remove the catheter as soon as possible after
conferring with physician.

OBJECTIVES TYPES OF CATHETERIZATIONS

1. To relieve discomfort due to bladder distention or 1. Foley catheter/indwelling urethral

to provide gradual decompression of a distended
bladder
2. To assess /measure amount of residual urine
3. To obtain a sterile urine specimen
4. To provide for intermittent or continuous bladder
drainage and/or irrigation
5. To obtain adequate and uncontaminated urine
specimen when a specimen cannot be secured
satisfactorily by other means.
6. To empty the bladder completely prior, during, or
after the surgery, or before diagnostic procedures
catheter/retention catheter
➢ used if the catheter is to remain in place for
continuous drainage
➢ It is designed so that it does not slip out of the
bladder. A balloon is inflated to ensure that the
catheter remains in the bladder once it is inserted
➢ The foley catheter has more than one lumen or
open tube within the catheter.
 2. Intermittent catheter/straight catheter has EQUIPMENTS
a single lumen.
➢ It is used to drain the bladder for shorter Straight Catheterization
periods (5-10 minutes).
1. Catheterization tray
➢ coude catheter is a variation of the straight ✓ straight catheter
catheter. It is more rigid than other straight ✓ sterile gauze (2)
catheters and has a tapered, curved tip. This ✓ sterile bowl
catheter may be used for men with prostatic ✓ sterile towel with hole (for male clients)
hypertrophy because it is more easily ✓ pair of sterile glove
controlled and less traumatic on insertion ✓ antiseptic solution (Betadine)
✓ Sterile forceps
✓ flashlight/lamp (optional)
 Foley ✓ water-soluble lubricant
✓ sterile specimen container
Straight → ✓ flushing tray
✓ bedpan
✓ waste receptacle

INDICATIONS EVALUATION
1. Spinal cord injury & 7.Urinary retention with
Pelvic nerve recurrent episodes of 1. Residual urine measured
damage Urinary Tract Infection
2. Neuromuscular 2. Sterile urine specimen obtained
degeneration 8.Clients with skin
3. Incompetent rashes, ulcer or wounds 3. Catheterization performed using sterile
bladder irritated by contact with techniques
4. Prostate urine
enlargement 4. Retention catheter inserted without difficulty
5. Clients undergoing 9.Pre-operative/post-
surgical repair of operative client 5. Bladder emptied when patient is unable to
the urethra and void
surrounding 10.Pre-partum/post-
structures partum client
6. Critically ill or
comatose client 11.Urinary incontinence
 APGAR SCORE ❖ The score obtained at the 1-minute determined
how well the baby tolerated the birthing process,
and the 5-minuto score tells of how the baby is
VIRGINIA APGAR
doing outside the mother’s womb.
1952

CLINICAL SCENARIO:
➢ Standard tool in assessing
newborn babies
1. A newly delivered infant has a pink trunk and
blue hands and feet, pulse rate of 60 and does
not respond to your attempts to stimulate her.
She also appears to be limp and taking slow,
Immediate assessment of a newborn
gasping breaths. What is her APGAR?
APGAR SCORE
➢ is a quick, overall assessment of newborn
Answer Choices:
well-being.
A. 3
➢ is use for a standardized evaluation of the
B. 7
newborn’s condition
C. 5
D. 10
scoring system used to assess:
✓ Health of the newborn
✓ Identify those who require emergent attention.
2. One of your patients arrives at labor and
delivery floor in active labor. After a period of
observation, she is now dilated to 10 cm and
having regular contractions. Delivered the
newborn and now you are assessing the one-
minute APGAR score for this baby. The baby
is pink all over with a pulse of 130. As you dry
her off, she cries vigorously and is moving all
4 extremities.What is her 1-minute APGAR
score?

Answer Choices:

INTERPRETATION OF RESULTS A. 3
B. 7

7-10 Excellent condition C. 5

D. 10
4-6 Moderately depressed
0-3 Severely depressed
 BALLARD SCORE growth. Conversely those that accelerate fetal growth
may delay in its maturation.
ASSESSMENT OF GESTATIONAL AGE
Post Natal Examination /Ballard Examination con’t

3 Different Methods in Assessing Gestational Age • Since certain fetal stresses may occur without
of Fetus or Newborn the patient’s or the physician’s knowledge, the
assessment of gestational age by maturation
1. the mother’s menstrual history (date of exam can also be in accurate.
LMP)
➢ with an accurate menstrual history • However, the neonatal maturational
remains the best measure of gestational examination still remains the most universally
age excepted method of assessing gestational
age after birth.
2. prenatal ultrasonography is one indirect
method of assessing GA of the fetus.
BALLARD SCORING
➢ uses fetal body part measurements to
estimate gestational age and therefore - process of rating the infant , completed shortly after
relies normally upon timed and birth, includes physical and neuromuscular maturity .
proportioned fetal growth rates.
➢ highly accurate method of assessing Assessment Score for the Newborn of (-1 to +5):
gestational age when performed early in
gestation Neuromuscular Maturity Includes:

➢ late trimester ultrasound measurement

✓ Posture
provide an inaccurate measure of fetal
✓ Square Window ( wrist)
gestational age.
✓ Arm recoil
✓ Popliteal Angle
3. Post Natal Examination /Ballard
✓ Scarf Sign
Examination (performed between 12 and
✓ Heel to Ear
24 hours of life)
➢ based upon indicators of fetal BALLARD SCORE CON’T
neuromuscular and physical maturation.
➢ Note: Stressful fetal experiences may Physical Maturity Includes:
accelerate lung and neuromuscular rates
of maturation while slowing or not ✓ skin

affecting physical maturation. ✓ lanugo

➢ The same events that accelerate fetal ✓ foot creases

maturation may adversely affect fetal ✓ breast maturity

✓ eyes and ears
✓ genitalia
 ✓ >90, 90, 60, 45, 30, and 0

BALLARD EXAMINATION (SCORE SHEET) ✓ The appropriate square on the score sheet
is selected.

3. ARM RECOIL:
✓ Infant lying on
his back the
examiner
places one
hand we need
the infant’s elbow for support. Taking the infants
hand, the examiner briefly bends the arm at the
elbow then momentarily straightens the arm, and
1. TO ELICIT THE
then releases the hands.
POSTURE ITEM:
✓ The more mature baby will bring the arm back to a
✓ The infant is placed on
bent position.
his or her back and
✓ The angle of recoil to which the forearm springs
examiner waits until
backs into flexion is noted,
the infant settles into a
✓ Appropriate square is selected on the score
relaxed or preferred posture, gentle manipulation
sheet.
of the extremities will allow the infant to seek the
✓ Square #4 is selected only if there is contact
baseline position of comfort.
between the infant’s fist and face. This is seen and
✓ Bending of the hips (flexion depicted in posture
term and post term infants
square) without abduction results in the frog leg
position as depicted in square # 3
✓ Hip abduction accompanying flexion is depicted by
the acute angle at the hips in posture square #4. 4. POPLITEAL ANGLE:

Note:

2. SQUARE WINDOW: WITH INFANT SUPINE a. It is important that the

examiner wait until the infant
✓ The examiner straightens
stops kicking actively before
the infant’s fingers
extending the leg.
and applies gentle
pressure on the dorsum b. The prenatal frank breech
(back) of the head close position will interfere with this maneuver for the first 24
to the fingers. to 48 hours of age due to prolonged intrauterine flex or
fatigue. The test should be repeated once recovery 6. HEEL TO EAR:
has occurred; alternately, a score similar to those
obtained for other items in the exam may be assigned ✓ The infant is placed supine
and the flexed lower
extremity is brought to rest
on the mattress alongside
5. SCARF SIGN: the infant's trunk.

✓ With the infant ✓ The examiner supports the infant's thigh laterally
lying supine, the alongside the body with the palm of one hand. The
examiner adjusts other hand is used to grasp the infant's foot at the
the infant's head sides and to pull it toward the ipsilateral ear (on the
to the midline and same side of the body).
supports the infant's hand across the upper chest
with one hand. The thumb of the examiner's other ✓ The examiner feels for resistance to extension of
hand is placed on the infant's elbow. the posterior pelvic girdle flexors and notes the
location of the heel where significant resistance is
✓ The examiner nudges the elbow across the chest, appreciated.
feeling for passive flexion or resistance to
extension of posterior shoulder girdle flexor
muscles.
SCORE SHEET
✓ The point on the chest to which the elbow moves
easily prior to significant resistance is noted.
Landmarks noted in order of increasing maturity
are:

❖ full scarf at the level of the neck (-1);

❖ contralateral (opposite side) axillary line (0);

❖ contralateral nipple line (1);

PHYSICAL MATURITY
❖ xyphoid process (2);

1. SKIN
❖ ipsilateral (same side) nipple line (3);
✓ Maturation of fetal skin involves the development
❖ ipsilateral axillary line (4).
of its intrinsic structures concurrent with the
gradual loss of its protective coating, the vernix
caseosa.
✓ The skin thickens, dries and becomes
wrinkled and/or peels, and may develop a rash
as
2. LANUGO
✓ In extreme immaturity, the skin lacks any lanugo.
It begins to appear at approximately the 24th to
25th week and is usually abundant, especially
across the shoulders and upper back, by the 28th
week of gestation.
✓ Thinning occurs first over the lower back, wearing
away as the fetal body curves forward into its
mature, flexed position. Bald areas appear and
become larger over the lumbo-sacral area. At
term, most of the fetal back is devoid of lanugo,
i.e., the back is mostly bald.
✓ Variability in amount and location of lanugo at a
given gestational age may be attributed in part to
familial or national traits and to certain hormonal,
metabolic, and nutritional influences.
3. PLANTAR SURFACE
✓ This item pertains to the major foot creases on the
sole of the foot. The first appearance of a crease
appears on the anterior sole at the ball of the foot.
This may be related to foot flexion in utero, but is
contributed to by dehydration of the skin. Infants of
non-white origin have been reported to have fewer
foot creases at birth.
✓ There is no known explanation for this.
✓ On the other hand, the reported acceleration of
neuromuscular maturity in black infants usually
compensates for this, resulting in a cancellation of
the delayed foot crease effect. Hence, there is
usually no over - or under-estimation
of gestational age due to race when the total score
is 10
✓ Very premature and extremely immature infants
have no detectable foot creases. To further help
define the gestational age of these infants,
measuring the foot length or heel-toe distance is
10,11 performed.
✓ helpful distance from the back of the heel to the tip
of the great toe. For heel-toe distances less than
40 mm, a minus two score (-2) is
assigned; for those between 40
and 50 mm, a minus one score (-
1) is assigned.
4. BREAST
✓ The examiner notes the size of the areola and the
presence or absence of stippling (created by the
developing papillae of Montgomery). The
examiner then palpates the breast tissue beneath
the skin by holding it between thumb and
forefinger, estimating its diameter in millimeters,
and selects the appropriate square on the score
sheet.
✓ Under- and over-nutrition of the fetus may affect
breast size variation at a given gestation.

NOTE: Maternal estrogen effect may produce
neonatal gynecomastia on the second to fourth day of
extrauterine life.
5. EAR/EYE
✓ The examiner notes the rapidity with which the
folded pinna snaps back away from the face when
released, then selects the square that most closely
describes the degree of cartilaginous
development.
✓ In very premature infants, the pinnae may remain
folded when released. In such infants, the
examiner notes the state of eyelid development as
an additional indicator of fetal maturation.
✓ The examiner places thumb and forefinger on the
upper and lower lids, gently moving them apart to
separate them. The extremely immature infant will
have tightly fused eyelids, i.e., the examiner will
not be able to separate either palpebral fissure
with gentle traction. The slightly more mature
infant will have one or both eyelids fused but one
or both will be partly separable by the light traction
of the examiner's fingertips.
6. GENITALS: MALE/FEMALE
✓ Testicles found inside the rugated zone are
considered descended. In extreme prematurity the
scrotum is flat, smooth and appears sexually
undifferentiated. At term to post-term, the scrotum
may become pendulous and may actually touch
the mattress when the infant lies supine.
Note:
✓ In true cryptorchidism, the scrotum on the affected
side appears uninhabited, hypoplastic and with
underdeveloped rugae compared to the normal
side, or, for a given gestation, when bilateral.
✓ To examine the infant female, the hips should be
only partially abducted, i.e., to approximately 45°
from the horizontal with the infant lying supine.
✓ In extreme prematurity, the labia are flat and the
clitoris is very prominent and may resemble the
male phallus. As maturation progresses, the
clitoris becomes less prominent and labia minora
become more prominent. Nearing term, both
clitoris and labia minora recede and are eventually
enveloped by the enlarging labia majora.
✓ The labia majora contain fat and their size is
affected by intrauterine nutrition. Over-nutrition
may result in large labia majora earlier in
gestation, whereas under-nutrition, as in
intrauterine growth retardation or post-maturity,
may result in small labia majora with relatively
prominent clitoris and labia minora late into
gestation.
MATURITY RATING
-10 20

-5 22

0 24

5 25

10 28

15 30

20 32

25 34

30 36

35 38

40 40

45 42

50 44
 REFLEXES ENHANCED
2. ROOTING REFLEX

Neuromuscular Function in term infants is

STIMULATION Stroke cheek near the corner of
demonstrated by the following:
the mouth

✓ moving their extremities

RESPONSE Turns head in that direction
✓ attempting to control head movement
✓ exhibiting strong cry
AGE OF 6 months of life
✓ demonstrating newborn reflexes
DISAPPEARANCE

NOTE: FUNCTION Helps find nipple

Limpness or total absence of a muscular response and

to manipulation is NOT NORMAL and suggests 3. SUCKING REFLEX
narcosis, shock or cerebral injury.
STIMULATION Lips are touch
Newborn - occasionally makes twitching or failing
movements of extremities in the absence of stimulus RESPONSE Makes a sucking motion

because of immaturity of the nervous system, these

AGE OF About 6 months of life
are common and normal.
DISAPPEARANCE
❖ disappear if not stimulated
Reflexes - muscle reactions, involuntary movements
FUNCTION Helps find food
or neurological responses to stimulation or triggers

REFLEXES
4. STEP (WALK) REFLEX

1. MORO “STARTLE” REFLEX STIMULATION Held baby under his armpit w/

feet touching a hard surface
STIMULATION Hold in a supine position, allow
head to drop backward about 1 inch
RESPONSE Take a few quick, alternating
Abducts and extend arms and legs,
steps
RESPONSE then swing arms in into an embrace
position and pulls up the legs AGE OF 3 months
against the abdomen DISAPPEARANCE
AGE OF End of 4th to 5th months
DISAPPEARANCE FUNCTION Prepares infant for voluntary
FUNCTION Protect the body walking
 5. GAG REFLEX 9. TONIC REFLEX / “BOXER OR FENCING” REFLEX
STIMULATION Food that reaches the posterior STIMULATION When lie on back head .Or If
portion of the tongue turn the head
RESPONSE Cough RESPONSE usually turns to one side,
AGE OF 6 to 7 months change extension and
DISAPPEARANCE contraction of legs and arms
FUNCTION Prevent choking AGE OF 2nd to 3rd month
DISAPPEARANCE
FUNCTION Stimulate eye coordination.
6. EXTRUSION REFLEX Signify handedness
STIMULATION Any substance placed on the
anterior portion of the tongue
RESPONSE Extrudes substance 10. PLANTAR GRASP REFLEX
AGE OF 4 months of life STIMULATION Objects touches sole of the foot
DISAPPEARANCE RESPONSE Toes grasp in same manner as
FUNCTION Prevent swallowing of inedible the fingers
substances AGE OF 8 to 9 months
DISAPPEARANCE
FUNCTION Preparation for walking
7. PALMAR REFLEX
STIMULATION Place object in their palm
RESPONSE Quickly closing their finger 11. BABINSKI GRASP REFLEX
AGE OF 6 weeks to months STIMULATION Stroke sole of foot in an
DISAPPEARANCE inverted J curved from heel
FUNCTION Helps in exploratory upward
RESPONSE Fans the toes (positive
Babinski)
8. BLINK REFLEX AGE OF Early as 12 months
STIMULATION Shining a strong light into an eye DISAPPEARANCE
RESPONSE Rapid eyelid closure FUNCTION Examine use to determine
AGE OF permanent adequacy of higher nervous
DISAPPEARANCE system
FUNCTION Protection
 12. MORO “STARTLE” REFLEX
STIMULATION Hold in a supine
position, allow head to
drop backward about 1
inch
RESPONSE Abducts and extend
arms and legs, then
swing arms in into an
embrace position and
pulls up the legs against
the abdomen
AGE OF DISAPPEARANCE Early as 4th to 5th
months
FUNCTION Protect the body
 ➔ Vertical gridlines: Indicate the time in hours
the patient is in active labor
PARTOGRAPH ➔ Graph is divided into 3 colors:
Green, yellow, and red

➢ The partograph is a graphic representation of

cervical dilatation during labor
➢ It is a valuable tool for monitoring the progress of
CASES WHEN PARTOGRAPH USE IS NOT
labor
RECOMMENDED:

✓ Very short stature ✓ Severe anemia

✓ Antepartum ✓ Multiple pregnancy
IT IS BENEFICIAL IN:
hemorrhage ✓ Malpresentation
✓ avoiding unnecessary interventions so maternal ✓ Severe pre- ✓ Very premature
and neonatal morbidity are not needlessly eclampsia and labor
increased eclampsia ✓ Obvious obstructed
✓ intervening in a timely manner to avoid maternal ✓ Fetal distress labor
and neonatal morbidity or mortality ✓ Previous CS
✓ to ensuring close monitoring of the woman in labor

INSTRUCTION FOR USE

PARTS OF THE WHO PARTOGRAPH
✓ If the woman is admitted in labor in the latent
phase (less than 4 cm dilated): use the LABOR
RECORD to record your findings (BP, FHT, ect.)
✓ If she remains in the latent phase for the next 8
hours, labor is prolonged and she must be
transferred to the hospital.
✓ Plot or record cervical dilatation on the alert line
whenever woman is admitted in the active phase
of labor

✓ The plotting of the cervical dilatation will remain on

or to the left of the alert line when there is
satisfactory progress in labor
➔ Divided evenly into small boxes by gridlines
vertically and horizontally ✓ Monitor every 4 hours [ or more frequently if

➔ Horizontal gridlines: corresponds to the necessary]: vital signs, BP and cervical dilatation

cervical dilatation in centimeters from 4 to 10

cm
 ✓ Monitor every hour the FHT, frequency and
duration of contractions, woman’s mood and
behavior.

Other findings to record:

1. Vaginal bleeding [0, +, ++, +++]

2. Urine voided [yes or no]
3. Status of membranes
▪ “I” if membranes are intact
▪ Time ruptured
▪ Color of Amniotic fluid
➔ “C” means clear
➔ “M” amniotic fluid stained
➔ “A” amniotic fluid is absent
➔ “B” amniotic fluid is bloody
4. Reassess woman and consider criteria for
referral
5. Alert transport services
6. Empty bladder
7. Ensure adequate hydration but omit solid
foods
8. Encourage upright position and walking if the
woman wishes
9. Monitor intensively. If the higher-level facility
is far, reassess in 2 hours and refer if there is
no progress.
10. If Partograph passes the ACTION LINE, the
woman should already be in the CEMONC
facility
 ✓ Situational low self-esteem
✓ Personal Identity disturbance
NURSING CARE PLAN (NCP)

➢ A nursing care plan (NCP) is a formal process

RISK:
that correctly identifies existing needs and
recognizes potential needs or risks
Nursing diagnoses that are in the “risk for” categories
may not need the AEB portion of the statement, since
there is no actual evidence.

❖ NURSING CARE PLANNING BEGINS WHEN

Ex: Risk for injury ( Nursing Problem)
THE CLIENT IS ADMITTED TO THE HOSPITAL
AND IS CONTINUOUSLY UPDATED
• Risk for injury related to restlessness
THROUGHOUT IN RESPONSE TO THE
PATIENT’S CHANGES IN CONDITION AND
EVALUATION OF GOAL ACHIEVEMENT.
PLANNING AND DELIVERING INDIVIDUALIZED HOW TO WRITE A NURSING CARE PLAN
OR PATIENT-CENTERED CARE IS THE BASIS
FOR EXCELLENCE IN NURSING PRACTICE. ✓ Begin with a compete assessment of your patient.
Get as much information as possible from the
chart, such as lab data, x-ray reports, physician
PURPOSE OF A NURSING CARE PLAN history and physical exam.

✓ Provides direction for individualized care of the DATA COLLECTION:

client.
✓ Continuity of care. 1. Subjective- this is what your patient tells

✓ Documentation. you.

✓ Establish goals.
Ex: “My head hurts” states on scale of 1-10 “My head
hurts at 8.”

TYPES OF NURSING DIAGNOSIS

2. Objective- this is what you see.

1. Actual – existing problem

2. Risk – potential

COMPONENTS
Related Nursing Diagnoses by NANDA :

1. Nursing Diagnosis
✓ Ineffective Role Performance
2. Rationale
✓ Body Image Disturbance
✓ Chronic low self-esteem
✓ Self-esteem disturbance
 3. Nursing intervention
4. Rationale for each intervention
5. Evaluation/ expected outcome
1. NURSING DIAGNOSIS
➢ It is not a medical diagnosis.
➢ A nursing diagnosis is the plan of care for your
patient which all member of the staff will follow as
they care for the patient.
✓ It must be individualized for your patient.
A 3 PART SYSTEM
• The nursing diagnosis- from NANDA-1 list
• “Related To” (R/T)- what is causing the
nursing diagnosis.
• Defining Characteristics- “AEB” (as evidence
by) signs and symptoms better known as
subjective and objective data.
MUST BE:
✓ Patient centered
✓ Clear and concise
✓ Observable and measurable
✓ Time limited
✓ Realistic
✓ One behavior/goal
✓ Determined by patient, family, nurse together.
SHORT TERM AND LONG TERM GOALS
• GOALS AND EXPECTED OUTCOMES MUST BE
MEASURABLE AND CLIENT-CENTERED.
• GOALS ARE CONSTRUCTED BY FOCUSING
ON PROBLEM PREVENTION, RESOLUTION,
AND REHABILITATION.
• GOALS CAN BE SHORT-TERM OR LONG-
TERM. MOST GOALS ARE SHORT-TERM IN AN
ACUTE CARE SETTING SINCE MUCH OF THE
NURSE’S TIME IS SPENT ON THE CLIENT’S
IMMEDIATE NEEDS. LONG-TERM GOALS ARE
OFTEN USED FOR CLIENTS WHO HAVE
CHRONIC HEALTH PROBLEMS OR LIVE AT
HOME, IN NURSING HOMES, OR IN
EXTENDED-CARE FACILITIES.
➔ Short-term goal – a statement distinguishing
a shift in behavior that can be completed
immediately, usually within a few hours or
days.
➔ Long-term goal – indicates an objective to be
completed over a longer period, usually over
weeks or months.
➔ Discharge planning – involves naming long-
term goals, therefore promoting continued
restorative care and problem resolution
through home health, physical therapy, or
various other referral sources.
2. RATIONALE
➢ This is the scientific reason for our intervention.
➢ Includes definition of the problem with schematic
diagram ad reference below this column.
3. NURSING INTERVENTIONS
➢ Nursing interventions are activities or actions that
a nurse performs to achieve client goals.
Interventions chosen should focus on eliminating
or reducing the etiology of the nursing diagnosis.
As for risk nursing diagnoses, interventions should
focus on reducing the client’s risk factors. In this
step, nursing interventions are identified and
written during the planning step of the nursing
 process; however, they are actually performed ✓ In line with the client’s values, culture, and

during the implementation step. beliefs.

✓ In line with other therapies.

TYPES OF NURSING INTERVENTION: ✓ Based on nursing knowledge and experience

• Independent nursing interventions – or knowledge from relevant sciences.

are activities that nurses are licensed to

initiate based on their sound judgement
and skills. Includes: ongoing 4. PROVIDING RATIONALE

assessment, emotional support, ➢ Rationales, also known as scientific

providing comfort, teaching, physical explanations, explain why the nursing

care, and making referrals to other health intervention was chosen for the NCP.

care professionals.
➢ Rationales do not appear in regular care plans.
They are included to assist nursing students in
• Dependent nursing interventions – are
associating the pathophysiological and
activities carried out under the
psychological principles with the selected nursing
physician’s orders or supervision.
intervention.
Includes orders to direct the nurse to
provide medications, intravenous
therapy, diagnostic tests, treatments,
diet, and activity or rest. Assessment and 5. EVALUATION
providing explanation while administering ✓ Evaluating is a planned, ongoing,
medical orders are also part of the purposeful activity in which the client’s progress
dependent nursing interventions. towards achieving goals or desired outcomes and
the effectiveness of the nursing care plan (NCP).
• Collaborative interventions – are
✓ Evaluation is an essential aspect of the
actions that the nurse carries out in
nursing process because conclusions drawn from
collaboration with other health team
this step determine whether the nursing
members, such as physicians, social
intervention should be terminated, continued, or
workers, dietitians, and therapists. These
changed.
actions are developed in consultation
with other health care professionals to
gain their professional viewpoint.

NURSING INTERVENTIONS SHOULD BE:

✓ Safe and appropriate for the client’s age,

health, and condition.
✓ Achievable with the resources and time
available.