NCM 107: Care of Mother, Child, Adolescent (Well-Client)

SUPPLEMENTARY VIDEOS 3rd Trimester: Month 7

PREGNANCY CHANGES (VIDEO 1) - Nesting impulse might kick in as you prepare
st
1 Trimester: Month 1 for baby’s arrival
- Sciatica may cause radiating back pain
Conception - Ease pressure with pregnancy pillow
- Embryo implants into uterus via fallopian Month 8
tube
- You wake up a lot to pee as uterus pushes
Month 2 into your bladder
- If skin itches from stretching use lotion and
- The hormone hCG increases
stay hydrated
- Causing “morning sickness”
- High estrogen and progesterone cause Month 9
breast tenderness
- Sensitivity to smells - You feel pressure in your lower abdomen as
- Ask your doctor about foods to avoid baby gets ready for delivery
- Prenatal vitamins are recommended - Pack your bags and get ready for labor
- If you deliver vaginally, you may have
Month 3 contractions, hot flashes, chills, nausea,
vomiting, gas
- Hormones may make nipples larger and
- Once your cervix dilates to 10cm, you’ll feel
darker
a strong natural urge to push
- Estrogen can cause pregnancy glow
- It’s time for new clothes!
2nd Trimester: Month 4
- As hCG decreases, you feel healthy, sexy,
energetic
- Blood flow may improve orgasms
- Hormones may make you feel clumsy
- Strange cravings kick in
- For the first time, you may feel your baby kick
Month 5
- Round ligament pain in abdomen
- Can cause pain when sitting
- A belly band may help
Month 6
- High estrogen = thicker hair
- High estrogen = stronger nails
- Swelling can cause carpal tunnel
- Uterus pushes stomach = acid reflux

MODULE 1F: CARE OF THE PREGNANT MOTHER (ANTE-NATAL PERIOD) YUSON, DREA
NCM 107: Care of Mother, Child, Adolescent (Well-Client)
PRE-RECORDED LECTURE There are many influences revolve around a
pregnant woman
DISCUSSION
Pregnancy is a unique, exciting and often joyous a. Social Influence
sign in a woman’s life. From the time she knew she
was pregnant until her delivery, this span of time are First Part of 20th Modern
filled with many physical and psychological changes Century
as well as change in lifestyle. Each change → Pregnancy was → As time speeds up,
possesses a challenge that can be met successfully considered as 9th month and information and
long illness. research advances,
when a woman shares her feelings and experiences
→ The pregnant pregnancy at the
with a partner and with her physician and nurse. woman should be present time is
separated from the considered to be a
family during birth, healthy span of time
Care of Pregnant Mother hospitalized, and no → Best shared with
during Ante-Natal Period visitors allowed supportive partner and
→ They’re also isolated family
from her newborn for → The pregnant women
one week also may choose as to
Pregnancy changes include both physical and what level of pain
psychological. management they want
to use for labor and
- Physical changes include the bodily changes delivery
and adjustments to deal with a growing fetus.
- Psychological changes include how she b. Cultural Influence
reacts and maintains her sanity all
throughout the pregnancy - A woman’s cultural background may strongly
influence how active a role she wants to take
PSYCHOLOGICAL CHANGES in her pregnancy
- Pregnancy is such a huge change in a - Certain beliefs and taboos may face
woman’s life and it brings about more restrictions on her behavior and activities
psychological changes than any other life - Some myths about pregnancy:
event besides puberty. a. Lifting arms around the head during
- A woman’s attitude towards the pregnancy pregnancy will cause the cord to twist
depends a great deal (?) on psychological b. Watching a lunar eclipse will cause a
aspects such as the environment in which birth deformity
she was raised, the messages about the c. Increasing their workload of daily chores
pregnancy her family communicated to her through the second and third trimester up
as a child, the society and culture in which to the point of exhaustion and miss their
she lives as an adult and whether the antenatal checkups in preparation for
pregnancy has come a good time or less their postnatal period in which they will
than a good time in her life. stay in their homes for three months
c. Family Influence
- People loved as they have been loved.
- How the pregnant woman was raised as a
child will greatly affect her pregnancy
- No matter how often a woman is told the
pregnancy is natural and simple, she will not
be overjoyed to find herself pregnant if all she

MODULE 1F: CARE OF THE PREGNANT MOTHER (ANTE-NATAL PERIOD) YUSON, DREA
NCM 107: Care of Mother, Child, Adolescent (Well-Client)
has heard are stories about excruciating pain
and endless suffering in labor
Individual Differences
- Refer to how the pregnant woman copes with
their situation along the stresses they are
facing
- The woman should feel secure in her
relationship with the people around her
especially the father of her child. This is very
important to her acceptance of pregnancy
Partner’s Adaptation
- Pregnancy do not only focus on the woman
only
- The partner also plays a great part in her
situation
- The more emotionally attached a partner is
to a pregnant woman, the close the partner’s
attachment is apt to be to the child
Psychological Tasks of Pregnancy
-The pregnant woman and her partner go
through the different stages of pregnancy,
they will also be facing and experiencing
different challenges and tasks in order to
proceed to the next stage
- These tasks are the psychological tasks of
pregnancy which aims to prepare the
couple to their new roles and
responsibilities as they enter parenthood
A. First Trimester
TASK: Accepting the Pregnancy
 Both pregnant woman and the partner
spend time recovering from the surprise of
learning that they are pregnant
 The common reaction of this stage is
ambivalence.
 Both of them are having mixed emotion,
feeling pleased, and not pleased during
pregnancy. They are happy, yet sad at the
same time.
 According to research, 49% of pregnancy
is still unintended, unwanted or mistimed.
That is why part of the task of the pregnant
woman is to accept the reality of
pregnancy.
 Initial reaction of a pregnant woman
include being surprised, also the women
MODULE 1F: CARE OF THE PREGNANT MOTHER (ANTE-NATAL PERIOD)
often feeling less pressure and closer to
anxiety
 Take note: Ambivalence towards
pregnancy does not mean that positive
feelings counteract negative feelings. So,
the woman is left feeling nothing toward
her pregnancy. Instead, it refers to the
interwoven feelings of wanting and not
wanting that can exist at high levels
 The partner on the other hand often feel
proud and happy about the pregnancy,
facilitating acceptance of it though they still
feel ambivalent about it, sometimes more
so than the pregnant woman
B. Second Trimester
As soon as fetal movements can be felt,
psychological responses of both partners are apt
to change.
TASK: Accepting the Fetus
 Both move through emotions such as
narcissism and introversion as they
concentrate on what it will feel like to be
apparent
 The common reaction in this stage is
role playing and increased dreaming
➔ This anticipatory role playing is an
important activity for mean(?)
pregnancy
➔ It leads them to a larger concept of her
condition and helps her realize that not
only is she pregnant but also there is a
child inside her
 They will now start to imagine themselves
as parent:
➔ Teaching their child
➔ Playing with him or her
➔ At this stage, the pregnant woman
begins to imagine how she will feel at
birth when the physician or the midwife
announces it’s a boy or it’s a girl
➔ She begins to imagine herself as a
mother perhaps teaching her child the
alphabet or how to ride the bicycle
➔ Now, she refers to the child as “he” or
“she” from it
A good way to measure the level of a woman’s
acceptance of the coming baby is to measure how
well she follows her prenatal schedules and
instructions.
- The partner now, this time, since the focus
is now on the baby, he feels left alone to
compensate for this feeling
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NCM 107: Care of Mother, Child, Adolescent (Well-Client)
- The partner may become overly absorbed
in work striving to produce something
concrete on the job as if to show the
woman is not the only one capable of
creating something
C. Third Trimester
TASK: Preparing for the Baby and End of
Pregnancy or Preparing for Parenthood
- They now begin nesting activities. These
nesting activities include:
➔ Preparing clothing and sleeping
arrangements of the baby
➔ As well as the name of the baby
- They also ensure safe passage by
attending prenatal classes and by learning
about birth, they also grow impatient as
they ready themselves for the delivery and
birth of the baby
RECAP:
First Trimester: Accepting the Pregnancy
Second Trimester: Where there is already fetal
movement that can be felt, Accepting the Fetus
Third Trimester: Preparing for the Baby and
The End of Pregnancy or Preparing for
Parenthood
These psychological tasks of pregnancy are
important to achieve so that the couple will have a
healthy pregnancy and a healthy baby.
EMOTIONAL RESPONSES THAT CAN CAUSE
CONCERNS IN PREGNANCY
Note: Some of these responses are normal, but
only worrisome and require psychological
attention if they become so extreme that they
create intolerable emotional and physical stress.
1. Grief
- Knowing that the pregnant woman will
never be as irresponsible and as carefree
as before
- Sleep soundly for the next years giving the
woman’s present role as she will never be
the woman she has been in exactly the
same way again
2. Narcissism
- Self-centeredness
- Example: A woman who was barely body
conscious suddenly begins to be
conscious on what to wear so that their
pregnancy will or will not show
MODULE 1F: CARE OF THE PREGNANT MOTHER (ANTE-NATAL PERIOD)
3. Introversion
- Turning inward to concentrate on oneself
and one’s body
4. Extroversion
- Some women however react in an entirely
opposite fashion and become more
extroverted
- They become more active, appear
healthier than ever before and are more
outgoing
5. Body Image and Boundary
- Body image is the way your body appears
to yourself
- Body boundary is a zone of separation that
you receive between yourself and objects
or other people
- Example of Body Image: When the
pregnant woman begins to see herself
becoming bigger
- Example of Body Boundary: When the
pregnant woman walks away from an
object such as a table to avoid bumping
against it
6. Stress
- Because pregnancy brings with it such a
major role change, it can cause extreme
stress in a woman
- The stress of pregnancy, like any stress,
can make it difficult for a woman to make
decisions, be aware of her surroundings
as usual, or maintain time management
with her usual degree of skill
7. Depression
- A feeling of sadness marked by loss of
interest in usual things, feeling of guilt, and
low self-esteem
8. Couvade Syndrome
- When the partner experiences physical
symptoms at same degree or even more
intensely than their partners which is the
pregnant woman
- So, if the pregnant woman is experiencing
vomiting, the partner also feels nauseous
and vomits as well
- As the woman’s abdomen begins to grow,
partners may perceive themselves as
growing larger too as if they were the one
experiencing it
YUSON, DREA
NCM 107: Care of Mother, Child, Adolescent (Well-Client)
9. Emotional Lability PHYSIOLOGIC CHANGES IN
- Mood changes occur frequently in a PREGNANCY:
pregnant woman partly as a manifestation
of narcissism
The Confirmation of Pregnancy
- Example: Her feelings are easily hurt by - Before there were sonograms and maternal
remarks that would have been left/laughed serum pregnancy tests, pregnancy was
off before and partly because of hormonal diagnosed on symptoms reported by the
changes Partly because of hormonal woman in the signs elicited by the health care
changes. particularly the sustained provider
increased in estrogen and progesterone - These signs and symptoms are traditionally
divided intro three classifications:
Presumptive, Probably, and Positive
CHANGES IN SEXUAL DESIRE Presumptive Symptoms
- This is very important to know for the partner  These symptoms are experienced by the
to adjust and to know the sexual desire and woman but cannot be documented by the
needs of each other examiner or the health care provider.
That’s why these symptoms are called to
During the First Trimester: be the subjective symptoms.
- Most women report a decrease in libido  These symptoms don’t necessarily confirm
because of the nausea, fatigue, and breast the pregnancy
Different Symptoms under Presumptive:
tenderness that accompany early pregnancy
a. Breast Changes
During the Second Trimester: ➔ Feeling of tenderness, fullness,
tingling, and enlargement felt by the
- As blood flows to the pelvic area increases to mother, and darkening of the areola
supply the placenta, libido, and sexual b. Nausea and Vomiting
enjoyment will rise ➔ There is nausea and vomiting felt on
arising(?) or when fatigue
During the Third Trimester: c. Amenorrhea (cessation of
menstruation)
- Sexual desire may remain high or it may
d. Increased urination or the increases
decrease because of difficulty finding a frequency of urination
comfortable position and in increasing ➔ Sense of having to void more than
abdominal size often than her usual pattern
e. Fatigue or the general feeling of
CHANGES IN EXPECTANT FAMILY tiredness
- As the new member of the family is waiting to f. Uterine Enlargement
come out, their older children should be well ➔ The mother can palpate the uterus
prepared and informed that the baby will be over the symphysis pubis
an addition to the family and will not replace g. Quickening
them or change their parents’ affection ➔ Fetal movement again felt by the
towards them woman
- Some of these responses are normal, but are h. Linea Nigra
only worrisome and require psychological ➔ Presence of dark line pigmentation on
attention if they become so extreme that they the abdomen
create intolerable, emotional, and physical i. Melasma
stress ➔ Dark pigmentations on face
j. Striae Gravidarum
➔ Red streaks that is formed on the
abdomen

MODULE 1F: CARE OF THE PREGNANT MOTHER (ANTE-NATAL PERIOD) YUSON, DREA
NCM 107: Care of Mother, Child, Adolescent (Well-Client)
TO EASILY MEMORIZE THE DIFFERENT c. Goodell’s Sign
SYMPTOMS UNDER THE PRESUMPTIVE: ➔ Softening of the cervix
(MNEMONIC) d. Hegar’s Sign
P – Period absent (amenorrhea) ➔ Softening of the lower segment of the
R – Really tired or Fatigue uterus
E – Evidence of Linea Nigra e. Sonographic Evidence of Gestational
S – Striae Gravidarum Sac
U – Uterine Enlargement ➔ The characteristic ring is already
M – Movement felt by the woman or Quickening evident
P – Pigmentation on Face f. Ballottement
T – Tenderness and Tingling ➔ Upon tapping of the lower uterine
I – Increased Urination segment on a bimanual examination,
V – Vomiting the fetus can be felt to rise against the
Take note that these symptoms when taken as abdominal wall
single entities could easily indicate other g. Braxton Hick’s Contraction
conditions that is why presumptive symptoms ➔ Presence of Periodic Uterine
are not confirmatory symptoms of pregnancy. Tightening
h. Fetal outline that is already felt by
examiner
Probable Signs ➔ So, the examiner can palpate the fetal
 These are signs that experienced by the outline through the abdomen
mother and can be verified or documented MNEMONIC
by the examiner or a healthcare worker P – Positive Pregnancy Test
 These signs are more reliable than R – Returning of the Fetus (when uterus is pushed
presumptive symptoms but still, they do forward/Ballottement)
not positively diagnose a pregnancy. O – Outline of the Fetus
 These are also called the objective signs. B – Braxton Hick’s Contraction
Probably Signs: A – A soft cervix
a. Positive Maternal Serum Test B – Bluish/Violet Vagina
➔ There is a presence of human L – Lower Segment Softening
chorionic gonadotropin detected or E – Evidence of Gestational Sac
your hCG These signs are not enough to diagnose or
➔ Why is this considered probable when confirm pregnancy.
it is already positive in hCG?
◼ Because there is a disease which
also causes the release of this Positive Signs
hormone  These signs are also used to confirm the
➔ Part also of your instruction for women pregnancy
taking the maternal serum test to have Positive Signs:
this early in the morning since the urine a. Sonographic Evidence of the Fetal
is still concentrated. Instruct also the Outline
woman not to drink a large quantity of ➔ The fetal outline can already be seen
water prior to test as this may dilute the and measured by a sonogram
urine. b. Audible Fetal Heart Tone
➔ Positive result indicate two strips on ➔ There is presence of a heartbeat that
the maternal serum test kit is revealed through a doppler
➔ Again, positive result does not yield to ultrasound
positive pregnancy c. Fetal Movement Felt by the Examiner
b. Chadwick’s Sign ➔ The examiner can palpate the fetal
➔ The discoloration of the vagina from movement through the abdomen
pink to bluish or violet color

MODULE 1F: CARE OF THE PREGNANT MOTHER (ANTE-NATAL PERIOD) YUSON, DREA
NCM 107: Care of Mother, Child, Adolescent (Well-Client)
These three signs are considered positive
signs because they highly suggest and
confirm pregnancy.
PHYSIOLOGIC CHANGES THAT
OCCUR DURING PREGNANCY
- This is important for us to know so that we
will know if the changes experienced by the
woman is normal or highly suggestive of
another disease
- The physiologic changes of pregnancy is
subdivided into two: Local and the
Systemic Changes
Local Changes
- These are changes which are confined to
the reproductive organs
REPRODUCTIVE CHANGES:
Uterine Changes (UTERUS)
 As the pregnancy progress, the length or
the height of the uterus also increases
from approximately 6.5 to 32 cm (6.5-32
cm)
➔ In order for us to measure the height of
the uterus, we use the landmark
symphysis pubis to the top of the
uterine fundus
 Depth: from 2.5 to 22 cm (2.5-22 cm)
 Width: from 4 to 24 cm (4-24 cm)
 As the pregnancy again progress, the
length, depth, and width of the uterus
increases as well to accommodate the
growing fetus
 Weight: from 50 to 1000 grams (50-1000
grams)
➔ This great uterine growth is due partly
to the formation of new muscle fibers
 By the end of pregnancy, muscle fibers in
the uterus come 2 to 7 times longer than
they were before pregnant
 Volume: from 2 to more than 1000 mL
➔ Because it can hold a 7-pound (lb)
fetus plus the amniotic fluid which is
1000 ml in total of 4000 grams after the
 The Uterine Wall Thickness:
➔ Early in pregnancy: 1 to 2 cm
➔ Towards the end of the pregnancy:
about 0.5 cm thick
MODULE 1F: CARE OF THE PREGNANT MOTHER (ANTE-NATAL PERIOD)
 By the end of 12 weeks of pregnancy, the
uterus is large enough that it can be
palpated as a firm globe under the
abdominal wall just above the symphysis
pubis.
 By the end of 20 or 22nd weeks of
pregnancy, it can now be palpated at the
level of the umbilicus
 By the end of 36 weeks, this now touches
the xiphoid process
➔ This is the main reason why pregnant
women complain of having difficulty
breathing because as the uterus
grows, it also depresses the
diaphragm
 About 2 weeks before term, the uterus
returns to the height it was at 36 weeks
 There is also cessation of menstrual
cycle that is your amenorrhea
➔ This occurs because of the
suppression of the Follicle Stimulating
Hormone or your FSH by the rising
estrogen level
CERVIX
 Becomes more vascular and edematous
➔ Because of the increased
vascularization of the cervix, this
causes it to soften which is termed as
the Goodell’s sign.
 There also presence and formation of
mucus plug which is termed as the
Operculum
➔ The operculum helps in preventing
infection of the fetus and its membrane
VAGINA
 Increased size of the vagina
➔ Because of the increased size of the
vagina, it causes it to increase in its
vascularity
 Increased vascularity
➔ Because of the increased vasculature,
that causes the color to change from
pink vagina to a bluish or violet color
termed as the Chadwick’s sign
 Change in the vaginal secretion
➔ The pH is now 4 or 5 = acidic
➔ The acidity of the vaginal secretion
helps make the vagina resistant to
bacterial invasion for the length of the
pregnancy
➔ This occurs because of the action of
the lactobacillus acidophilus which is a
YUSON, DREA
NCM 107: Care of Mother, Child, Adolescent (Well-Client)
bacteria that grows freely in the SYSTEMIC CHANGES
increased glycogen environment - These are changes which occur in almost
which increases the lactic acid content all of the body systems
of the secretions
➔ NOTE: As the pH changes Endocrine System
unfortunately because of this pH level, PLACENTA
this also favors the growth of candida  Additional gland of being pregnant
albicans which is a species of yeast-  The placenta produces estrogen which
like fungi causes the breast and the uterine
OVARIES enlargement
 Ovulation stops  The placenta also produces progesterone
➔ Because of the active feedback which maintains the endometrium lining
mechanism of estrogen and  It also inhibits uterine contractility and aids
progesterone produced by the corpus in developing the breast for lactation
luteum early in pregnancy  Presence of hCG and hPL
➔ In later part of the pregnancy, the ➔ The human chorionic gonadotropin
stopping of ovulation is caused by the stimulates progesterone and estrogen
placenta. This feedback causes the synthesis until placenta assumes this
pituitary gland to halt production of role
your FSH (Follicle Stimulating ➔ The human placenta lactogen that
Hormone) and LH (Luteinizing serves as antagonists to insulin.
Hormone) Making the insulin less effective and so
➔ Because with that, the simulation from allows more glucose to become
your hormones, the ovulation now available for fetal growth
does not occur  Relaxin and Prostaglandins
BREAST ➔ The relaxin helps and inhibits uterine
 There is a feeling of fullness, tingling, or activity to soften the cervix
tenderness ➔ The prostaglandins initiate the labor
 Increased size of the breast PITUITARY GLAND
➔ Because of the growth of the  FSH and LH productions stop
mammary alveoli ➔ Because of the high level of estrogen
 Areola darkens and increases the and progesterone produced by the
diameter to 5 to 7.5cm placenta
➔ Some women form secondary areola  Increased production of growth hormones
which is the additional darkening of the and melanocyte stimulating hormone
skin surrounding the areola ➔ Causes the skin pigmentation
 Blue veins become prominent  Prolactin and oxytocin
 Nipples are more erectile ➔ Also occurs in late pregnancy
➔ This helps the breast prepare for
lactation and aiding in labor process
THYROID AND PARATHYROID GLAND
 Increase of the size of these glands
 Because of the increase in size there is
also increased production of hormones
created by these glands
 That is the reason that the woman’s
metabolic rate increases by about 20% or
increased Basal Metabolic Rate

MODULE 1F: CARE OF THE PREGNANT MOTHER (ANTE-NATAL PERIOD) YUSON, DREA
NCM 107: Care of Mother, Child, Adolescent (Well-Client)
ADRENAL GLANDS
 Double production of corticosteroids and
aldosterones
➔ Helps in reducing the probability that
the woman’s body will reject the
foreign protein of the fetus
PANCREAS
 In response to the higher level of
glucocorticoids produced by the adrenal
glands, there is an increased production of
insulin
➔ Take note that even though there is an
increased production of insulin, they
are less effective than usual.
However, this diminished action of
insulin is beneficial to the fetus
because it ensures a ready supply of
glucose for fetal growth
IMMUNE SYSTEM
 There is a decreased production of
immunoglobin g (IgG)
➔ To decrease or reduce the
immunologic competency
➔ This is important because this prevents
rejection of fetus as if it were a
transplanted organ
INTEGUMENTARY SYSMTEM
 Presence of striae gravidarum
 Presence of linea nigra
 Presence of melasma
 Presence of vascular spiders seen on the
patient’s or the woman’s body
 Presence of protrusion of umbilicus
RESPIRATORY SYSTEM
 Shortness of breath is present and
becomes more rapid
➔ Because of the growing fetus which
depresses the diaphragm making it
hard to breathe
MODULE 1F: CARE OF THE PREGNANT MOTHER (ANTE-NATAL PERIOD)
CARDIOVASCULAR SYSTEM
 Increased circulatory blood volume and
plasma
➔ Which results to pseudoanemia in
pregnancy
➔ Pseudoanemia happens because the
plasma volume increases faster than
the rbc production therefore the
concentration of hemoglobin and rbc
declines
 Increased RBC production
➔ The reason that the pregnant woman
requires additional iron need(?)
 Increased cardiac output
➔ 25 to 50%
 Blood pressure:
➔ During 2nd trimester: slightly
decreases (because of the expanding
placenta causes peripheral resistance
to circulation to lower)
➔ During 3rd trimester: blood pressure
rises to first trimester level
 Decreased peripheral blood flow during
the 3rd trimester
 Increased level of fibrinogen and leukocyte
DIGESTIVE SYSTEM
 Decreased stomach acidity
 Slowed intestinal peristalsis
➔ Because of the action of the relaxin
and progesterone present during
pregnancy
 Slowed emptying time
URINARY SYSTEM
 Increased aldosterone production and
sodium reabsorption
 Increased GFR and renal plasma flow by
30 to 50%
➔ Leads to increased filtration of glucose
 Increased urinary frequency
➔ Because of the pressure from the
growing uterus to the bladder
 Increased ureter diameter and bladder
capacity
MUSCULOSKELETAL SYSTEM
 Gradual softening of a woman’s pelvic
ligament and joints
➔ This happens because this is to create
pliability and facilitate the passage of
the baby
YUSON, DREA
NCM 107: Care of Mother, Child, Adolescent (Well-Client)
➔ The softening is influenced of both Dental Care
relaxin and placental progesterone
 Wide separation of symphysis pubis
 “Pride of Pregnancy”
➔ A stance of a pregnant woman in which
she stands straighter and taller with the
shoulders back and abdomen forward
➔ This is to change her center of gravity
MATERNAL HEALTH DURING
ANTE-NATAL PERIOD
- This is very important for us to identify the
health of the pregnant woman especially for
the first-time mothers since they do not have
yet the experience of being pregnant
Perineal Hygienes
Bathing
- Including vaginal discharges during
pregnancy
- Daily tub baths or showers should be strictly
followed
- Take note: upon showering or having tub
bath, make sure not for long periods in
extremely hot water
Breast Care
- As a general rule, the pregnant woman’s
breast size increases
Clothing
- The woman should wear a firm supportive
brassiere or brazier with wide straps to
spread the breast weight across the
shoulders
- Take note: upon washing the brassiere,
make sure to use a clear tap water and
AVOID using soap because soap causes
drying and causes nipple cracking
- Washing of the breast should be done daily
especially when colostrum secretions begin
- Drying of the nipples should be done using a
Sexual Activity
soft towel in a patting manner
- Take note: If the colostrum is so profuse, the
pregnant woman may place gauze squares
or breast pads inside her bra and change it
frequently
MODULE 1F: CARE OF THE PREGNANT MOTHER (ANTE-NATAL PERIOD)
- Very important because there is a strong
correlation between poor oral health and pre-
term birth
- Brushing of the teeth should be done on
arising, after meals, and at bedtime
- Advise the pregnant woman to avoid eating
sweets
➔ Exposure of sweets in the mouth lowers
the pH of the mouth creating an acid
medium that can lead to etching or
destruction of tube enamel
- Encourage the pregnant woman to have a
regular dental visits
- Wipe the area from front to back
➔ To avoid bringing the contamination from
the rectum to the vagina
- Douching is contraindicated during
pregnancy
➔ Because this alters the vaginal pH and
may lead to infection
- Shaving during pregnancy is also
contraindicated
➔ This produces or leaves open wounds
➔ Trimming is advised
- The woman should wear something that is
comfortable
- Instruct to avoid garters, extremely firm
girdles with panty legs and knee high
stockings
➔ Because these pieces may impede lower
extremity circulation that lead to certain
problems
- Shoes must be with moderate to low heel
- As pelvic congestion increases, most women
have increased clitoral sensation
➔ Thus, some women experience orgasm
for the first time during pregnancy
- CAUTION: oral-female genital contact
➔ Accidental air embolism has been
reported
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NCM 107: Care of Mother, Child, Adolescent (Well-Client)
- Anal sex is also not advised
- Side by side position or a woman in a
superior position may be practiced
➔ To promote comfortability of the woman
Exercises
- There is a misconception about exercises
during pregnancy that it shouldn’t be done
however it is highly advised and encouraged
to perform moderate exercises
- Moderate exercises means that it is done
three times weekly for 30 consecutive
minutes
➔ Consists of 5 minutes of warm up
➔ 20 minutes active exercise
➔ 5 minutes cool down exercise
- Walking is the best exercise for a pregnant
woman
➔ Because this allows movement of the
large muscle groups rhythmically
Sleep
- A good resting or sleeping position is left
sided Sim’s position with top leg forward
➔ This position puts the weight of the fetus
on the bed and promotes good circulation
in the lower extremities of the mother
- AVOID resting flat on her back
➔ As they may cause Supine Hypotension
Syndrome
➔ Supine Hypotension Syndrome results
from the compression of the vena cava
from the growing fetus if the mother is
lying on her back
MODULE 1F: CARE OF THE PREGNANT MOTHER (ANTE-NATAL PERIOD)
COMMON DISCOMFORTS OF
PREGNANCY DURING ANTENATAL
PERIOD
First Trimester
Breast Tenderness
- One of the symptoms noticed especially
when the breast is exposed to the cold air
- What we can do here is to encourage the
woman to wear a bra (brassier) with wide
shoulder strap
NURSING INTERVENTIONS:
- Encourage the woman to dress warmly
- AVOID the use of soap on the nipples and
areola area to prevent drying off the skin
Palmar Erythema
- This is because of the increasing level of
estrogen occurring during pregnancy
- The pregnant woman may apply calamine
lotion on her hands
- TAKE NOTE: You need to emphasize that
palmar erythema is considered normal
because some mothers overthink and they
may think that this is already a symptom of
an ongoing allergy
Nausea and Vomiting
- Also called morning sickness
- Very common
- This occurs in the first trimester and usually
subsides by the third month
- This is caused by the elevation of the human
chorionic gonadotropin and other pregnancy
hormones as well as there is a change in
carbohydrate metabolism occurring during
pregnancy
NURSING INTERVENTIONS:
- Encourage the pregnant mother to eat dry
crackers before arising
- Avoid brushing teeth immediately after
arising
- Eating small frequent, low fat meals during
the day
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NCM 107: Care of Mother, Child, Adolescent (Well-Client)
- Drinking liquids between meals rather than at
meals
- Avoiding fried and spicy foods
Constipation
- This results from increased in progesterone
production, decreased intestinal motility,
displacement of intestines, pressure of
uterus and taking off iron supplements during
pregnancy
NURSING INTERVENTIONS
- Instruct the pregnant mother to eat fiber
foods such as whole grains, fruits, and
vegetables
- Drinking no less than 2000 mL per day
- Regular exercise
Pyrosis
- Heartburn
- This results from increased progesterone
levels, decreased GI motility, esophageal
reflux and displacement of the stomach by
the enlarging materials
NURSING INTERVENTIONS:
- Instruct the pregnant mother to eating small
frequent meals
- Sitting upright for 30 minutes after a meal
- Drinking milk between meals
- Avoiding fatty and spicy foods
- Performing tailor sitting exercises
Fatigue
- Usually caused from a hormonal changes
NURSING INTERVENTIONS:
- Arranging frequent rest periods throughout
the day
- Using correct postures and body mechanics
upon doing things
- Obtaining regular exercise
- Performing muscle relaxation and
strengthening exercises for the legs and hip
joints
MODULE 1F: CARE OF THE PREGNANT MOTHER (ANTE-NATAL PERIOD)
Muscle Cramps
- This results from an altered calcium
phosphorus balance and pressure of the
uterus on nerves or from fatigue
NURSING INTERVENTIONS:
- Increase the intake of calcium as prescribed
also by the healthcare provider
- Getting regular exercise such as walking
- Muscle cramps is best relieved when the
woman lies on her back momentarily and
extends the involved leg while keeping her
knees straight and dorsiflexing the foot
Hypotension
- This results from the compression of the
vena cava from the growing uterus when the
woman lies on her back
NURSING INTERVENTIONS:
- Advise the pregnant woman to always rest
and sleep on their side and not on their back
- If they can only fall asleep on their back, they
should insert a firm and small pillow under
the right hip
➔ This is to cause the weight of the uterus
to shift off from the vena cava
Varicosities
- This is caused by the pressure on the veins
returning blood from lower extremities from
the pregnancy weight called the
tortuous/tortuous leg veins
- The veins become enlarged, inflamed, and
very painful
NURSING INTERVENTIONS:
- Resting in the Sim’s position or on the back
with the legs raised against the wall or
elevated on a foot stool for 15 to 20 minutes
twice a day
- Avoid crossing legs or using constrictive
knee-high hose or garters
- Avoid long periods of standing
- If it is really inevitable for the pregnant
woman to stand, encourage to move while
standing to improve the circulation
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NCM 107: Care of Mother, Child, Adolescent (Well-Client)
Hemorrhoids
- This is caused by the pressure on rectal
veins from the both/butt of the growing fetus
NURSING INTERVENTIONS:
- Daily bowel evacuation
- Adequate fluid intake
- Eating high fiber food
- Sitting on a soft pillow
- Soaking in a warm sitz bath
- Exercising regularly
Heart Palpitations
- This is caused by the circulatory adjustment
in order for the pregnant woman to
accommodate her increasing blood supply
NURSING INTERVENTIONS:
- Encourage the pregnant woman to move
slowly and gradually
Frequent Urination
- This is caused by the pressure on the
bladder from the growing fetus
- This usually disappears during mid
pregnancy as the uterus rises above the
bladder and returns late pregnancy
NURSING INTERVENTIONS:
- Encourage the woman to void as necessary
➔ The woman should not hold her urge to
urinate because urine stasis leads to
infection
- AVOID restricting fluid intake however there
is a need to reduce caffeine and cola drinks
- Instruct the pregnant woman to limit the fluid
intake only in the evening before sleeping
- Sleep side lying at night
- Performing Kegel exercises may also be
helpful
MODULE 1F: CARE OF THE PREGNANT MOTHER (ANTE-NATAL PERIOD)
Leukorrhea
- Whitish viscous vaginal discharge in
response to high level of estrogen and the
increased blood supply to vaginal epithelium
and cervix
NURSING INTERVENTIONS:
- Daily baths
- Wearing cotton underpads
- Sleeping at night without underwear may
also be a help
- Instruct the pregnant woman to avoid
douching
Second Trimester and Third Trimester
Backache
- This is caused by the exaggerated
lumbosacral curve resulting from an enlarged
uterus
- The mother risk for falls
NURSING INTERVENTIONS:
- Emphasize to the pregnant woman to move
slowly
- The woman should wear low heeled
comfortable and supportive shoes
- Apply local heat on the area
- Squatting when picking up objects than
bending over
- Lift objects by holding them close to the body
- Pelvic rocking and tilting
Headache
- This is caused by the pressure on the
cerebral arteries from expanding blood
volume
NURSING INTERVENTIONS:
- Avoid triggers such as eye strains or tension
- Resting with ice pack on forehead
- Changing position slowly
YUSON, DREA
NCM 107: Care of Mother, Child, Adolescent (Well-Client)
Dyspnea RECOMMENDED WEIGHT GAIN DURING
PREGNANCY
- This is caused by the growing uterus places
pressure on the diaphragm which leads to
long compression leading to dyspnea Normal Weight 25-35 lbs
Woman
NURSING INTERVENTIONS:
Underweight Woman 28-40 lbs
- Advise to sleep with her head and chest Overweight Woman 15-25 lbs
elevated Obese Woman 11-20 lbs
- She may use two or more pillows
Ankle Edema Normal Weight Gain: 25-35 lbs

- This is caused by the fluid retention and First 1.5 lbs/month 4.5 lbs
reduced blood circulation in the lower Trimester (for the whole
extremities trimester)
- Considered normal as long as there is no Second 1 lb/week 12 lbs
Trimester (for the whole
proteinuria and hypertension because the
trimester)
presence of proteinuria and hypertension
Third 1 lb/week 12 lbs
suggests that it is a …… (choppy) Trimester (for the whole
NURSING INTERVENTIONS: trimester)

- Left side-lying position

➔ This increases the kidney’s glomerular COMPONENTS OF HEALTHY NTURITION
filtration rate and allows good venous FOR THE PREGNANT WOMAN
return Nutrition needs of the pregnant woman:
- Elevation of the legs
Energy 2,500 calorie (complex
- Avoiding wearing of constricting clothings
(Calorie) carbohydrates)
- Avoid sitting or standing in one position for Protein 71 g daily (complete proteins:
long periods meat, poultry, fish, yogurt)
Braxton Hick’s Contraction Fat Needs 200-300 mg of Omega-3 fatty
acid
- Periodic uterine contractions and plays a (Linoleic Acid) daily
great role in the fetal health and development Vitamins Vitamin A
- This is very important for us to assess the Vitamin D 600 IU
pregnant mother Vitamin C
Folic Acid 0.4-0.6 mg
- To prevent renal tube
defects of the fetus
Minerals Calcium 1000-1300 mg
Phosphorus
Iodine
Iron
Fluoride
Zinc
Sodium
Zinc 12 mg
Fiber
Fluids 8 glasses a day

MODULE 1F: CARE OF THE PREGNANT MOTHER (ANTE-NATAL PERIOD) YUSON, DREA
NCM 107: Care of Mother, Child, Adolescent (Well-Client)
Module 2F: Obstetric Anatomy
- In this module, you will learn about the bony
structures with the most importance for
pregnant woman and the baby she will give
birth to.
- The bones of the skeleton have the main
function of supporting our body weight and
acting as attachment points for our muscle.
- The female pelvis supports the major load
of the pregnant uterus and the fetal skull
which has to pass through the woman’s
pelvis when she gave birth.
Conceptual Framework
- In our conceptual framework, we have here
a mother who is pregnant
High Level Wellness
- If the mother is going through her regular
prenatal checkups, the mother is also
performing yoga and exercises, eating a
lot of healthy foods and fruits and
vegetables, have a good support system
and has a good psychological
development
- The mother is aware of everything that is
good for her baby and is educated
enough, then it will lead her to a high level
wellness
MODULE 2F: OBSTETRIC ANATOMY
Premature Death
- A mother who has vices all throughout her
pregnancy, drinking smoking, etc., has a
very bad psychological development not
just for her pregnancy but towards other
people,
- The mother is eating a lot of sugar or
unnecessary food intake
➔ We all know that sugar is prohibited
➔ If there is too much consumption of it,
it could lead to gestational diabetes
- The mother is also stressed all throughout
her pregnancy, eating a lot of unhealthy
foods like pizza, coffee, bacon, wine, etc.
➔ Could result to signs and symptoms of
disability
➔ It if is not treated, it could lead to
premature death not just for the mother
but also for the baby.
Labor
- A series of events by which uterine
contractions and abdominal pressure expel a
fetus and placenta from the uterus
- It is the process of delivering a baby and the
placenta, the membranes, and umbilical cord
from the uterus to the vagina to the outside
world
First Stage of Labor
- Dilatation
- The cervix dilates fully to a diameter of about
10 cm (2 inches)
First stage of labor is divided into 2 phases:
1. Latent Phase
2. Active Phase
Theories of Labor
- Normally begins between 37 and 42 weeks
➔ As early as 37 or as late as 42
- If the labor can begin before fetus is mature
this is premature labor
- If labor occurs or is delayed until fetus and
placenta have both passed beyond the
optimal point for birth this is termed as post
term labor
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NCM 107: Care of Mother, Child, Adolescent (Well-Client)
- The exact mechanism that triggers the onset Passage
of labor is unknown - Refers to the maternal pelvis
➔ There are a lot of mechanism that could - Refers to the route that the fetus must travel
trigger the onset of labor from the uterus through the cervix and vagina
Current beliefs that focus on the combination of to the external perineum
occurrences as responsible for initiating the FOCUS:
start labor:
- Shape of Pelvis
➢ Uterine stretching - Bony Structures
➔ Also caused by hormones or increase or - Pelvic Diameter
decrease in hormones that could affect - Soft Tissues
the uterine wall
➢ Changes in estrogen and progesterone Pelvis
balance
➢ Oxytocin Stimulation
➢ Cervical Pressure
➢ Prostaglandin production by the fetus
➢ Aging of the placenta
➢ Increased Fetal Cortisol Level

Components of Labor
There are four (4) important components of labor
which must work together for a normal labor process - From an obstetrical standpoint, it is useful to
to begin: consider the bony pelvis as a whole rather
than a separated part
1. Passage
- A pelvis is a bony ring formed by four united
➔ Refers to the maternal pelvis itself
bones:
2. Passenger
1. Two innominate (flaring hip) bones
➔ A maternal pelvis should be suitable to
2. The coccyx
also the passenger which refers to the
3. The sacrum
fetus
- These four bones serve both to support and
3. Power
protect the pelvic organs
➔ Refers to the amount of push the mother
- These united bones together also form four
will exert during the delivery
joints
4. Psyche
➔ Or psychological development of the
mother is very important all throughout
her pregnancy process
➔ Could refer to the past experiences a
mother had prior to pregnancy
If one is altered in these four components of labor,
the outcome of labor can be adversely affected.

MODULE 2F: OBSTETRIC ANATOMY YUSON, DREA

NCM 107: Care of Mother, Child, Adolescent (Well-Client)
Four Pelvic Joints Pelvic Divisions:
- The bony structures of the pelvis, including - The pelvis is anatomically divided into a
the pelvic joints and bones are important in False Pelvis and a True Pelvis
the labor and delivery.
1. Symphysis Pubis
2. Right Sacroiliac Joint
3. Left Sacroiliac Joint
4. Sacrococcygeal Joint
- Pelvic joints to provide stability to the pelvis.

- The bony line being the brim of the pelvis

False Pelvis
- located in the superior half of the pelvis
- the upper portion of the pelvic inlet
→ support the internal organs and upper body

Pelvis (Parts and Functions)
- Vital in the birthing process
- Innominate bones: ilium (upper and lateral
portion), ischium (inferior portion), and pubis
- Hip (the crest of the ilium)
- Ischial tuberosities (important markers
used to determine lower pelvic width)
- Ischial spines (mark the midpoint of the
pelvis)
- Symphysis pubis
- Sacrum (upper posterior portion of the pelvic
ring)
- Coccyx (below the sacrum)
True Pelvis
- located in the inferior half of the pelvis
- includes the pelvic inlet, pelvic outlet, and pelvic
cavity
- Chiefly of concerned of the obstetrician as it forms
the canal through which the fetus has to pass
Pelvic Inlet
- entrance to the true pelvis
- also called as the pelvic brim
Pelvic Outlet
- inferior portion of the true pelvis
Pelvic Cavity
- space between the inlet and the outlet

Front View

Pelvic inlet is the upper portion while the middle

part is a pelvic cavity and the lower part or the
lowest part is the pelvic outlet.
- The line that separates between the true
pelvis and the false pelvis: Imaginary line
(LINEA TERMINALIS) which separates
the false pelvis from true pelvis

MODULE 2F: OBSTETRIC ANATOMY YUSON, DREA

NCM 107: Care of Mother, Child, Adolescent (Well-Client)
Difference of a Male and a Female Pelvis

Male Pelvis
- Its arc is only 70 degrees = acute angle
- It is much more narrower and longer than the
female pelvis
Female Pelvis
- Its arc is 90 to 100 degrees = obtuse angle
anatomically called sub arc
- It is much broader and larger
Types of Pelvis
1. Gynecoid-shaped Pelvis
- “Female” pelvis
- Has an inlet that is well-rounded forward and
backward
- Has a wide pubic arch
- Ideal type for childbirth
- Most common type of pelvis for women
- This is what we call as the “child bearing
hips”
- A lot of women has a very perfect body like a
wide hips and betty boop type of body, or in
old terms like coca-cola body
- Easy passage of the fetal skull and the
shoulders
2. Android-shaped Pelvis
- “Male” pelvis
- The pubic arch forms an acute angle, making
the lower dimensions of the pelvis extremely
narrow
- A fetus may have difficulty exiting from this
type of pelvis
➔ Sometimes it could lead into cesarean
delivery or it could lead to a forceps
delivery or a vacuum delivery
➔ It depends on a lot of factors
3. Anthropoid-shaped Pelvis
- “Ape-like” pelvis
➔ Shaped as a monkey
- The transverse diameter is narrow
- The anteroposterior diameter of the inlet is
larger than usual
- It’s oval with longer anteroposterior diameter

MODULE 2F: OBSTETRIC ANATOMY YUSON, DREA

NCM 107: Care of Mother, Child, Adolescent (Well-Client)
4. Platypelloid-shaped Pelvis
- “Flattened” pelvis
- Has a smoothly curved oval inlet, but the
anteroposterior diameter is shallow
- The pelvis is super wide and super big that it
causes a lot of factors to have a difficulty
delivering the baby because the shape of this
pelvis is flattened oval
- A lot of women, mostly in the states, women
who are obese have a flattened pelvis, very
big and super wide hips

GYNECOID (50%) ANDROID (20%) ANTHROPOID (25%) PLATYPELLOID

(5%)
PELVIC BRIM Slightly ovoid or Heart shaped Oval, wider Flattened
transversely angulated anteroposteriorly anteroposteriorly
rounded
ROUND HEART OVAL FLAT
DEPTH Moderate Deep Deep Deep
SIDEWALLS Straight Convergent Straight Straight
ISCHIAL Blunt, somewhat Prominent, narrow Prominent, often with Blunt, widely
SPINES widely separated interspinous narrow interspinous separated
SACRUM Deep, Curved Slightly curved, Slightly curved Slightly curved
terminal portion
often beaked
SUBPUBIC Wide Narrow Narrow Wide
ARCH
USUAL MODE - Vaginal - Cesarean - Vaginal Vaginal
OF DELIVERY Spontaneous - Vaginal * Forceps - Spontaneous
(Occipitoanterior Difficult with * Spontaneous
position) forceps (Occipitoanterior/posterior
Position)

- 50% of women have gynecoid pelvis - Usual mode of delivery (gynecoid): normal
- 20% of women have android pelvis spontaneous vaginal delivery if the position
- 25% of women have anthropoid pelvis of the baby is in occipitoanterior position
- 5% of women have platypelloid presentation is on occiput

MODULE 2F: OBSTETRIC ANATOMY YUSON, DREA

NCM 107: Care of Mother, Child, Adolescent (Well-Client)
➔ Flexion is fully flexed: position of the baby
occipitoanterior, fully flexed meaning chin
is touching the chest
- Usual mode of delivery (android): usually
cesarean
➔ Women should assess first their body
types and pelvic types before getting
pregnant so to be prepared for financial
circumstances; there are times the ob
depending on the factor causes what,
vaginal but with the help of forceps or
vacuum
- For anthropoid, vaginal but with the help of
forceps and sometimes it is NSVD, but the
position of the baby should be
occipitoanterior or occipitoposterior.
➔ The position of the babies should
coincide with the type of pelvis that we
are going to deliver
- For platypelloid, we have vaginal
spontaneous delivery, but the size of the fetal
skull should be proportionate with the
diameter or the measurements of the pelvic
cavity itself
Pelvic Inlet Diameters and Measurements:
- Pelvic inlet is in the true pelvis and the upper
part of the true pelvis
Anteroposterior View
- Anteroposterior Diameters: 11 cm
 From the pubis to the sacrum
(anteroposterior view)
- Transverse Diameter: 5 3/8 inches (13.5cm
or greater)
 From the ilium to the ilium of the pelvis
- Oblique Diameter: 5 inches (12.7cm)
MODULE 2F: OBSTETRIC ANATOMY
Sagittal View
- Anteroposterior is from the sacrum to the
pubis (sagittal view)
- Anteroposterior Diameters: 11 cm of the
pelvic inlet considered adequate for vaginal
delivery
- The use of 3 conjugates is very important in
the birthing process
- Pelvic inlet is considered adequate for
vaginal delivery if the measurement of their
conjugates are as follows:
• True Conjugate: 4 3/8” (11cm) or
greater
 Also called as the Anatomical
Conjugate
• Diagonal Conjugate: 4 7/8” to 5 1/8”
(12.5cm to 13cm)
• Obstetric Conjugate: 10 cm
Pelvic Outlet Diameters and
Measurements:
- Pelvic Outlet is considered as adequate for
vaginal delivery if the following
measurements are as follows:
• Anteroposterior Diameter: 4 5/8”
(11.7cm)
 From sacrum or symphysis pubis to
coccyx
• Transverse / Intertuberous Diameter: 3
7/8” to 5 3/8” (10 to 13.5 cm)
 From left ischial tuberosity to the right
side of ischial tuberosity
• Posterior Sagittal Diameter: 3 ½ inches
(9cm)
 From this part here to the sacral iliac
joint
 Either left or right
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NCM 107: Care of Mother, Child, Adolescent (Well-Client)
Soft Tissues
- Also play a role in labor and delivery
- The lower segment of the uterus expands to
accommodate the intrauterine contents as
the walls of the upper segment thicken
- There are also a lot of factors which also
causes the intrauterine wall to soften and that
also aids the passage of the baby going out
- The cervix is drawn up and over the
presenting part as it descends
- The Vaginal Canal distends to accommodate
the passage of the fetus
Passenger
- Refers to the fetal skull
- Refers to the fetus and its ability to move
through the passage and affected by several
fetal features:
• Presentation
• Attitude
• Station
• Lie
• Position
MODULE 2F: OBSTETRIC ANATOMY
Fetal Skull
- Size is important as the fetus travels through
the birth canal
- Fetal skull is very important because this is
very significant during the labor and delivery
as we also check for any disabilities
- Fetal skull is some extent compressible and
made mainly of thin pliable tubular flat bones
- Contains 8 bones:
➔ 2 fused frontal bones
➔ 2 parietal bones
➔ 1 occipital bone
➔ Anchored to the rigid and incompressible
bones at the base of the skull
- Other 4 bones of the skull:
➔ Sphenoid
➔ Ethmoid
➔ 2 temporal bones
- The bones meet at suture lines composed of
strong, flexible, fibrous tissue which allow the
cranial bones to move and overlap, making it
possible for the skull to decrease in size
- It is very important to know the type of
sutures of the skull because for example,
during delivery or when the baby is delivered
you will experience conditions like caput
succedaneum, molding, cephalohematoma,
etc…
➔ You will determine that type of specific
condition by the determinants of these
suture lines
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NCM 107: Care of Mother, Child, Adolescent (Well-Client)
- Typically, the smallest diameter of the fetal
skull is the one that enters the pelvis first.
- The head can flex and extend 45 degrees
and rotate 180 degrees, which allows its
smallest diameter to move down the birth
canal and pass through the maternal pelvis.
➔ During childbirth, the fetus will rotate on
its own
➔ The fetus, while still inside, have instincts
already when and where to turn
- Fetal skull is very important also because it
has sutures
Sutures – seams between the bones of the skull
- Coronal – Frontal and parietal
- Lambdoid – Occipital and parietal
- Sagittal – Two parietal bones
- Squamous – Parietal and temporal (can be
viewed in a lateral view)
- NOTE: These sutures fuse or they are the
ones that compresses the bones
Fontanelles – Flexible fibrous tissue.
- Gap between the suture lines
- Anterior Fontanel
➔ Diamond shaped
➔ Located at the juncture of the frontal and
parietal bones
➔ Measures 1 1/8 inch to 1 5/6 inches (3 to
4cm) long and ¾ inch to 1 1/8 inch or 2 to
3 cm wide
➔ Formed by joining of the four sutures. (2
frontal bones and 2 parietal bones)
➔ Closes on about 12 to 18 months
MODULE 2F: OBSTETRIC ANATOMY
- Posterior Fontanel
➔ Triangular shaped
➔ Formed by the junction of 3 suture lines
(sagittal suture anteriorly and lambdoidal
suture on either side)
➔ Located at the juncture of occipital and
parietal bones
➔ Measures about 0.5 to 1 cm across
➔ Closes on about 8 to 13 weeks
➔ Is membranous but becomes bony at
term, thus truly its nomenclature as
fontanel is misnomer, it denotes the
position of the head in relation to the
maternal pelvis
Diameters of the Fetal Skull
Biparietal Diameter (9.25cm)
- Smallest diameter of the fetal skull
- Also called as “transverse diameter”
- When we say biparietal = 2 parietal are the
bones that are involved in the measurement
- Measure 9.25cm and it extends between 2
parietal bones or eminences
- Whatever may be the position of the head,
this diameter nearly always engages
Suboccipitobregmatic Diameter (9.5cm)
- Smallest anteroposterior diameter
- Measured from the inferior aspect of the
occiput to center of the anterior fontanelle
- Bregma – forehead
- Occipito – occiput
- Measure up to down
YUSON, DREA
NCM 107: Care of Mother, Child, Adolescent (Well-Client)
Occipitomental Diameter (13.5cm)
- Widest anteroposterior diameter
- Measured from the posterior fontanelle to the
chin
- This diameter is usually what we are going to
see if the fetus or the baby is in full flexion
meaning good flexion
➔ Because the chin of the baby will touch
the chest
➔ What we are going to see is the
occipitomental or vertex part
Poor Flexion results to:
Factors of Unusual Fetal Position:
Degree of Flexion
- The degree of flexion is very important during
the labor and delivery because this is where
we can determine that the baby is or will pass
the line passage or the maternal pelvis in
good condition
Full Flexion
- Fetal head flexes so sharply
- The chin rest on the chest
- Smallest anteroposterior diameter and
suboccipitobregmatic diameter is present
in the birth canal
- Type of Cephalic Presentation: Vertex
➔ Most reliable presentation during
childbirth
MODULE 2F: OBSTETRIC ANATOMY
Moderate Flexion
- Occipitofrontal Diameter presents in the
birth canal
- One who presents during the birth that
refers to either the brow
Poor Flexion
- When the head is hyperextended
- Largest diameter
- Occipitomental Diameter presents in the
birth canal
➢ Small mother
➢ The position of the baby is not very
accurate during the delivery, so the baby
would have a malposition which results to
poor flexion
➢ Small uterus
➔ The baby would curl up
➢ Malformed fetus
➢ Uterine fibroids
➢ Multiple fetus or gestation
➔ Example: The twin A is in a good
position, and we can deliver the twin A
or the first baby successfully. During
that time na nabilin si twin B and will
suddenly malposition, this is the time
we can deliver it either cesarean
➔ We can have a normal delivery and
after that CS.
➔ We can also have both vaginally if both
the mother has a good pelvis
measurement and the baby’s position
is in good position or full flexion. (Both
baby)
➢ Large fetus
➢ Unusual placental site
➔ Example: If the baby has really a bad
position, the placenta could dislodge,
implant, block, etc…
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NCM 107: Care of Mother, Child, Adolescent (Well-Client)
➢ When the baby is really large, and the
mother’s pelvis is really small which could
lead to cesarean delivery because we
cannot deliver the baby through normal
spontaneous or NSVD
Fetal Attitude
- Describes the degree of flexion a fetus
assumes during labor and delivery or the
relation of the fetal parts to each other.
- Review: During delivery, it is in relation of the
fetal parts

Molding
• Normal
• Overlapping of the skull bones along the
suture lines
• Changes in shape of the fetal skull to long
and narrow shape that facilitates passage
through the rigid pelvis
• Molding is also the alteration of the shape
of the fore coming head while passing
through the resistant birth passage during
the labor
➔ There is however very little alteration in Complete Flexion or Full Flexion in other books =
size of the head as a volume of the Vertex Presentation
content inside the skull is
Moderate Flexion = Military Presentation
incompressible, although small
amount of cerebrospinal fluid and • Ang bregma ang makita
blood can escape in the process
• During a normal delivery, usually an Poor Flexion (Extension) = Brow Presentation
alteration of 4 mm in the skull diameter
commonly occurs Full Extension = Face Presentation
• Only last a day or two Complete Flexion
• It is normal during delivery that mugawas • Good Attitude
ang tae because as the baby go outside, • The usual “fetal position” or the ideal one
the baby would compress the surrounding • Advantageous for birth because it helps
tissue or the soft tissue that is why it is also fetus presents the smallest anteroposterior
affected, and the baby would compress
diameter of the skull
the sigmoid colon. That is why the mother
• Occupies the smallest place possible
would poop during the delivery.
Example:
Molding results into that kind of shape kay sige ug Moderate Flexion
push ug balik ang mother. • Chin is not touching the chest anymore
• “Military Position or Military Presentation”

Partial Extension
• Poor flexion
• It presents the brow of the head to the birth
canal
• “Brow Presentation”

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NCM 107: Care of Mother, Child, Adolescent (Well-Client)
Complete Extension
• Full extension
• Unusual position
• It occurs when there is less or minimal
amount of amniotic fluid
(oligohydroamnios or oligohydramnios)
• The presentation is either the face or the
chin
Fetal Lie
- The relationship between the long
(cephalocaudal) axis of the fetal body to the
long axis of a woman’s body
Longitudinal Lie
- Classified as cephalic or breech
- Occur 96% of pregnancies
- Longitudinal lie could either be the head is
below or the head is above
- Cephalic Presentation
➔ When the head is below
- Breech Presentation
➔ When the head is above
Transverse Lie
- Shoulder presentation
- When the lie is perpendicular to the mother’s
axis
- When the long axis of the mother is
perpendicular to the fetus
MODULE 2F: OBSTETRIC ANATOMY
Fetal Presentations
- The fetal body part that will be first to pass
through the cervix and be delivered
- Determined by the fetal attitude, lie and
position
- Affects the duration and the difficulty of labor
- Affects the method of delivery
- Most affected part
Caput Succedaneum
- Cap goes across the suture lines
- Boggy edematous swelling of the fetal scalp
- It usually disappears without treatment
- No pathological significance
- Swelling and edema of the fetal scalp
Ayaw pag libog sa molding and caput succedaneum:
- Molding = when the fetal bones that are
overlapping
- Caput Succedaneum = edema part of the
head or swelling
Subgaleal Hemorrhage
- This involves bleeding in the specific portion
of the head of the baby which is the
subgaleal space
- Bleeding in the subgaleal space
Cephalohematoma
- This involves the bleeding in the periosteum
Cephalic Presentation
- Head presents first
- Most common type of presentation:
Types of Cephalic Presentation:
1. Vertex
2. Brow
3. Face
➔ Poor Flexion
4. Mentum (Chin)
➔ Complete Extension
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NCM 107: Care of Mother, Child, Adolescent (Well-Client)
Breech Presentation Complete Breech
- Buttocks or feet presents first Lie: Longitudinal or vertical
- The presenting part for a breech presentation Presentation: Breech (sacrum and feet
is the sacrum presenting)
Presenting Part: Sacrum (with feet)
Types of Breech Presentation: Attitude: General Flexion
1. Complete
2. Frank Shoulder Presentation
3. Footling Lie: Transverse or horizontal
a. Could be Single Leg Presentation: Shoulder. Could also be the elbow
b. Could be Double Leg or the knees
Presenting Part: Scapula or the angel wings in the
bones
Attitude: Flexion

- Presenting part is the shoulder, iliac crest,

hand and elbow, fetus is lying horizontally
in the pelvis
- The mother is vertical while the baby is
horizontal
➔ This is called perpendicular
Causes:
- Relaxation of the abdominal walls
- Pelvic contraction
- Placenta previa
- Polyhydroamnios or Polyhydramnios
➔ There are a lot of fluid that is made up
in the abdominal wall of the mother and
it could lead into a lot of turning of the
baby

Frank Breech
Lie: Longitudinal or vertical
Presentation: Breech (incomplete)
Presenting Part: Sacrum
Attitude: Flexion, except for legs at knees

Single Footling Breech

Lie: Longitudinal or vertical
Presentation: Breech (incomplete)
Presenting Part: Sacrum
Attitude: Flexion, except for one leg extended at
hip and knee

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NCM 107: Care of Mother, Child, Adolescent (Well-Client)
Fetal Position Four (4) Landmarks to Describe the Presenting
- Relationship of the presenting part to the Part to One of the Pelvic Quadrants:
specific quadrant or part and side of a 1. Vertex – Occiput
woman’s pelvis 2. Face – Chin (Mentum)
- Maternal pelvis is divided into 4 3. Breech – Sacrum
quadrants: 4. Shoulder – Acromion Process
1. Right Posterior
2. Left Posterior
3. Right Anterior
4. Left Anterior

-
LOA
- Most common fetal position
ROA
Four parts of the fetus are also chosen as - Second most common fetal position
landmarks: • Fetus born fastest on either position
1. Right occipitoposterior (ROP)
➔ Right part of the maternal pelvis
➔ Occiput for the fetus
➔ Posterior for the maternal pelvis
2. Left occipitoposterior (LOP)
➔ Left part for the maternal pelvis
➔ Occiput for the fetus
➔ Posterior part of the pelvis
3. Right occipitoanterior (ROA)
➔ Right side of the maternal pelvis
➔ Occiput for the fetus
➔ Anterior portion of the maternal pelvis or
quadrant
4. Left occipitoanterior (LOA)
➔ Left side of the maternal pelvis
➔ Occiput for the fetus
➔ Anterior portion of the maternal pelvis or
quadrant

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NCM 107: Care of Mother, Child, Adolescent (Well-Client)
Engagement 7 Cardinal Movements
- Refers to the settling of the presenting part Acronym: EDFIREERE (to easily memorize)
of the fetus far enough into the pelvis that it
E – Engagement
rests to the level of the ischial spine,
midpoint of the pelvis. D – Descent
F – Flexion
I – Internal
R – Rotation
E – Extension
E – External
R – Rotation
E – Expulsion
The degree of engagement is established by a
vaginal examination:

• Floating
➔ Presenting part is not engaged
• Dipping
➔ Descending but not yet touched the
ischial spine
➔ Nagka anam anam ug ka us us ang ulo
sa baby

Station
- Refers to the relationship of the presenting
part of the fetus to level of the ischial spine

Power
- Refers to the extent of push that the mother
will exert during the delivery
- Third important requirement for successful
labor
- This is very important as it is the force that is
supplied by the fundus of the uterus and
implemented by uterine contractions, which
causes cervical dilatation and expulsion of
the fetus from the uterus
- As the mother felt the contraction, that is the
time that she is going to push.
- What will if dili pa contracted ang abdomen
unya mupush siya?
➔ It could result to laceration
 Magisi kay magpataka ug utong
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NCM 107: Care of Mother, Child, Adolescent (Well-Client)
Uterine Contractions Psyche
- There are True Labor and False Labor - A woman’s psychological state which may or
inhibit labor
True Labor - It can be based on past experience as well
• Contractions are: as her present psychological state
➔ Regular
➔ Increase in intensity and duration with There are a lot of women nowadays, the
walking psychological problems increased after giving birth.
➔ Felt in lower back, radiating to lower Taas ang postpartum depression because it started
portion of abdomen in postpartum blues leads to postpartum psychosis
• Bloody Show and leads to postpartum depression.
• Dilatation and Effacement
• Fetus usually engaged - As a nurse, you need to orient, educate, and
give awareness especially to first time
mothers, single mothers, and for those
False Labor mothers who are not financially capable of
• Contractions are irregular having a kid, and also to multigravid.
• Often stop with walking (mawala ra diay
siya)
• Contractions felt in abdomen above
umbilicus (abdominal pain)
➔ But does not radiate in the back or vice
versa
• No change in cervix
• Fetus is ballotable

Leopold’s Maneuver
- Systematic method of palpation to determine
the fetal presentation and position
- Done as a part of physical examination
L1: Fundal Grip
- Findings: Fundal height and Fundal Content
L2: Umbilical Grip
- Findings: Fetal Back, Fetal Small Parts, and
Fetal Heart Tone
L3: Pawlick’s Grip or Pawlik’s Grip
- Determine if Cephalic or Breech
L4: Pelvic Grip
- Engaged or Floating

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NCM 107: Care of Mother, Child, Adolescent (Well-Client)
DEFINITION OF TERMS
1. Labor
- A series of events by which uterine contraction
and abdominal pressure expel a fetus and
placenta from the uterus
- Begins within 37–42 weeks
➔ Considered the term age of pregnancy
- Primipara: 14–16 hours
- Multipara: 6–8 hours
However, this could be longer. Recently, research
suggests that this could be longer.
2. Episiotomy
- A surgical incision made at the opening of the
vagina during childbirth to aid a difficult delivery
and prevent rupture of tissues
- 2 kinds of Episiotomy:
A. Midline – lesser chance of bleeding, less
painful
B. Mediolateral – less risk of greater
laceration
- Allows the accommodation of the fetal head
- In the perineum, as the mother is delivering her
child, if the doctor sees that the fetal head
needs some assistance in being delivered, the
doctor or obstetrician may opt to make a small
cut at the perineal area
- In order to facilitate the delivery of the fetus
and at the same time prevent further injury
- One of the duties of a student nurse is to
support the perineum using the hands and a
towel so that as the mother delivers the child,
the perineal incision or the episiotomy won’t
tear all the way down.
➔ Support the perineal area in order to
prevent that from further lacerating
- Each kind of episiotomy have their pros and
cons but in the end, it will be the obstetrician
who will decide which one is the more
appropriate incision for the mother.
MODULE 3F: INTRA-NATAL CARE
3. Duration
- Length of a uterine contraction
- How long a contraction lasts
4. Intensity
- Strength of a uterine contraction
5. Frequency
- Measured from the beginning of one
contraction to the beginning of the next
- As labor increases, the frequency also increases
6. Increment
- Building-up phase of the contraction
7. Acrement
- Peak of the contraction
8. Decrement
- Letting down phase of the contraction
Interval
- Space between two contractions
The Augmentation of Labor and Induction of Labor
procedures help initiate or at least strengthen labor.
9. Augmentation of Labor
- Assisting labor that has spontaneously started
but is not effective or strong enough
- As the mother approaches true labor, there
may be times wherein her labor contractions
are not strong enough or not effective enough
and that could cause her to be prolonged in a
certain stage
- In order to enhance that labor, the obstetrician
can administer oxytocin through IV fluids
- Other way to augment the labor is through
amniotomy
➔ Artificial rupture of membranes during
labor
➔ The mother would experience bursting of
the bag of waters. Sometimes, it doesn’t
happen spontaneously during labor so the
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NCM 107: Care of Mother, Child, Adolescent (Well-Client)
doctor can actually induce that using
forceps in order to rupture the bag of
waters so that labor can be triggered
10. Induction of Labor
- Applicable when the mother is already of term
age. Around 37-40 weeks of gestation but has
not yet initiated labor yet. The mother has not
felt any contractions.
- Labor started artificially
- It can be inducted through oxytocin or
amniotomy as well. But amniotomy is the most
common.
- Labor that is started by the obstetrician rather
than the mother’s body itself
11. Dysfunctional Labor
- Prolonged labor due to the sluggishness of
contractions
- Indication of augmentation of labor
12. Eutocia
- Normal labor
13. Dystocia
- Difficult labor
14. Amniotomy
- Artificial rupture of membranes during labor
15. Trial of Labor
- Full acronym is TOLAC (Trial of Labor after
Cesarean Delivery)
- An attempt labor to determine whether labor
will progress normally especially for women
who have experienced cesarean section
- For women post-cesarean section
- Ideally, if the mother has experienced cesarean
section in her previous delivery, she would
ideally still be in cesarean section in the
following delivery
- The mother would need to undergo cesarean
delivery due to various reasons and one of that
is the shape of her pelvis is not wide enough or
not conducive enough for labor and delivery
MODULE 3F: INTRA-NATAL CARE
➔ In that case if that is the reason why she
requires CS, there is a chance that in her
following delivery, she would still need to
undergo CS
➔ But there are also some mothers whose
reason may not be the shape of the pelvis
but other reasons and maybe this mother
would want to try vaginal birth instead. So,
instead of going to vaginal birth directly, the
mother would still have to undergo through
trial of labor wherein the obstetrician will
observe and assess if the mother is ready
for a normal spontaneous vaginal delivery.
THEORIES OF LABOR
Progesterone levels will decrease slightly during the
later weeks of pregnancy especially as the mother
approaches labor and delivery.
- This is actually due to various factors and one of
the theorized factors is actually due to the
increase of estrogen and also the increase in
prostaglandins.
How Does Labor Start?
LABOR
- Series of events by which uterine contractions
and abdominal pressure expel a fetus and
placenta from uterus
- Normally begins between 37 and 42 weeks of
pregnancy
Many factors known to be responsible for the initiation
of spontaneous labor:
1. Uterine muscle stretching resulting in release of
prostaglandins
• As the fetus continues to grow, it also
continues to expand the uterus
• One of the theories in labor that is the
uterus expands to a certain size, the body
recognizes it as the fetus being ready to be
delivered therefore resulting in the release
of prostaglandins in the uterine area
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NCM 107: Care of Mother, Child, Adolescent (Well-Client)
2. Cervical pressure
• Fetus pressing on the cervix stimulates the
release of oxytocin from the posterior
pituitary gland
• As the fetus becomes bigger, the fetal head
presses into the cervix so the fetus pressing
the cervix can stimulate the release of
oxytocin from the posterior pituitary gland
• Oxytocin is also known as labor hormone
Oxytocin stimulation + Prostaglandins
- Oxytocin stimulation works together with
prostaglandins to initiate contractions
- Together, they are very much observed during
the initiation of true labor or labor itself
3. Estrogen – Progesterone Ratio
• Progesterone withdrawal: Increasing
estrogen in relation to progesterone can
trigger or initiate labor
• Throughout pregnancy, we have there a
stable ratio or sustained level of estrogen
and progesterone, particularly
progesterone. It’s actually the high levels of
progesterone that prevents the initiation of
uterine contractions.
• Near the end of the pregnancy, what
happens is progesterone, the pregnancy
hormone, decreases. In this case, there is an
increasing level of estrogen and that these
two have an inverse relationship.
• As the estrogen increases, especially due to
the secretion of prostaglandins,
progesterone will reduce or decrease. Or
rather the prostaglandins will overpower
the effects of progesterone, therefore
leading to labor and delivery.
4. Placental Degeneration
• Placenta is thought to have a set age
• So, if the placenta reaches around 37 to 40
weeks of age, the placenta starts to
degenerate because it has reached the peak
of maturity and therefore could lead to
labor and delivery
MODULE 3F: INTRA-NATAL CARE
5. Rising Fetal Cortisol Levels
• Reduction of progesterone and increase in
prostaglandins
• In the fetal area or the fetal side of the
pregnancy, the fetus will experience
secretion of rising fetal cortisol levels
• The fetal cortisol levels can stimulate the
increase of prostaglandins in the mother
which will also inhibit or reduce
progesterone
6. Fetal Membrane prostaglandin production
• The fetal membrane also continues to
secrete prostaglandins leading to labor and
delivery
PREPARATION FOR LABOR
- Where we observe the signs and symptoms of a
mother who is about to go through labor and
delivery
Preliminary Signs of Labor
- Subtle signs or symptoms
- Days or hours before labor begins.
- NOTE: These signs don’t occur on the same day
during delivery. They could occur as early as
days away from the labor
- It is important that you, especially when you are
conducting your health teaching, it’s important
to inform the mother of these signs, especially
the first-time mother so that they will not panic
and instead, they will have a better experience
in preparing themselves for the upcoming labor
and delivery
1. Lightening
- Sinking of fetal head into the true pelvis
- Changes in abdominal contours (“Decreasing”
fundal height)
- Causes relief from diaphragmatic pressure
➔ Encourage deep breathing exercises for the
mother in preparation for the labor and
delivery
- There’s a chance if you take your Leopold’s
maneuver again, you might notice a decrease in
the fundal height. So, do not panic if you
observe that.
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NCM 107: Care of Mother, Child, Adolescent (Well-Client)
➔ That just means that the baby is sinking into
the true pelvis or descended
➔ Because of this, there is lesser pressure in
the lungs and also in the abdominal area
- At the same time, the relief from the
diaphragmatic pressure and also from the
abdomen, this may cause feelings of nausea. So,
be mindful of that. At least you could explain it
to the mother
Primiparas: Approximately 10-14 days before labor
Multiparas: On the day of labor/after the beginning
of true labor
2. Slight weight loss
- 1-3 lbs.
➔ Due to the decreasing levels of
progesterone which leads to increased fluid
excretion, one of the effects of decreasing
progesterone, which then leads to
increased urine production
- Not the loss of fat but rather the loss of fluid
- Progesterone level decreases
- Increased fluid excretion
- Increased urine production
MODULE 3F: INTRA-NATAL CARE
3. Excess energy
- Burst of adrenaline to provide energy for labor
- The mother’s body actually recognizes that the
mother’s about to go and give birth. So, the
body also prepares by supplementing the
mother with a burst of adrenaline especially
during delivery to provide energy for labor
4. Backache
- One of the most common complaints of
mothers who are experiencing labor and
delivery
- Onset of true labor contractions
- Intermittent, stronger than usual backache
- Labor contractions begin in the back
- Why backache?
➔ There’s the pressure because of the weight
distribution and also more significantly is
the location of your uterus
➔ In anatomy and physiology, the location of
your uterus is retroperitoneal. So, the pain
is actually strongest at the back and then it
sweeps throughout the abdomen.
- When a nurse or a student nurse is assigned to
perform labor watch, what you can do is to
provide back rubs.
➔ Not too deep pressure just back rubs in
order to relieve the pressure and also
provide for relief from pain
5. Cervical Ripening
- Cervix feels very soft upon palpation during
internal examination
➔ In internal examination, what happens is
the obstetrician will be inserting 2 of her
fingers into the birth canal to both assess
the cervical dilation and also the
effacement
➔ The mother will be placed in a lithotomy
position
- “Butter soft” (usual assessment finding)
- Goodell’s sign – earlobe consistency of cervix
throughout pregnancy
- Marks the beginning of true labor
- Refers to the steady thinning of the cervix
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NCM 107: Care of Mother, Child, Adolescent (Well-Client)
waters has already been ruptured, amniotic
fluid still continues to be produced until
delivery.
➔ At least there’s still some fluid that is
buffering the baby and also ensuring that
the baby will be delivered properly

6. Rupture of Membranes

- Sudden gush or scanty, slow seeping of clear

fluid from the vagina
- Early rupture of membranes helps fetal head
descent and engagement (engaged into the true
pelvis)
➔ Therefore, the rupture of the bag of waters
could lead to enhanced cervical dilation and
labor progression
- Amniotic fluid continues to be produced until 7. Show
delivery of the membranes after the birth of the
- Internal cervical mucus plug has been released
child
- “Bloody Show” – blood from cervical capillaries
- Risks to need to watch out for
mixed with mucus plug
➔ Intrauterine Infection – labor does not
- As the mother approaches true labor, her cervix
before spontaneously by 24h
will get rid of the mucus plug.
◼ You need to observe for maternal or
- The picture is what she may find in her pads.
intrauterine infection
Sometimes it may be bloody
➔ Umbilical Cord prolapse
- Assure the mother that this is a normal finding
◼ What happens is the umbilical cord of
because as the cervical mucus plug detaches
the baby may be pushed downwards
from the cervix, some of the capillaries of the
and instead of the presenting head, that
cervix will also rupture and will induce a slight
is really directly presenting into the
bleeding. The blood from these capillaries may
cervix, you might find there an umbilical
be mixed with the mucus plug. Therefore,
cord.
leading to a bloody show.
◼ This is very dangerous for the baby.
◼ You need to watch out for this as well.
- Amniotic fluid is colloquially known as bag of
water.
- In movies, the pregnant mothers would say,
“my water broke”
➔ This is actually the rupture of the bag of
water
- Maybe, you may encounter some mothers who
may be concerned especially if they early
rupture of membranes. They may be concerned
if the delivery is “dry”. 8. Uterine Contractions
➔ One health teaching to give them is that it’s
not possible because even if the bag of - Braxton Hicks

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NCM 107: Care of Mother, Child, Adolescent (Well-Client)
➔ Known as the trial contractions
➔ Can start Last week or days before labor
begins
➔ May be extremely strong for the mother
(but the frequency varies or there is no
change in strength)
➔ Localized mostly in the abdomen
◼ It does not radiate from the back or
towards the legs
➔ Triggered due to decreasing progesterone
levels
➔ Primigravid mothers may not be able to
distinguish between Braxton Hicks and true
contractions
◼ Assure them and also give them
adequate health teaching
➔ You know that this is not yet true labor
because the contractions is relieved by rest,
activity, or repositioning
- True Labor
➔ Begin at the back and sweeps forward
across abdomen and possibly legs
➔ Gradually increases in frequency and
intensity
➔ Painful, wavelike, building and receding
➔ Not relieved by rest
◼ It constantly increases
➔ Uterus becomes hard on palpation,
indentation with fingers is not possible
◼ When you try to palpate the fundus, it
is hard and indentation cannot be done
3 Main Signs:
- Rupture of membranes
- Show or the bloody show
- Uterine contractions
COMPONENTS OF THE BIRTHING PROCESS
Successful labor depends on the 4 concepts or
components: passage, passenger, powers, and psyche
- A problem in one of these can significantly
impact the progression of labor
- Why do we need to review this again and again?
MODULE 3F: INTRA-NATAL CARE
➔ Because knowing this will help us create the
nursing care plan of a mother who is
undergoing labor and delivery
➔ It is really important not to just focus on the
physiologic aspects but also focus on the
psyche of the mother, assist her as she
experiences her uterine contractions, etc…
➔ All of these components has to be good in
order to ensure both the survival of the
mother and the baby
PASSAGE
- Mother’s pelvis
- Route a fetus must travel from the uterus
through the cervix
- Fetopelvic disproportion – commonly caused
by the insufficient pelvic structure
➔ One problem involving this factor
➔ In some examinations, the fetal head may
be a bit too big for the pelvis
➔ If that’s the case, it is really not the fetal
head that is too big but rather the uterus is
not really conducive for labor and delivery
- Shape of Pelvis
• Gynecoid (maternal pelvis)
• Android
• Anthropoid
• Platypelloid
PASSENGER
- Refers to the fetus and its ability to move
through the passage
- Affected by the following fetal features
• Fetal skull
• Fetal Presentation (Cephalic)
• Fetal Lie (Longitudinal)
• Fetal Attitude
• Fetal Position
• Fetal Station
POWER or POWERS
- Uterine contractions
- Phases
• Increment – building up phase (longest)
• Acrement or Acme – peak of contraction
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NCM 107: Care of Mother, Child, Adolescent (Well-Client)
• Decrement – letting down phase ◼ Can also contribute to the knowledge of
- Characteristics the mother
• Duration • Past experiences
◼ Beginning of increment to end of • Accomplishment of pregnancy tasks
decrement • Feeling of control over situation
◼ Early labor: 30 seconds
◼ Late labor: 60-90 seconds
• Frequency STAGES OF LABOR
◼ Beginning of one contraction to the
FIRST STAGE OF LABOR
beginning of the next
- From onset of true labor contractions until full
◼ Early labor: 5-30 mins apart
cervical dilation
◼ Late labor: 2-3 mins apart or even lesser
- Average – 12 hours
• Intensity
• Primipara: 6-18 hours
◼ Measured through palpation itself or
• Multipara: 2-10 hours
through insertion of intrauterine
- Recent research suggests that normal labor can
catheter
take longer

PSYCHE
- Maternal psychological state
- Feelings that the mother brings to the labor
- Apprehension, fear, wonder, excitement
- Factors affecting psychological readiness
• Presences of support system
◼ Very crucial according to studies.
◼ The mother is able to undergo effective
delivery with the presence of her
partner or support system
◼ In the local setting, our institutions
don’t allow the partner to be physically
there for the mother. So, in lieu of the
partner, we, nurses, get to be their
support system
◼ We need to keep the family and the
partner updated
• Degree of preparation from the mother’s
side
• Childbirth education classes
MODULE 3F: INTRA-NATAL CARE
Three Phases:
1. Latent Phase
- Begins at onset of regularly perceived uterine
contractions
- Ends when rapid cervical dilatation begins
- Cervical dilation: 0-3 cm
- Mild and short contractions
• 20-40 seconds
• May be irregular Longer for women with
“nonripe” cervix
- Primipara: around 6 hours
- Multipara: 4 ½ hours
Nursing Care:
Pain Management
❖ Analgesia may be given but if given too early, it
may prolong the stage
❖ Assist mother to prepare psychologically
❖ Teach controlled and deep breathing exercises
❖ Encourage activity, ambulation, and other non –
pharmacotherapeutic measures
❖ Offer clear liquids or ice chips Involve partner,
family, or support person
❖ Provide calm environment
Psychological Maternal Responses
- Anticipation
- Excitement
- Apprehension
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NCM 107: Care of Mother, Child, Adolescent (Well-Client)
2. Active Phase
- More rapid cervical dilatation (4-7 cm)
- Uncomfortable phase for the mother
- Stronger contractions (40-60 seconds every 3-5
minutes)
- Bloody show and spontaneous rupture of
membranes may occur
- Primipara: around 3 hours
- Multipara: around 2 hours
Nursing Care
❖ Frequent perineal care
❖ Encourage mothers to keep active and assume
most comfortable position except flat on back
❖ Pain management
❖ Anticipate mood swings and difficulty in coping
(offer support)
❖ Continue to involve family and partner
❖ Positioning
• Upright
• Left side lying
3. Transition Phase
- Cervical Dilatation (8-10 cm)
- Contractions reach peak of intensity
- Longer contractions (60-70 seconds every 2-3
minutes)
- Full cervical dilatation and effacement
- ROM may occur at full cervical dilation
- Strong urge to push
Nursing Care:
❖ Mothers may experience intense discomfort,
nausea and vomiting, feeling of loss of control,
anxiety, panic, or irritability
❖ Help direct maternal focus to birthing of baby
❖ Provide support
❖ Stay with the mother at all times
SECOND STAGE OF LABOR
- Complete cervical dilatation to delivery of the
neonate
- Lasts 2-60 minutes Primipara: 40 mins average
- Multipara: 20 mins average
- Fetus moved along the birth canal by the
mechanisms of labor
Psychological Maternal Responses:
- Focus from discomfort to active pushing
MODULE 3F: INTRA-NATAL CARE
- Exhaustion
Nursing Care:
❖ Assist with second stage pushing
❖ Prepare birthing area
❖ Assist mother in birthing position
❖ Be ready to assist in episiotomy
❖ Prepare for and assist with delivery
Mother may feel:
- Uncontrollable urge to push
- Nausea and vomiting (due to decrease in
abdominal pressure)
Cardinal Movements of Labor
1. Fetal Engagement, Descent, and Flexions
2. Internal Rotation
- Of the fetal head at the internal perineum
- Aligns fetal head in the most optimum position
for descent (widest part at widest inlet area)
- Perineum may appear bulging and tense
- Anus may be everted; stool may be expelled
- Crowning – fetal scalp visible at the opening of
the vagina
3. Extension
- Delivery of the head
- Compression of presenting parts
4. External Rotation
- Head rotates to being the anterior shoulders
into the best line with the pelvis
- Slight upward flexion needed to deliver
posterior shoulder
- Watch for: Shoulder dystocia in macrosomic
babies
5. Expulsion of the baby
- The baby is considered born once the entire
body is already delivered and exposed to the
extrauterine life
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NCM 107: Care of Mother, Child, Adolescent (Well-Client)
THIRD STAGE OF LABOR Fourth Degree Entire perineum, rectal sphincter,
- Begins with the birth of the infant and ends and some of the mucous
with the delivery of the placenta (1-30 mins) membrane of the rectum

Two Phases:
1. Placental Separation
- Placenta detaches from the uterine wall
Signs:
➢ Lengthening of the umbilical cord
➢ Sudden gush of vaginal blood
➢ Placenta is visible at the vaginal opening
➢ Uterus contracts and feels firm
➢ Presentations: Schultze and Duncan

2. Placental Expulsion
- Placenta is delivered through natural bearing
FOURTH STAGE OF LABOR
down or gentle pressure on the contracted
- Time immediately after placental delivery
uterine fundus (Crede’s Maneuver)
- First hour after delivery (recovery period)
- No pressure on noncontracted uterus – can
cause uterine eversion and massive hemorrhage - Beginning of the postpartum period
- Excessive hemorrhage with poor contraction – - Postpartum period: 6 weeks
administer Hemabate or Methergine (Check BP - High risk for hemorrhage
before administration)
Psychological Maternal Responses:
- Note time of placental delivery
- Inspect intactness of placenta - Attention towards neonate
- Inspect for placental remains (leads to - Adjusting to maternal role
uncontracted uterus and bleeding)
Psychological Maternal Responses: Nursing Care:
- Concern for neonate’s condition
❖ Primary activity is stabilizing the status of the
- Discomfort from uterine contractions before
placental expulsion neonate and helping neonate get acclimated to
Nursing Care: extrauterine life
❖ Assist with the delivery of the placenta ❖ Focus on maternal-neonatal bonding
❖ Assist with episiorrhaphy ❖ Obtain vital signs every 15 mins for the first
❖ Administer oxytocin as ordered (IV) hour
❖ Introduce neonate to the parents and allow ❖ Assess lochia, consistency and position of the
breastfeeding fundus, episiotomy site
❖ Be prepared to initiate emergency procedures if
mother’s or child’s condition do not stabilize
Classification of Perineal Lacerations
Classification Description of Involvement
First Degree Vaginal mucous membrane and skin
of the perineum to the fourchette
Second Degree Vagina, perineal skin, fascia, levator
ani muscle, and perineal body
Third Degree Entire perineum, extending to reach
the external sphincter of the
rectum

MODULE 3F: INTRA-NATAL CARE YUSON, DREA

NCM 107: Care of Mother, Child, Adolescent (Well-Client)
DEFINITION OF TERMS
1. Operative Obstetrics
- Uses procedures that assist the mother in labor
and delivery
- It may be mechanical or chemical procedures to
save life of both the mother or fetus
➔ Mechanical – with the use of stainless
instruments or the vacuum extraction
➔ Chemical Procedures – with the use of
medications
- It also facilitates the process of labor
2. Induction of Labor
- Labor is started artificially
- With this, the doctor will be requiring for
administration of medicines that would help in
choosing the labor of the mother
3. Amniotomy
- Artificial rupturing of membranes during labor if
they do not rupture spontaneously to allow the
fetal head to contact the cervix more directly
- This also increases the speed of labor and
utilizes at least 2 types of instruments:
1. Amniohook – long thin crochet-like
instrument
2. Hemostat
4. Analgesia
- Medications that alleviates the sensation of
pain
- When we say, alleviates the sensation of pain, it
would be a reduction of the pain, yet the pain is
still there
5. Anesthesia
- An absence of sensation or pain sensation by
interrupting the nerve impulse
- In anesthesia, there is a total absence of pain
MODULE 4F: OPERATIVE OBSTETRICS
6. Cesarean Delivery
- Or birth accomplished through an abdominal
incision in the uterus
- In the picture, we have here the abdominal
incision through horizontal incision or your low
segment type of cesarean delivery
7. Normal Delivery
- Is otherwise known as NSVD
- Normal Spontaneous Vaginal Delivery
8. Forceps Delivery
- A method of delivery with the use of obstetrical
forceps
- The obstetrical forceps being utilized in here are
made of stainless steel and they had been
sterilized
9. Vacuum Extraction Delivery
- Uses a vacuum device to assist in extracting a
baby
We must know that both vacuum extraction and forceps
are methods that can be used to assist the birth of the
baby especially the fetal head. The woman as well as
the infant needs special or specific observation after
these procedures to detect head trauma or cervical or
vaginal tearing
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NCM 107: Care of Mother, Child, Adolescent (Well-Client)
- In the picture, there will be an insertion of those
instruments inside the vagina of the mother to
facilitate the delivery of the head of the baby
- So, it is very much needed that right after the
delivery, one must assess for the head trauma
of the baby and as well as the cervical or vaginal
tearing of the mother
10. Amniotomy
- Increases the efficiency of contraction and
therefore increases the speed of labor
- However, it puts a fetus momentarily at risk for
cord prolapse if a loop of cord escapes into the
vagina with the fluid
- It is also a risk for possible cesarean section
- Amniotomy itself increases the speed of labor
- Now, in amniotomy, the mother who is in labor
still has her membrane intact and so, if there
will be a prolonged intact of the membrane
then there is a possibility that the labor itself is
slower on its base.
- So, with amniotomy, there will be an increase of
labor by rupturing the amniotic membrane and
so there will be an escape of the amniotic fluid.
This puts the fetus momentarily at risk for cord
prolapse especially if the fetal cord is within the
presenting part of the baby.
➔ If there will be a cord prolapse or if the cord
escapes to the vagina, you have to
immediately cover the exposed cord with
sterile saline compress to the presenting
part.
➔ You must not attempt to push back the
exposed cord to the vagina because this
would add additional risk or compression
MODULE 4F: OPERATIVE OBSTETRICS
Prior to amniotomy or Before:
✓ The mother must assume a dorsal recumbent
position that would mean supine position with
knees flexed
After Amniotomy:
✓ which the mother and the baby must be
assessed.
✓ First you have to time as to when the amniotic
membrane has been ruptured followed by
assessing for the fetal heart rate.
Why is this important?
- Because we have to rule out cord prolapse.
- Now, if there will be a cord prolapse and then
core compression happens, then the supply of
oxygen to the baby will be compromised. Thus,
would put the baby at risk
➔ At the same time also, we have to time as
to when the amniotic membrane has been
ruptured so that we can observe for
possible or potential for infection
- As mentioned earlier amniotomy utilizes both
amniohook and hemostat.
DIFFERENT FACTORS OF WHICH WOMEN
AT RISK FOR OPERATIVE DELIVERY
Maternal Factors
1. Active genital herpes or (perhaps) human
papillomavirus
• If the patient is having herpes or HIV or AIDS
as much as possible it is advisable to undergo
cesarean section because genital herpes is a
communicable disease and could be
transmitted especially genital herpes.
• The baby will be coming out from the vagina
and will be exposed with this infection
2. AIDS or (perhaps) HIV-positive status
3. Cephalopelvic disproportion
• The pelvis itself is not conducive for normal
delivery
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NCM 107: Care of Mother, Child, Adolescent (Well-Client)
4. Cervical cerclage
• Cervical cerclage is when there has been a
stitching of the cervix.
• Probably the reason for this treatment that
had happened to the mother was because of
some cervical weakness
5. Disabling conditions, such as severe gestational
hypertension, that would prevent pushing to
accomplish the pelvic division of labor
• You must know that if there is an intensity of
the contraction itself then the vital signs
would go up.
• So, if the mother has a severe gestational
hypertension, this is not advisable
6. Failed induction or failure to progress in labor
7. An obstructive benign or malignant tumor
8. Previous cesarean birth by classic incision
9. Fear of birth or wish to help prevent uterine
prolapse or urinary incontinence in later years
Placental Factors
1. Placenta previa
• It is when there is attaching of the placenta
inside the uterus but is normally positioned
near or lower or over the cervical opening
2. Premature separation of the placenta
3. Umbilical cord prolapse
• This would put the child’s life or the baby’s
life at risk for possible compression of the
cord and lack of oxygen
• In order to save the baby, obstetrical
procedures has to be done
Fetal Factors
1. Compound conditions such as macrosomic fetus
in a breech lie
2. Extreme low birth weight
Fetal Distress
1. A major fetal anomaly, such as hydrocephalus
2. Multigestation or conjoined twins
3. Transverse fetal lie and perhaps breech
presentation
MODULE 4F: OPERATIVE OBSTETRICS
INDUCTION OF LABOR
- Labor is started artificially whether through
medical or surgical means of stimulating the
uterine contractions prior to onset of
spontaneous labor
- It is initiated before the time when it would
have occurred spontaneous contractions
because the fetus is endanger.
- Usually, if the mother probably has not yet
started labor but when they were assessing for
the fetal heart rate, the fetal heart rate is not
conducive anymore or not normal. So, there is a
fetal distress that is why there would be an
induction of labor.
- However, in Augmentation of Labor, this refers
to assisting labor that has started
spontaneously but is not effective
➔ The labor started itself however possible
there is a prolonged time.
➔ So, the progress that the duration of labor
for the primigravida and also for the
multigravida. Under estimation, if it is way
too more then that would still put the baby
and the mother’s life at risk. That is why
augmentation or a certain assistive like
medications has to be done so that there
will be a faster or you will be able to hasten
the progress of the labor itself
➔ Augmentation of labor is used when labor
contractions becomes weak, irregular or
ineffective
Indications for Induction of Labor
1. Pre-eclampsia
• Onset of high blood pressure and often a
significant amount of protein in the urine
• So, for those pregnant mother whose blood
pressure is way above the normal could be
one of the candidate for the induction of
labor
2. Eclampsia
3. Severe Hypertension
4. Diabetes
• Because there will be a constant
consumption of energy or glucose during the
labor itself
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NCM 107: Care of Mother, Child, Adolescent (Well-Client)
5. Rh Sensitization
• It is when there is incompatibility of Rh
between the mother and the baby
6. Prolonged ruptured of the membranes or PROM
• We have to detect this one because if there
will be a prolonged rupture of the
membranes as earlier being stated, this
would put the child’s life at risk
7. Intrauterine Growth Restrictions and Post
Maturity
• We all know the maturity or the AOG of a
fetus or a baby that is without complications
would be approximately between 36 to 40
weeks AOG
• So, with this one, the lung is already
functioning and vital to be outside the world
Contraindications for Induction of Labor
1. Complete Placenta Previa
• When there is an attachment of the placenta
near or over the cervical opening
2. Abruptio Placentae
• This happens when your placenta separates
early from the uterus before childbirth
• In this case, it is very alarming because the
baby is still inside and then your placenta
already detached.
• So, where will the baby get its nutrients and
its oxygen if the placenta will detach from the
uterine wall of the mother?
3. Transverse Fetal Lie
4. Prolapsed Umbilical Cord
5. Prior Classic Uterine Incision that entered the
uterine cavity
• Usually with the previous cesarean section
6. Pelvic structure is abnormal
• Cephalopelvic disproportion
7. Previous Myomectomy
8. Unknown cause of vaginal bleeding
• Why is this important?
➔ Because some factors wherein causes of
the bleeding could either be genetically
or you have your clotting factors that are
deficient enough so if you will do these
things, you will be inducing labor and
then the process would go on and with
the labor and delivery, there will be a
tendency that there will be a possible
MODULE 4F: OPERATIVE OBSTETRICS
bleeding, hemorrhage would happen and
this could lead a patient into shock
9. Invasive Cervical Cancer
10. Active genital herpes infection
11. Abnormal FHR (fetal heart rate) patterns
Considerations for Induction of Labor
1. Ultrasound
- We have to check the position of the baby,
the placement
2. Pelvimetry
- To rule cephalopelvic disproportion
3. Nonstress Test
- This would be checking the contraction also
both from the mother and the fetal heart
rate of the baby
4. Phosphatidylglycerol
- It is a glycophospholipid that is found in
pulmonary surfactant in the membrane
- This would help us determine if the baby is
mature enough with the lecithin and
sphingomyelin surfactant
- The lungs surfactant are normal level so the
baby is viable
5. Nitrazine Paper or Fern Test
- This would help us check if there is a
premature rupture of membrane wherein
upon testing the vaginal fluid, we detect that
there will be a change of color
- The color will be blue on the nitrazine paper.
This would indicate that the membrane has
ruptured
6. CBC and Urinalysis
- We have to know the baseline data for the
blood level of your client and possible also for
any infections either also in the urine
7. Vaginal Examination
- This would help us more to determine the
effacement and dilation of the cervix
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NCM 107: Care of Mother, Child, Adolescent (Well-Client)
Risk Factors of Induction of Labor
1. Uterine Rupture
2. Decrease in the fetal blood supply
3. From prior cotyledon filling
- Cotyledon are the ones that are found in your
placenta.
- This is a part of your embryo but are
commonly found in your placenta because
your placenta is the first organ of
development
- So, there would be a possible risk of fetal
blood supply decrease
3. Premature separation of placenta
METHODS OF INDUCTION
1. Oxytocin or Oxytocin Injection
- Oxytocin is a synthetic form of naturally
occurring pituitary hormone that can be used
to initiate labor contractions if a pregnancy is
at term
- Usually, once the mother is already admitted
and the labor has started, you have to assess
the characteristics of the contraction and also
if it is strong or not
➔ Prior to informing the doctor and for the
duration of time before the doctor would
decide and countercheck if there is a
need for an induction of labor
- It is administered intravenously
➔ Usually this is mixed with your
intravenous fluid
- The other name for oxytocin would be Pitocin
or syntocynon or syntocinon
- Solution: mixed in the proportion of 30 iu in
1000 ml of Ringers’ Lactate
➔ Ringers’ solution would be your LR
➔ You will be indicating this one in your IV
tab that there is medication being added
Indications of Oxytocin:
• Inadequate uterine contractions
• Premature rupture of the membranes
• Post term pregnancy
• Pregnancy-induced Hypertension
• Fetal Demise
➔ Fetal demise would be still birth
MODULE 4F: OPERATIVE OBSTETRICS
➔ If there will be a still birth, then a
tendency that the contraction is not that
strong enough. The mother will be having
a difficulty to push.
➔ Pain is subjective, so if the pain will be on
the abdomen or lower back then that
would help the mother to push more so
that there will be an explosion of fetus
but if there will be a fetal demise then
possible there will be no or less
contraction because there will be no
more pain
➔ That is why we have to induce the labor
Contraindications of Oxytocin:
• CPD, Cord Prolapse, Transverse Lie
• Placenta Previa
• Prior classic uterine incision
• Active genital herpes
• Invasive cancer of the cervix
Criteria to maintain dose:
a. Check the intensity of the contractions
results in intrauterine pressure of 40 to 90
mmHg
b. Duration of contractions: 40-90 seconds
c. Frequency of contractions: 2-3 minute
interval
d. Cervical dilation of 1 cm/hr. in the active
phase
REPORTABLE CONDITIONS:
• Uterine hyperstimulation
• Non reassuring fetal heart rate pattern
➔ There will be a possibility for fetal
distress
• Suspected uterine rupture
• Inadequate uterine response at 20 mU/min
Maternal and Fetal Assessment with Oxytocin
administration:
✓ Assess maternal pulse and blood pressure,
and watch for hypotension
➔ These are vital thing to assess because
this would help us determine also if there
is a possibility that our client is going for
a shock or there is a bleeding inside
✓ Monitor fetal heart rate for signs of fetal
distress
✓ Monitor the frequency, duration and
strength of contraction during the infusion
✓ Monitor the intake and output and watch for
signs of water intoxication
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NCM 107: Care of Mother, Child, Adolescent (Well-Client)
➔ Oxytocin would promote fluid retention
to the mother that is why we have to
check the intake and output and signs for
water intoxication of the mother
✓ Check for possible adverse effects like
nausea, vomiting, cardiac arrhythmias,
uterine hypertonicity, tetanic contractions,
uterine rupture and bradycardia
EMERGENCY MEASURES WHEREIN WE HAVE TO
STOP THE OXYTOCIN ADMINISTRATION DIRECTLY:
❖ Discontinue use of oxytocin per hospital
protocol
❖ Turn the mother to her left side
➔ This would promote oxygenation also for
the baby by not compressing the major
blood vessel which is the vena cava
❖ Increase primary IV rate up to 200 ml/hr
unless patient has water intoxication, in
which case, the rate is decreased to one that
keeps the vein open
➔ Usually, the primary IV is your plain NSS
and it should be without incorporation
meaning without medications
incorporated to the IV unless the patient
has water intoxicity
➔ Take note on this one because if there
will be a fluid retention, you can see that
the mother is already having breathing
problem and edema or swelling. So, you
cannot add more water or more fluid into
her body or else she will be drowning (?)
from it
➔ So, the purpose of your primary IV line
for this area is to keep vein open in cases
we need access for emergency
medications. Around 15 gtts/min or 15 to
20 gtts/min, sometimes 10 to 15 as
advised by the physician or by the doctor
❖ Give woman oxygen by face mask at 6 to 10
L/min or per protocol of the hospital or
physician’s order
➔ Some hospitals will allow you to give
oxygen to the patient at 2 L/min
regardless if there is a physician order or
not because sometimes doctors are not
always there by your side. So, they have
this standard protocol that if in cases
there are emergency and your client is
having difficulty in breathing, you can
MODULE 4F: OPERATIVE OBSTETRICS
begin with a low dose of oxygen at 2
liters
➔ By the time on, if there will be an
increase in the rate, then you have to
refer ahead of time to the attending
physician
2. Amniotomy
- Artificial rupturing of membranes
Characteristics of Amniotic Fluid:
• Odorless
• Color: clear/straw
➔ Color straw is much lighter than yellow.
Yellow is darker
➔ The color should be a bit lighter that is
light yellow or straw
• pH: 7-7.5
Advantage of Amniotomy:
 It increases the efficiency of contractions and
therefore increases the speed of labor
Disadvantage of Amniotomy:
 It puts the fetus at risk for cord prolapse
You have to know that there will be an expectation of
putting the mother into cesarean delivery
Nitrazine Test
- Identify rupture of amniotic sac
- Green to blue would mean there is a
presence of amniotic fluid
- Yellow – no presence of amniotic fluid
Klelhauer-Betke (Kleihauer-Betke)or Fetal Cell Blood
Test
- Used to determine if the blood cells are
maternal or fetal
- Maternal: remains colorless when stained
➔ There is no amniotic fluid leakage
- Fetal: turns purple pink in color when stained
Nursing Responsibilities:
✓ Explain the procedure to the client and
family
➔ This will reduce the anxiety of both the
client and the family regardless if they
are medically oriented or not
➔ This would also promote cooperation
both to the client and the family
themselves
✓ Assure the client that the procedure is
painless to her and her baby
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NCM 107: Care of Mother, Child, Adolescent
✓ Assess the fluid color, odor, and consistency
of the amniotic fluid
➔ This is to disregard if there is an infection
➔ So, again it has to be a pH of 7 to 7.5
➔ It has to be odorless and clear or straw
➔ If you find that there is a color change
you need to report that. Like blood and
things like that
✓ Note and document the time of rupture
➔ This is very important because we have
to know if the onset of the labor itself
started and to prevent at the same time
infection and distress to the baby
✓ Note and document the fetal heart rate
before and after the procedure
✓ Assess the client’s temperature every 1 to 2
hours to check for infection
✓ Frequently assess the client’s level of comfort
✓ Maintain adequate intake and output records
✓ Document maternal and fetal assessments in
the medical record
Nipple Stimulation to Induce Labor
- This helps in releasing the hormone oxytocin,
that initiates labor by increasing the intensity
of contraction
- So, this will be done by the mother, or the
health care staff
- Now you have to inform the mother ahead of
time. Some mothers are against or let's just
say would feel awkward if the staff who will
be doing this one will be a male. So, out of
respect it should be a female staff
- Nipple stimulation usually are very
observable during the pushing delivery of the
baby we do this one in the delivery room
because this would help in the contraction
Advantage:
 Shortens Labor
 Avoids the necessity of cesarean section
MODULE 4F: OPERATIVE OBSTETRICS
(Well-Client)
NORMAL SPONTANEOUS VAGINAL
DELIVERY
Episiotomy
- Surgical incision of the perineum made to
prevent tearing of the perineum
Uses:
- It uses to facilitate birth in the presence of
maternal and fetal distress
- It creates more room in the presence of
breech presentation or multiple gestation
- It creates room for the use of instruments to
assist birth
Factors that predispose a client to episiotomy:
• Primigravida
➔ First time mother
➔ Usually they are done with episiotomy
because this would prevent laceration
➔ There are four categories of laceration:
a. First degree
b. Second degree
c. Third degree
d. Fourth degree
➔ Primigravida patients or clients usually
there is a technique as to when to push
➔ The mother has to push at the peak of
the contraction and not at the beginning
of the contraction and must know when
to exert more effort and when to stop
• Macrosomic fetus
➔ The big baby
• Occiput posterior position
• Use of forceps or vacuum extractor
• Shoulder dystocia
➔ Shoulder dystocia is wherein the baby
cannot fully be out without some
interventions especially something done
with the shoulder of the baby like a
breakage on the clavicle side just to
facilitate faster delivery of the baby
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NCM 107: Care of Mother, Child, Adolescent (Well-Client)
Types of Episiotomy:
1. Midline Episiotomy
- Incision is made with blunt-tipped scissors in
the midline of the perineum
- This is less painful, it easily heals, decreases
blood loss, less postpartum discomfort
- If there would be a tendency that it will not
properly support that during the birth or
delivery of the head, then there will be a
possibility for a further laceration that would
go directly to the anus compared to your
mediolateral which is slanting position on the
side
2. Mediolateral Episiotomy
- Begun in the midline but directed laterally
away from the rectum
- Creates less danger of a rectal mucosal tear
Episiorrapphy
- The surgical repair of injury to the vulva by
suturing
- If the mother has had Episiotomy, the
surgical repair is known as your episiorrapphy
Episiotomy Degrees
1st Degree Laceration
- The area that is affected would be your
vaginal mucosa, perineal fascia and perineal
skin
nd
2 Degree Laceration
- Vaginal mucosa
- Perineal body muscle
➔ It goes a bit deeper now
- Perineal fascia
3rd Degree Laceration
- Vaginal mucosa, perineal fascia and muscles,
rectal wall, anal sphincter
4th Degree Laceration
- Vaginal mucosa
- Perineal fascia and muscles
- Rectal wall
- Anal sphincter
- This will be stitched with the different
sutures that are available and corresponding
sutures between your absorbable and non-
absorbable sutures
MODULE 4F: OPERATIVE OBSTETRICS
Nursing Responsibilities:
During/Immediate:
1. Monitor the vital signs
➔ Vital signs is very important because if
there is intense bleeding then we can
prevent for possible shock and we can
intervene with the hemorrhage
2. Observe aseptic technique
➔ This is to prevent infection
3. Support perineum properly
➔ Upon delivery of the baby, especially if
you are the assist nurse, you have to hold
the perineal area properly and not to let
go or else once the baby’s head comes
out and out of your anxiety(?), expect
that there will be a laceration on the
perineal area
After/Postpartum:
1. Do perineal care
➔ Initially, during your perineal care, it will
be washing it right after episiotomy
➔ The area will be washed to check and
internal examination will be done
➔ Wash with aseptic solutions
➔ Instruct the mother in every time after
urinating or possible for toilet to be very
careful on the sutures side and wiping
from front to down and not the other
way around
2. Apply ice pack or cold compress within three
hours
➔ This would cause vasoconstriction thus to
lessen the bleeding
3. Provide hot sitz bath
➔ This is to decrease the pain and promotes
healing on the suture side
➔ This would usually happen after 8 to 12
hours and not prior to that or
immediately
4. Render Perilite Exposure after 24 hours
➔ Perilite exposure would be the use of
light ball and the client will be positioned
in a dorsal recumbent and this will be put
in between the legs with an appropriate
distance and it will be lit for 15 to 30
minutes
➔ This will promote healing and drying of
the surgical site
5. Administer analgesics as ordered
YUSON, DREA
NCM 107: Care of Mother, Child, Adolescent (Well-Client)
NSVD Cervical Ripening Methods
Possible complications: -
Is a change in cervical consistency from firm
• Bleeding from undetected low-lying placenta to soft
• Inadvertent rupture of membranes 1. Chemical Agents
• Introduction of infection a. Prostaglandin E1 – ex. Misoprostol (Cytotec)
➔ If aseptic technique has not been ◼ This would encourage faster delivery of
followed the baby since your cervix is ripe and soft
Nursing Responsibilities: enough. This would facilitate with labor
1. Document the number of dilators and b. Prostaglandin E2 – Dinoprostone (Cervidil
sponges inserted during the procedure insert; prepigil gel)
➔ After the delivery of the baby there will ◼ Used before induction to “ripen” (soften
be cleaning on the inside so the doctor and thin) the cervix
will be inserting some sponges okay so as 2. Mechanical Methods
a nurse you have to count those a) Laminaria tents – natural cervical dilators
whatever that has been put in should be made from seaweeds
the number that has been put out b) Hydroscopic dilators – substances that
2. Assess for urinary retention absorb fluid from surrounding tissues and
➔ You have to see that during either then enlarge
delivery or incision suturing, the urinary c) Synthetic dilators containing magnesium
area has not been damaged at the same sulfate (Lamicel) – inserted into the
time endocervix without rupturing the membranes
➔ You can ask the mother if still probably d) Stripping the membranes – separating the
there's still a sense of urgency to urinate membranes from the lower uterine segment
but you have to double check most of ◼ This would promote labor itself
most mothers at this time most not all
are with urinary catheter
3. Assess for rupture of membranes, uterine FORCEPS DELIVERY
tenderness/pain - One of the method for delivering or assisting
4. Assess vaginal bleeding and fetal distress the delivery of the head of the baby
- Uses a stainless-steel instrument, similar to
Types of Episiotomy
tongs, with rounded edges that fit around a
Characteristic Midline Mediolateral
Easy (because More difficult fetus’s head for delivery
Surgical Repair
the cut is (since it is Purpose:
straight) slanting on the
side) • To prevent pressure from being exerted on the
Faulty Healing Rare (heals fast More Common fetal head
and good) • To avoid subdural hemorrhage in the fetus as
Postoperative Minimal Common the fetal head reaches the perineum
Pain
Anatomical Excellent Occasionally Indications:
Results faulty
1. Mother At Risk:
Blood Loss Less More
Dyspareunia Rare Occasional • Heart disease problems
Extensions Common Uncommon ◼ Because most of this mother cannot bear
enough to push harder
• Acute pulmonary edema
• Intrapartal infection

MODULE 4F: OPERATIVE OBSTETRICS YUSON, DREA

NCM 107: Care of Mother, Child, Adolescent (Well-Client)
• Maternal exhaustion
• Unable to push with contractions in the pelvic
division of labor such as after regional
anesthesia

2. Fetal Conditions:

• Fetal distress
• Premature separation of the placenta
• Prolapsed of the umbilical cord
• Arrest of rotation
• Abnormal position - In here you can see the station zero should be
in line with your ischial spine
3. Cessation of progress in the 2nd stage of labor
- Forceps delivery should not be on your pelvic
- The labor itself is ineffective that is why we floor so it should not go down to your positive
have to induce by cervical five six seven it should be between your two
and your three
Categories - This can be determined when your physician
1. Outlet Forceps will do the internal exam
Criteria:
• Forceps are applied when the fetal skull has
reached the perineum
• Scalp is visible between the contractions
• Sagittal sutures is not more than 45 degrees
from the midline

2. Low Forceps
Criteria:
• Presenting part of the skull must be at a
station of +2 or below (e.g. +3) but not on the Certain Conditions before forceps delivery:
pelvic floor
• Rotation of the fetal head is less than 45 • Membranes must have ruptured
degrees • CPD is not present
• Cervix must be fully dilated to avert lacerations
and hemorrhage
3. Midforceps
• Presenting part must be engaged
Criteria:
• Woman’s bladder must be empty
• Fetal head must be engaged (level of ischial
spine, station 0) but the presenting part of ➔ So that this will not be the problem upon
the skull is above a station of +2 (e.g. +1, 0, the delivery of the baby and also at the
-1, -2) same time this would help hasten the
delivery of the baby itself

MODULE 4F: OPERATIVE OBSTETRICS YUSON, DREA

NCM 107: Care of Mother, Child, Adolescent (Well-Client)
Nursing Responsibilities when it comes to forceps 4. Simpson’s Forceps – used most commonly as
delivery: outlet forceps
5. Tarnier’s – Axis traction forceps
✓ Explain the procedure to the mother, tell her
what to expect Complications of Forceps Delivery:
➔ We don't want the mother to be surprised
• Laceration of the vaginal canal
how come there are some markings on the
fetal head when she will be seeing her • Cerebral trauma of the baby
newborn for the first time that is why we • Increased perinatal morbidity and mortality
have to tell and explain what is the • Low IQ
outcome of this procedure ➔ Because there will be an insertion of this
➔ In Philippine settings, usually the doctor instrument
who explained for this things that to get the ➔ There is a tendency that there will be a
concept from the mother but regardless of compression of the blood supplies on the
that one we have to know “ma'am was the head area
doctor was able to explain to you the
procedure the outcome of this one” and so
on and so forth
✓ Assess and record FHR before and after
application
➔ Again because there will be a possibility
that there it might cause injury to the baby
✓ Assess the mother for vaginal and cervical
laceration
✓ Record the time and amount of first voiding
➔ Especially if there is some trauma that
happens on the vaginal area on the
perineum
✓ Assess the newborn for facial palsy and
subdural hematomas
➔ Since the forceps will be clipped on the
head area
✓ Explain to the parent that a forceps birth may
have a transient erythematous mark on the
newborn’s cheek, face in 1 to 2 days

Different Types of Forceps Delivery:

1. Barton – used to rotate the fetal head to a more

favorable position (ROP to ROA)
2. Kielland’s - With short handles and marked
cephalic curve.
◼ Used to rotate the fetal head to a more
favorable position
3. Piper – Used to deliver the head in a breech
presentation or position

MODULE 4F: OPERATIVE OBSTETRICS YUSON, DREA

VACUUM ASSISTED 1. It causes a marked caput

DELIVERY that may be noticeable as long

as 7 days after birth.

Vacuum Extraction Delivery
- so there is like a cone head
- Birth method involving the
attachment of a vacuum cup to the
that would occur on the top
fetal head, using negative
pressure to assist in the birth of
nose.
the head.

2. Tentorial tears from

Advantages Over Forceps
extreme pressure can occur.
Delivery:
- especially of the pulling

✓ Little anesthesia is delivery of the baby.

necessary

✓ Fewer lacerations of the Indications:

➢ Prolonged labor
birth canal occur
➢ Mother with cardiopulmonary
disease
➢ Mother with high BP

- why is it ? because you are

Contraindication:
cupping the head rather than
➢ Preterm (soft skull)
- because of their soft skull it
in the forceps, there will be
is not allowed.
- we know that there will be a cup
a use of instrument that is
being put on the scalp of the baby
and negative pressure will be
made of stainless steel.
done.
- Preterm babies are not allowed
or contraindicated in your vacuum
extraction delivery.
Major Disadvantages:
➢ Fetus who have undergone scalp
blood sampling (high risk for
bleeding)

Bandiola, Jovelyn P.
 ✓ Vaginal cervical
Nursing Responsibilities:
laceration of your soft
1. Provide emotional support to
both mother and significant
tissue trauma
others.

- prior to your vacuum extraction

it should also have been explained
of the possible outcome or outlook
of the baby with the caput.
- emotional support to the mother
and significant other sometimes
they would ask you questions, will
the baby be okay? Will there be
some mental issues and so on and
so forth.

3. Asses fetal heart rate (FHR)

during the procedure.

4. Position the mother in

lithotomy position to allow for
- there will be some degree of
sufficient traction.

lacerations on the perineum

5. Newborn should be observed for
signs of trauma and infection at
area.
the application site and for
cerebral irritation.

Newborn Complications:
Risk of Vacuum Extraction
1. Cephalhematoma -
Delivery
happening on the inside.
- pressure that is applied to

the fetal head

- there could be some under

maternal complications:

✓ Perenial
Bandiola, Jovelyn P.
2. Scalp laceration - there may be done either internally

is a shape of the cup of the or externally.

vacuum cup.

External cephalic version

- quite familiar to us here as

for those “manghihilot” or

“mananabang”, especially if

they can sense that the baby

is not in the normal position,

they will try to move it

3. Subdural hematoma - which
externally by massaging on
is also on the inside.
the client’s abdomen.

➢ Turning of the fetus to a

vertex presentation by

external exertion of

pressure on the fetus

through the maternal

VERSION
abdomen.
- the turning of the fetus
➢ Turning of the fetus from
artificially from one
a breech to a cephalic
presentation to another and
position prior to birth.

Bandiola, Jovelyn P.
➢ Attempted in a labor and abdomen with the

birth setting after 37 administration of the

weeks of gestation tocolytic agents.

- magnesium sulfate will be

- this is attempted after 37 given IM near your buttocks

weeks of gestation because area.

earlier we all do know that

fetus are considered to be

mature between 36 to 40 weeks.

So with this if there will be

a problem then the fetus is

viable already in the outside

world.

➢ Tocolytic agent such as

magnesium sulfate is given

to relax the uterus and

Contraindications:
facilitate the maneuver.
⚫ Uterine anomalies

⚫ Previous cesarean birth

- there has to be no
⚫ CPD (cephalopelvic
contractions to be happening
disproportion)
and we can manipulate the
⚫ Placental previa
Bandiola, Jovelyn P.
 ⚫ Check maternal vital signs
⚫ Multifetal/multiple
⚫ Ultrasound should be recorded
continuously
gestation
⚫ Assess the woman’s level of
comfort
⚫ Oligohydramnios

⚫ Rh incompatibility Internal Version

➢ The fetus is turned by the
- you are to avoid the
physician who inserts a hand
into the uterus and changes
separation or the mixing of
the presentation to cephalic
or podalic (feet)
the fetal maternal blood .
➢ May be used in multifetal
pregnancies to deliver the
⚫ Unexplained third
second fetus.
- especially this happens if the
trimester bleeding
baby is not yet fully engaged, so
the baby would still turn.
- there will be some unknown
- upon internal exam, the doctor
will notice that there has been a
bleeding or clotting factors
change on the presentation of the
baby, provided that it is not on
disorder that happens to the
a transverse, then this can be
done.
mother or not yet diagnosed
- maybe used in multifetal
pregnancy to deliver the second
and this would promote
baby.

possible for hemorrhage later

on.

⚫ Ruptured amniotic

membrane

⚫ History of premature labor

Nursing Responsibilities:
Contraindications:
⚫ Continuously monitor FHR
especially bradychardia ⚫ Lack of anesthesia

Bandiola, Jovelyn P.
- there has to be an anesthesia
because this is internally done
before the baby is out for
delivery.
⚫ Unskilled health care team
member in internal podalic
version
⚫ Retracted cervix or
contracted thickened uterus.
- the uterus has to be on a relaxed
state and there has to be an
anesthesia in order to perform
internal version.
PAIN
- pain in peripheral terminals is
automatically reduced by the
production of endorphins and
encephalins, naturally occurring
opiates that limit transmission
of pain from the end terminals.
Pain can be reduced further at
these end points by mechanically
irritating nerve fibers through
an action such as rubbing the skin,
which blocks nerve transmission.
A major way to block spinal cord
neurotransmitters (i.e., never
allowing the pain impulse to cross
to a spinal nerves) is by the
administration of pain
medications. In addition, the
brain cortex can be distracted
from sensing impulses as pain by
such techniques as imagery ,
thought stopping, and perhaps
aromatherapy or yoga.
Sensory impulses from the
perineum, which is involved in the
second stage of labor are carried
by the pudendal nerve to join the
spinal column at S2, S3, and S4.
When the perineum is initiating
the pain, anesthetic pain relief
must block these lower receptor
sites. Some interventions
relieve pain for both the first
and second stages of labor whereas
others work for one stage but not
both.
- because we all know nothing is
a subjective.
✓ So the pain that the mother
feels could be different from
the other. One person might
have a higher threshold of
pain compared to the other.
Intrapartum pain experience
Pain
- any sentation of discomfort
- a subjective symptom
Subtle signs of pain:
- facial tenseness
- flushing or paleness
- rapid breathing, rapid PR
- fisted hands
- muscle tension
- muscle activity like pacing,
turning, twisting
- nonverbal expressions of pain
may include withdrawal,
hostility, fear or depression
- verbal expressions of pain may
include statements of pain,
moaning or groaning
Etiology:
⚫ contracting of the uterus
⚫ stretching of the cervix
during dilation and
effacement
Bandiola, Jovelyn P.
 - DILATION is the opening of equipment, this would lessen the
the cervix, if basement is anxiety and lessen the pain felt
your thinning of the cervix. by the mother.
⚫ Traction on stretching and
displacement of the perineum 2. Provide comfort measures
⚫ Pressure on the presenting - example: backrub (always ask
part of the fetus on tissues permission to the mother)
and surrounding organs such as
urethra, bladder and rectum 3. Encourage comfortable
during descent positioning
⚫ Uterine anoxia due to - position the mother on the left
compressed muscle cells side, you can add additional
during contraction pillows if the mother feels
⚫ Stretching of uterine uncomfortable
ligaments (area of the pelvic
area) 4. Assist with prepared
⚫ Distention of the lower childbirth exercises (e.g.
uterine segment breathing exercise, Lamaze)
⚫ Compression of the nerve distraction by focusing on
ganglia in the cervix and external object, therapeutic
lower uterine segment during touch, muscle therapy, guided
the contraction. imagery, hypnosis
- it has to be done prior to the
active stage of labor as much as
possible.
Intrapartum Pain Management
- you have to orient your patient
Goals: and teach your patient of some of
1. To provide maximal relief of this non-pharmacological pain
pain management so that this would
2. To provide maximal safety for facilitate and help you during the
the mother and the fetus active phase of labor.
3. To facilitate labor and
delivery as a positive family Nonpharmacologic Methods:
experience 1. Support from a doula or couch
Doula
Nonpharmacologic Pain - woman who is experienced in
Management: childbirth and postpartum
1. Reduce anxiety with support.
explanations of the labor - may hold certificates as
process. birth or postpartum doulas.
- if we are able to educate our - increase woman’s self esteem,
patient and explain the speed the labor process, and
procedures that we will be doing improve breastfeeding success
to her even attaching, monitoring as well as decrease rates of

Bandiola, Jovelyn P.
 oxytocinaugmentation, there will be a removal of
epidural anesthesia, cesarean anxiety and fear.
birth, and postpartum - if there is no tension built
complications. up there will be less pain to
the client.
✓ Support group or individual
who could teach women of the Lamaze Method
possible outcome of the (Psychoprophylactic)
pregnancy or birth or delivery
itself would help the mother. - combine’s relaxation,
concentration, focusing and
2. Hypnosis complex well-paced breathing
- used for relief in both patterns to reduce the
obstetrics and surgical perception of pain through a
patients conditioned response to labor
- reduces or eliminates the contractions.
need for depressant drugs
Bradley Method (Husband - Coached
3. Acupressure Childbirth)
- your pressure points
- husband takes an active role
4. Yoga in assisting the woman to
- teaches relaxation, relax during labor and use
concentration and “complete correct breathing techniques
breathing” ( combination of - focuses on slow breathing
abdominal and chest and deep relaxation for labor
breathing) - focuses on reduced
responsiveness to external
Dick-Read Method stimuli
- emphasized the use of - focuses on the role of the
relaxation and proper male partner as coach
breathing with contractions
as well as family support and Pharmacologic Pain Manageent:
education
- provides information on 1. Narcotic Analgesics
labor and birth as well as
nutrition, hygiene and - given in labor because of
exercise. analgesic effect
- it is the total control of - contraindicated in preterm
your pain wherein if the labor because it is a CNS and
patient is more or less almost respiratory depressant.
the same with doulas, there
will be an explanation on why Examples:
these things happen so that

Bandiola, Jovelyn P.
✓ Demerol (meperidine
hydrochloride)
- has additional sedative and
antispasmodic actions
- Given IM or IV
- Crosses the placental barrier
thereby causing fetal
depression
- Fetal liver takes 2-3 hours to
activate the drug so must be
given 3 hours away from birth
✓ Morphine Sulfate
✓ Nalbuphine (Nubain)
✓ Fentanyl (Sublimaze)
✓ Naloxone (Narcan) - narcotic
antagonist should be
available
- it is a must if the client
has a possibility or is given
Demerol, Morphine, Nalbuphine,
Fentanyl and Naloxone on hand
since it is your antagonist
from this narcotics.
- narcotics would cause CNS
and respiratory
depression,not just on the
baby but also the mother.
2. Sedative-Hypnotics and
Ataratics (compliments the
action of narcotics)
✓ Secobarbital sodium (Seconal)
- to encourage rest
✓ Promethazine (Phenergan) - to
decrease anxiety
Post-op Pain:
⚫ Narcotic analgesia given with
a PCA pump for the 1st to 48
hours after the surgery
⚫ Oral analgesic like
acetominophen are given
1. PCA - Patient Controlled
Analgesia
- A method of pain control
- Patient administer doses of
IV narcotic analgesic
2. TENS - Transcutaneous Nerve
Stimulation
- Transmission of
electrical impulses/ current
across theskin
- Two electrodes are
positioned on each side of the
abdominal surgical incision
- Effective in controlling
pain
REGIONAL ANESTHESIA
- injection of a local anesthesia
to block specific nerve pathways
interspace.
Spinal Anesthesia
- injection of bupivacaine
(Marcaine) into the subarachnoid
space at the level of 3rd and 4th
lumbar interspace
- block nerves and suspend
sensation and motion to the black
nerves and suspend sensation and
motion to the lower extremities,
perineum and lower abdomen.
Major Complications:
✓ Hypotension - validation
- turn the woman to her left
side to reduce a vena cava
compression
✓ Spinal Headache
Bandiola, Jovelyn P.
 - Administer analgesic
- advise to lie flat

✓ Epidural - introduced in the

epidural space
- blocks the sympathetic nerve
in order to increase
contraction strength and
blood flow to the uterus.
- Side effect: Spinal headache
rarely happens
- otherwise known as PAINLESS
DELIVERY

Advantage:
➢ Used with heart problem,
pulmonary disease
➢ Used in diabetic mother
Disadvantage:
➢ Induced hypotension
Nursing Responsibilities:
➢ Start IV to hydrate the mother
and for emergency purposes
➢ Elevate leg
➢ Administer oxygen
Local Anesthesia
( Pudendal Block/Pudendal Nerve
Block)
✓ Injection in the right or left
pudendal nerves at the level
of the ischial spine
✓ Position mother in the dorsal
recumbent position
✓ Provides relief of perineal
pain
✓ Check FHR and maternal blood
pressure
✓ Takes effects and after 2 to
10 mins and lasts for 60 mins
- given if there will be a
Physiography or the repair of the
surgical side of your episiotomy.

General Anesthesia
✓ Never preferred for
childbirth because of dangers

Bandiola, Jovelyn P.
 of hypoxia, possible
Common indications for
inhalation of vomitus.

cesarean section include:

Examples:
1. Dystocia
➢ Inhalant (nitroud axide, 2. Placenta previa
Halothanol) and Intravenous 3. Fetal distress
(Penthotal)

Drugs that should be readily Other conditions requiring

available: cesarean may include:

1. Ephedrine - used when blood 1. Multiple births
pressure falls 2. Large tumors of the uterus
2. Atropine Sulfate - to dry and 3. Genital herpes or other
respiratory secretions to prevent infections
aspiration 4. Uncontrolled diabetes or
3. Thiopental Sodium - rapid hypertension
induction of a general anesthetic
in an emergency
4. Succinylcholine - to achieve
Before the procedure:
laryngeal relaxation for
intubation in an emergency 1. IV line
5. Diazepam - to control 2. Catheter
convulsions, a reaction to 3. Regional or general anesthesia
anesthetic
6. Isoproterenol - to reduce
After the procedure:
bronchospasm if aspiration should
occur
1. 3-5 day hospital stay
2. Breastfeed, nap when the baby
sleeps, and get out of bed
CESAREAN DELIVERY
3. 6-8 weeks for full recovery
A surgical procedure in which the 4. Scar lightens as it heals
newborn is delivered through the
abdomen from the incision made
2 TWO TYPES OF CESAREAN
through the maternal abdomen and
the uterine myometrium
SECTION:
Done to preserve the life of the 1. Scheduled Cesarean Section
mother and her fetus 2. Emergency Cesarean Section

Bandiola, Jovelyn P.
Indications of CS:
Maternal factors
- CPD
- severe hypertension during
pregnancy
- active genital herpes
inspection
- previous cesarean section
Fetal factors
- transverse fetal lie
- breech presentation
- Fetal distress
- Extreme low birth weight
- macrosomia
- multiple gestation
Placental factors
- placenta previa
- abruptio placenta
Classical Incision
- made vertically
Advantages:
- bigger space for the baby
- larger version, less possible
trauma
Can be used in placenta previa
Disadvantages:
- more blood loss
- risk for rupture of the uterus
- higher incidence of infection
Low Segment Incision
- most common type
- a.k.a. Pfannenstiel incision or
bikini incision
Advantages:
- less uterine rupture
- Less blood loss
- easier to suture
- less likely to cause postpartum
or gastrointestinal
complications
Disadvantages:
- visual area is small
- prone to infection (located near
the perineum (located near the
perineum)
- impractical for emergency
cesarean section
MATERNAL RISK FACTORS:
- pulmonary embolism
- wound infection
- hemorrhage
Bandiola, Jovelyn P.
- Injuries to the bladder or bowel wearing of hospital gown, remove
nail polish
Effects of Surgery: - Gastrointestinal tract prep
1. stress response (enema)
✓ Epinephrine - increase HR, - Baseline intake and output
blood glucose level, determination
bronchial dilation - Hydration (IVF is given)
✓ Norepinephrine with - Preoperative meds:
circulatory function - IM Cimetadine (tagamet) -
decrease stomach secretions
2. Interference with body - No citrate (Bicarta) -
defenses neutralize stomach secretions
- Prepare the client’s chart and
3. Interference with circulatory surgery checklist
function - Transport mother to operationg
✓ Extensive blood loss - room for delivery
hypovolemia, lowered BP

4. Interference with body organ In the Operating Room

function
5. Interference with self - image
or self - esteem
Pre-operative interview
- establish operative risk
- person must be in the best
possible physical and
psychological fit before surgery
- skin preparation
- Administration of anesthesia by
anesthesiologists
- Surgical procedure
- Birth of the infant
- Immediate newborn and mother
care
- Woman is transferred to the
recovery room

Nursing Problems:
Preoperative diagnostic
procedures - Fear related to impending
surgery
- Vital signs determination - Pain r/t a surgical incision
- Urinalysis - Deficient fluid volume related
- Blood studies (CBC) to blood loss from surgery
- Serum electrolytes and pH - Powerlessness r/t medical need
- Blood typing and crossmatching for episiotomy or cesarean birth
- Sonogram - Risk for anxiety r/t
- Immediate pre-operative care unanticipated circumstances
measures surrounding birth
- Obtain informed consent - Risk for infection related to
- Overall hygiene-shower, surgical procedure

Bandiola, Jovelyn P.
- Risk for hemorrhage related to
surgical procedure
- Risk for impaired parent-infant
attachment related to unplanned
method of birth
- altered skin integrity r/t
surgical incision
- High risk for altered peripheral
tissue perfusion related to
immobility during and after
surgery

Bandiola, Jovelyn P.
NCM 107: Careof Mother, Child, Adolescent (Well-Client)
The Postpartum Period or Puerperium - 2nd day - it descends one fingerbreadth per day
- Is the first 6 weeks after the birth of the infant - By the 14th day, it is in the pelvic cavity and
- It comes from the Latin puer, for child and cannot be palpated abdominally
parere, for to bring forth - The uterus within a week weighs about 500 g
- It is the interval between the birth of the (1lb) and by 6 weeks it weighs about 60 g (2 oz)
newborn and the return of the reproductive
organs to their normal nonpregnant state
- It is a time of maternal changes that are both
retrogressive and progressive
➔ Example for retrogressive: involution of the
uterus
➔ Progressive changes: lactation and return of
menses
- It is also termed the fourth trimester of
pregnancy

REPRODUCTIVE SYSTEM - How do you assess the fundus?

Involution of the uterus ➔ One hand is cupped to massage and gently
compress the fundus towards the lower
- Entails three processes: uterine segment
1. Contraction of muscle fibers ➔ The other hand remains cupped against the
2. Catabolism – process of converting cells uterus at the level of the symphysis pubis to
into simpler compounds support the uterus
3. Regeneration of uterine epithelium - The descent is documented in relation to the
- Begins immediately after the delivery of the umbilicus
placenta ➔ For example, U = 1 → which indicates the
- When uterine muscle fibers contract firmly fundus is palpable 1 fingerbreadth below
around maternal blood vessels at the area the umbilicus
where the placenta was attached - So the fundus may be slightly higher in
- The placental site, which is about 7 cm, heals by multiparous or in women who had over
process of exfoliation meaning the scaling off distended uterus
dead tissue
- The healing at the placental site takes During postpartum, the mother will have lochia
approximately 6 weeks discharge.
- The location of the uterine fundus helps
determine whether involution is progressing
normally
➔ Descent of the uterine fundus
- Immediately after the delivery, the uterus is
about the size of a grapefruit and weighs
approximately 1000g (2.2 lbs)
- The fundus can be palpated midway between
the symphysis pubis and the umbilicus in the
middle of the abdomen
- So within 12 hours the fundus rises to about
the level of the umbilicus
POSTNATAL CARE YUSON, DREA
NCM 107: Care of Mother, Child, Adolescent (Well-Client)
Lochia ASSESSMENT OF THE CERVIX
- are composed of vaginal blood tissue and Cervix
nucleus loss after birth lasting up to 6 to 8
- Immediately after childbirth the cervix is
weeks
formless, flabby and open wide
Three types of Lochia - Healing occurs rapidly.
- End of the first week – it feels firm and external
Lochia Rubra os is dilated the width of a pencil
Post-part day: 1-3 days (color red)
Composition: Blood, with small particles of decidua
and mucus (flesh, earthly odor)
Abnormal Discharge: Large clots, saturated pad, foul
odor

Lochia Serosa
Post-part day: 3-10 days
A. Nulliparous cervix
Composition: Serous exudate, leukocytes,
erythrocytes and cervical mucus ➔ Round
Abnormal Discharge: Excessive amount, foul smell, B. Parous cervix
continued recurrent reddish colour ➔ Shape remains slightly open and appears
slitlike

Lochia Alba VAGINA

Post-part day: 10-14 (could last until 6 weeks) [color - The vaginal walls appear edematous and
yellow or white] multiple lacerations may be present
Composition: leukocytes, decidua and epithelial cells, - Very few reginal rugae are present
fat and cervical mucus Hymen
Abnormal Discharge: Persistent lochia serosa, return ➔ May be Permanently torn and heals with
to lochia rubra, foul odour, continuing discharge small irregular tags of tissue visible at the
Changes in color and amount of local also provide vaginal introitus
information about whether involution is progressing - It takes 6 weeks – 10 weeks to gain
normally. Estimating the amount of lochia is difficult. So, approximately the same size and contour it had
nurses frequently record lochia in terms that are difficult before pregnancy
to quantify. - However, the vagina does not entirely regain
Method for estimating the amount in 1 hour: the nulliparous size
1. Scant – less than 2.5 cm (1 inch) stain on the
peri pad
2. Light – 2.5-10 cm (1-4 inch) stain
3. Moderate – 10-15 cm (4-6 inch) stain
4. Heavy – saturated perineal pad in 1 hour
5. Excessive – saturated pad in 15 minutes
- Determining the time the peri pad has been
placed is important in assessing the lochia
- Lochia is usually heavier when mother gets out
of bed because gravity allows blood that is
pulled in the vagina during the hours of rest to
flow freely when she stands
POSTNATAL CARE YUSON, DREA
NCM 107: Care of Mother, Child, Adolescent (Well-Client)
PERINEUM
- It may be edematous or bruised
- Episiotomy – surgical incision of the perineal
area (median and mediolateral)
➔ May take 4-6 months to heal
- Lacerations may occur during pregnancy
4 Degrees of Laceration:
The first degree it involves the vaginal mucus
Second degree involves the vaginal mucosa the perineal
skin and the partitions which may include muscles of
the perineum
Third degree laceration involves the anal sphincter
Fourth degree laceration extends through the inner
specter into the rectal mucosa
SYSTEMIC CHANGES
All body systems undergo retrogressive changes as well.
Cardiovascular System
- Average blood loss in vaginal deliveries is 500
ml
- For mothers who have cesarean births is 1000
ml
- Increase in stroke volume which is the amount
of blood pumped by the left ventricle of the
heart in one contraction causes bradycardia, a
PR (50-60 bpm) but return to normal level by 6-
12 weeks after birth
- Blood Values
• WBC count may be as high as
30,000/mm3 during labor and the
immediate postpartum period
POSTNATAL CARE
• WBC average range is 14,000 to
16,000/mm3 and falls to normal values
by 6 days after birth
- Plasma fibrinogen and other factors necessary
for coagulation increase
- The elevation of clotting factors continue for
several days or longer, causing a continued risk
of thrombus formation
- Women who have varicose veins, history of
thrombophlebitis or CS are at further risk for
thrombophlebitis
➔ Which is an inflammatory process that
causes blood clot to form and block one or
more veins
Hormonal System
- Pregnancy hormones (estrogen, progesterone,
and human placental lactogen) begins to
decline after the expulsion of the placenta
- HCG may remain for several weeks if the
mother is not breastfeeding
- Prolactin returns to nonpregnant levels in about
2 weeks
- The average time for non-nursing mothers to
resume menstruation is 7-9 weeks after
childbirth (although it may vary)
- Menses while lactating may resume as early as
8 weeks or as early as 18 months
- Women who breastfeed for less than 28 days
ovulate at approximately the same time as non-
nursing mothers
- First few cycles for both lactating and non-
lactating women are often anovulatory,
ovulation may occur before the first menses
Neurologic System
- Because of the effect of anesthesia or analgesia,
there could be temporary lack of feelings in the
legs and dizziness
➔ During this time, the priority is prevention
of injury that could occur as a result of
falling
- Bilateral and frontal headaches is common in
the first postpartum week as a result of changes
in fluid and electrolyte balance
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NCM 107: Care of Mother, Child, Adolescent (Well-Client)
- Headache with blurred vision, photophobia,
abdominal pain and proteinuria may indicate
development of preeclampsia
Urinary System
- During pregnancy, as much as 2000 to 3000 ml
of excess fluid accumulates in the body
- The mother will experience diaphoresis, which
is excessive sweating, and diuresis, which is
increased in urination, which begins almost
immediately after birth to rid the body of this
fluid
- A single void can be 500 cc or more
- Urethra, bladder and tissue around the urinary
meatus may become edematous and
traumatized
- Because of urinary retention and over
distension of the bladder, it may cause
postpartum hemorrhage
➔ Why postpartum hemorrhage? Because a
full bladder displaces the uterus to the right
or left which causes uterine acne or the
failure of the uterus to contract thus leading
to hemorrhage
- The structures generally regain their non
pregnant state by 6-8 weeks after delivery
- To prevent urinary retention or postpartum
hemorrhage, it is important to remind mothers
of keeping the bladder empty and the uterus
contracted
- One exercise that can help restore vaginal
muscle or the muscles in under the uterus and
the bladder would be Kegel Exercises
➔ Which is the tightening of the muscles that
control uterine flow and it can be
performed three times a day
Integumentary System
- Estrogen, progesterone, and melanocyte
stimulating hormone which cause
hyperpigmentation during pregnancy decrease
rapidly after childbirth and pigmentation begins
to recede
- Melasma (mask of pregnancy) and linea nigra
fade and disappear for most women
POSTNATAL CARE
- Striae gravidarum (stretch marks) gradually fade
to silvery lines but do not disappear
Gastrointestinal System
- Digestion and absorption begin to be active
again after birth
- Constipation is a common problem for a variety
of reasons:
1. Bowel tone and gastric motility diminish as
a result of progesterone which remains
sluggish for several days
2. Restricted food and fluid during labor leads
to hard stools
3. Perineal discomfort can interfere with
effective elimination
- First stool usually occurs within 2-3 days
postpartum
- Normal pattern of bowel elimination usually
resume by 8-14 days after birth
- Hemorrhoids develops before and during
pregnancy and are exacerbated or traumatized
during birth
- Remind women that preventing constipation
will relieve hemorrhoids
Musculoskeletal System
- First 1 to 2 days after childbirth, many women
experience muscle fatigue and aches because of
the effort of labor
- First few days, level of hormone relaxin
gradually subside, and ligaments and cartilage
of the pelvis begin to return to their pre-
pregnancy position. These changes can cause
hip or joint pain
➔ Good body mechanics and correct posture
are extremely important during this time to
help prevent low back pain and injury to the
joints
➔ It is also helpful if the mother understands
that discomfort is temporary and does not
indicate medical problem
- During pregnancy, the abdominal walls
stretched to accommodate the growing fetus,
and muscle tone is diminished. The abdominal
walls become weak, soft and flabby
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NCM 107: Care of Mother, Child, Adolescent (Well-Client)
➔ It can cause diastasis recti or the
longitudinal muscles may separate
➔ The separation may be minimal or severe.
➔ The diastasis usually resolves within 6
weeks
➔ To strengthen the abdominal wall, the
mother may benefit from gentle exercise
POST PARTUM DISCOMFORTS
1. Afterpains
- There are intermittent contractions and are
source of discomfort for many women
- The discomfort is more acute for multiparous
because repeated stretching of muscle fibers
leads to loss of muscle tone that causes
alternate contraction and relaxation of uterus
- Oxytocin release during breastfeeding may also
cause strong uterine contractions of uterine
muscles
Nursing Intervention:
- Provide ice packs on the abdomen
- Place in prone position with pillow under the
abdomen
2. Perineal Pain
- Caused by episiotomy wound or laceration
Nursing Intervention:
- Provide ice packs on the 1st 24 hours
- Perilite exposure or hot sitz bath after 24 hours
➔ Because if this is done in the first 24 hours it
could cause bleeding
- Perineal care
➔ To prevent infection
- Analgesics as ordered to relieve pain
3. Sweating or Excessive Perspiration
- Remember that the mother experiences
diaphoresis
Nursing Intervention:
- Offer fresh dry gown or linen
- Encourage showers
- Increase fluid intake to replenish fluid loss
POSTNATAL CARE
4. Constipation
Nursing Intervention:
- Encourage fluid intake
- Eat high fiber foods
- Encourage moderate activity e.g. walking
- Use stool softeners if indicated
5. Fatigue/Maternal Exhaustion
Nursing Intervention:
- Encourage rest periods within activities
- Encourage other family members to participate
in child-care
6. Nipple Soreness
Nursing Intervention:
- Instruct the mother to rotate breastfeeding
positions
- Instruct the mother to use finger to break
suction before removing infant
- Apply cool compress after feeding
- Use proper breast support
7. Urinary Incontinence or Difficulty Voiding
Nursing Intervention:
- Encourage Kegel Exercises to strengthen the
muscles in the uterus or in the bladder
- Provide hot tea or fluids of choice to promote
voiding
- Running water in the sink or shower within
earshot
- Pouring water over the vulva would promote
urination
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NCM 107: Care of Mother, Child, Adolescent (Well-Client)
PSYCHOLOGIC CHANGES DURING 3. LETTING-GO PHASE
POSTPARTUM - Woman finally redefines her new role
- Postpartum is the culmination of the child
bearing here
- Many adaptations and adjustments by the
woman and her family must be made to
accommodate the new family member into an
already established structure
- Rubin identified restorative phases that
mothers go through to replenish the energy loss
during labor and to attain comfort in the world
Process of Maternal Adaptation – Puerperal
Phase (Rubin)
1. TAKING-IN PHASE
- Mother is focused primarily on her own need
for fluid, food and sleep
- She takes in every detail of the neonate, but she
seems content to allow others to make
decisions
- So for an inexperienced nurse she may wonder
why the mother has passive behavior as she
takes in or receive attention and physical care
- During this 1-3 day period, a woman is largely
passive
- Major task is to integrate her birth experience
into reality. so to do this the mother discusses
her labor and delivery in detail with visitors or
on the telephone.
➔ It is important for the nurse to listen and
help the mother interpret the events of
delivery to make them more meaningful
➔ This is not an optimum time to teach
mother about baby care
2. TAKING-HOLD PHASE
- The mother becomes more independent
- She exhibits concern about managing her own
body functions and assumes responsibility for
her own care
- It usually starts from the third day to 10 days (3-
10 days period)
- This is the optimum time to teach about baby
care
POSTNATAL CARE
- She gives up the fantasy image of her child and
accepts the real one
- She gives up her old rule of being childless, or
the mother of one or two
- This process requires some grief work and
readjustments of relationships
- Teenage mothers need special attention
because of the conflict taking place within them
as part of adolescence
- When do you know if the mother is already in
the letting-go phase?
➔ When her own needs no longer
predominate
Maternal Role Attainment
(Mercer)
Maternal Role Attainment is a process in which the
mother achieves confidence in her ability to care for an
infant and becomes comfortable with her identity as a
mother
1. The Anticipatory Stage
- Begins during pregnancy
- The mother might choose a physician or a
midwife
- Attend birthing classes and seek out role
models
2. Formal Stage
- Begins with the birth of the infant and
continues approximately 4-6 weeks
- The mother becomes acquainted with the
infant and behaviors are guided mainly by
parents, friends or health professionals
3. Informal Stage
- Begins once mother have learned appropriate
responses to their infant cues or signals
- Mothers begin to respond according to the
unique needs of the infant
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NCM 107: Care of Mother, Child, Adolescent (Well-Client)
4. Personal Stage PROCESS OF FAMILY ADAPTATION
- Mothers feel a sense of harmony in their role,
see the infant as a central person in their lives
and have internalized the parental role
- It is important for the nurse to remember not to
take over the care of the infant but to allow
mother to perform as much of the caretaking as
possible and to praise every attempt even if the
mother's care is awkward
Major Maternal Concerns
Body Image
- Concerned about regaining their normal figure
and may have unrealistic expectations about
with loss
- So, nurses must emphasize that weight loss
should be gradual
- Appropriate exercise should be discussed with
their physician
Postpartum Blues
- Also known as baby blues, maternity blues or
mild depression
- It begins in the first week and ends by 10 days
- It should last no longer than two weeks
- Postpartum blues is characterized by insomnia,
fatigue, tearfulness, mood instability and
anxiety
- The symptoms are usefully unrelated to events
and the condition does not seriously affect the
mother's ability to care for the infant
- Direct cause is unknown but may be related to
mother's emotional let-down after birth
- Postpartum discomforts, fatigue, anxiety and
concerns about her ability to care for an infant
- Empathy and support are important
- It is also important to distinguish from
postpartum depression and postpartum
psychosis which are disabling conditions. So you
have to tell the mother to seek help if
depression lasts longer than two weeks or if she
is unable to cope with daily life
POSTNATAL CARE
The birth of an infant requires that roles and
relationships within the family be organized. Each family
is affected.
Rooming-in
- Many hospitals practice rooming-in
- Rooming-in is a placement of a newborn with its
mother rather than in a nursery during the
postpartum hospital stay
- This arrangement gives opportunity for the
parents to know their baby
- Studies show it could lead to positive effects on
maternal behavior
FATHERS
Engrossment – it is the father’s developing bond with
the newborn
- It is characterized by intense interest in how the
infant looks and responds and a desire to touch
and hold the baby
- They may lack confidence in providing infant
care
En face is the position that allows eye to eye contact
between the newborn and a parent
- It is the father’s attachment behavior increase
when the infant is awake, makes eye contact,
and responds to the father’s voice
- So the nurse's role would be to assist the new
father by involving him in child-care activities
soon after birth
SIBLINGS
- Sibling response depends on age and
developmental level
- TODDLERS may view the infant as competition
or fear they maybe replaced in the parents’
affection
➔ Negative behaviors such as sleep problems,
attention seeking, bed wetting may occur
➔ Parents must find opportunities to affirm
their continued love and affection
- PRESCHOOL SIBLINGS engage in more looking
than touching
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NCM 107: Care of Mother, Child, Adolescent (Well-Client)
➔ A relaxed approach without time PSYCHOPHYSIOLOGIC PROCESS OF
constraints may make it easier for young
children to interact with the infant
➔ Special care must be taken by the parents,
visitors, and nurses to pay much attention
to the siblings as to the new baby
➔ Preschoolers most spend time in proximity
to the infant and talk to the mother about
the infant
GRANDPARENTS
- Involvement of grandparents depends on many
factors
- One most important factor is proximity
- Grandparents who live near the child frequently
develop strong attachment
- Often, they are a major part of the support
system especially grandmothers because they
need help in providing assistance with
household tasks and infant care which allow
mother to recover from childbirth
Factors that Affect Adaptation
✓ Lingering discomfort or pain
➔ Which make it difficult to focus on
newborn’s needs
✓ Chronic fatigue
✓ Knowledge of infant needs
➔ First-time moms are unsure about how to
care for the infant
✓ Available support system
➔ A strong consistent support system is a
major factor in the adjust of the new
mother
✓ Expectations of the newborn
➔ Multiparous are more comfortable with
infants and exhibit attachment behaviors
earlier than primiparous
✓ Previous experience with infants
✓ Maternal temperament
✓ Infant characteristics, other factors: CS birth,
preterm or ill infant, multiple birth
POSTNATAL CARE
LACTATION
4 Phases in the Physiology of Lactation:
• Preparation of Breasts (Mammogenesis)
• Synthesis and lactation from the alveoli
(Lactogenesis)
• Ejection of milk (Galactokenesis)
• Maintenance of Lactation (galactopoesis)
So when the baby sucks on the mother's breast to
receive the mother's milk. Baby's sucking triggers nerve
cells in the nipple signaling the brain to release the
hormone oxytocin. Milk ducts widen and muscles
around milk cells contract due to oxytocin. Breast milk
comes out of the milk ducts, into the baby's mouth.
- Prolactin stimulates the production of milk
while oxytocin stimulates the let-down reflex or
the release of milk from the breast
- So aside from that, oxytocin produces a
peaceful, nurturing feeling that allows mother
to relax focus on her child and it promotes a
strong sense of love and attachment between
her and her baby
Composition of Breast Milk:
Colostrum
- The major secretion of the breasts during
pregnancy and the first seven to ten days after
giving birth is colostrum
- A thick, yellow substance which is rich in
immunoglobulins especially IgA
- It helps establish the normal flora in the
intestines and has laxative effects
Transitional Milk
- Appears as the milk changes from colostrum to
mature milk
- Immunoglobulins decrease and lactose, Fat and
calories increase
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NCM 107: Care of Mother, Child, Adolescent (Well-Client)
Mature Milk

- Replaces transitional milk after two weeks

- It contains 20 kilocalorie per ounce and
nutrients sufficient to meet infant’s needs

Maternal Concerns regarding breastfeeding

Engorgement

- May become a problem if feedings are delayed

or too short
- It begins on the second through the fourth day Sign 2 1 0
after birth A Activity Active Arms and Absent
legs flexed
- Breasts become edematous, hard and tender
P Pulse >100 bpm <100 bpm Absent
- May lead to nipple trauma, mastitis and even
G Grimace Sneeze, Grimaces No
the discontinuation of breast feeding coughs, response
- With regards to nipple trauma, nipple pain pulls
usually peaks at the third to 6th day and resolves away
soon after A Appearance Normal Normal Cyanotic
- So part of your health teaching would be breast over except or pale
entire extremities all over
care and breastfeeding technique
body
INITIAL GOALS (once the baby is out) R Respiration Good, Slow, Absent
crying irregular
1. Airway 2. Warmth
➔ So because the first vital test of the ➔ Provide warmth to the baby
newborn adaptation is the initiation of ➔ The neonate must produce and maintain
respirations heat to prevent the serous effects of good
➔ So, once the baby is out in the first one- stress when it moves from the warm uterus
minute APGAR score is done to the cooler outside environment
➔ It is to describe the condition of the new ➔ So once the baby is out you should assess
born immediately after birth and conducted the umbilical cord and it should have two
one minute then again at five minutes or at arteries and one vein
10 minutes
For the vital signs:
➔ It also provides a mechanism to record fetal
to neonatal transition - Respiratory rate is 30 to 60 breaths per minute
➔ What do you assess? - Heart rate is 110 to 160 bpm
Activity ➔ it is important to listen to the optical pulse
Pulse in a quiet or sleeping infant so the sounds
Grimace (reflex irritability) can be heard more clearly
Appearance (skin color) ➔ 180 bpm – if crying
Respiration ➔ 100 bpm – if sleeping
➔ APGAR Score: - Blood pressure is not done routinely
7-10 = supportive care ➔ Systolic – 60-80 mm Hg
4-6 = moderate depression ➔ Diastolic – 40-50 mm Hg
Less than 4 = aggressive resuscitation may - Temperature – Rectal (36.5-37.7 degree
be performed and there is risk for mortality Celsius)

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NCM 107: Care of Mother, Child, Adolescent (Well-Client)
Signs of Respiratory Distress:
• Retractions
 Retractions occur when soft tissue around
the bones of the chest is drawn in with the
effort of pulling air into the lungs
 Especially the substernal retractions occur
when the area under the sternum retracts
each time the infant entails
• Nasal flaring
 It is a reflex widening of the nostrils occur
when the infant is not receiving sufficient
oxygen
• Cyanosis
 Is a purplish-blue discoloration that
indicates the infant is not getting enough
oxygen
GENERAL CHARACTERISTICS OF A
NORMAL NEWBORN
Head Circumference
- Should be around 32-39 cm or 14-15 inches
Chest Circumference
- Should be cylinder in shape
- Around 30-36 cm or 12-24 inches
Expected Length
- 44-45 cm or 17-22 inches
Expected Weight
- 5 lbs to 8 lbs or 14 oz
Intake and Output
- First 2 days of life:
Intake
➔ 40-60 ml/kg a day
Output
➔ At least 1-2 voids daily
- After the first 2 days:
Intake
➔ 100-150 ml/kg daily by 7 days
Output
➔ At least 6 voids daily by the 4th day
POSTNATAL CARE
The newborn would pass out the first stool which is
called the meconium stool and followed by transitional
stools.
- Your meconium stools contain particles from
amniotic fluids such as virionic (?) skin cells and
hair along with cells shed from the intestinal
tract bile and other intestinal secretions
- The first meconium is usually passed within 12
hours of birth and 99% of infants have the first
2 within 48 hours
In a normal newborn the usual color is pink or tan with
acrocyanosis (there is a bluish discoloration of hand and
feet caused by reduced peripheral circulation)
Mongolian Spots
- Bluish black marks that resembles bruises on
the sacrum, buttocks, arms and shoulders
Vernix Caseosa
- Vernix caseosa increases
- A thick, white substance that provides
protective covering for the fetal skin in utero
Lanugo
- Lanugo over shoulders, side of face, forehead or
upper back
- Fine hairs that covers the fetus during
intrauterine life
Milia
- White spots
- 1-2 mm in size
- Caused by distention of sebaceous glands
Milia or Mongolian Spots may be noted but are normal
variations.
When you examine the newborn set sutures are
palpable with small separation between each. So these
are spaces between infused bones on the infant's head.
Anterior Fontanelle
- Should be diamond in shape
- Soft and flat
- May bulge slightly with prying (?)
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NCM 107: Care of Mother, Child, Adolescent (Well-Client)
Posterior Fontanelle Nose Both nostrils open to airflow
If you observe nasal flaring, it could
- Triangular be a sign of respiratory distress
Fontanels Mouth Tongue pink, lips and palate intact,
sucking, swallowing, rooting and gag
- Are spaces between unfused bones on the reflexes present
infant’s head If there is a protruding tongue, it
could be a sign of down syndrome
Sunken Fontanelle Neck/Clavicles Short neck, turns head easily side to
- A sign of Dehydration side
Infant raises head when prone
Bulging Fontanelle Clavicle should be intact
Abdomen Rounded, soft
- There could be a possibility that the newborn is Meconium pass within 12 to 48
experiencing Increased intracranial pressure hours
(ICP) or hydrocephalus Urine pass within 12 hours
If it is distended, it could be a sign of
Normal Variations would be molding because of the
obstruction and enlarged organs
overriding of sutures or Caput Succedaneum or
Genitals Female – Urinary meatus and vagina
Cephalohematoma present
Caput Succedaneum - Sometimes there is a small
amount of mucous vaginal
- An edematous swelling formed under the discharge
presenting part of the scalp as a result of a - Labia majora is dark,
trauma Covered (?) clitoris and labia
minora
Cradle Cap Male – Meatus at the tip of penis
Extremities Equal and bilateral movement of
- Greasy, yellowish, scaly rash that commonly
extremities should be observed with
affects infants in the first few weeks of lie
good muscle tone
Normal Newborn If there is diminished or absent
Posture Flexed extremities, resist extension, movement, it could be a sign of
return quickly to flexed state. Hand paralysis
usually clenched. Movement Observe also for the correct number and formation of
symmetric fingers and toes.
Cry Lusty and strong
Warning Signs
Ears Well-formed and complete
- Temperature greater than 39 degrees Celsius
If you observe low set ears, it could
be a sign of chromosomal disorders. (100.4 Fahrenheit)
The baby responds to loud noises ➔ Could be a sign of infection
and alerts to high pitch voice. - Poor feeding effort
- Vomiting and diarrhea
Face Symmetric in appearance and ➔ Which would put the baby at risk for
movement dehydration
If there is asymmetry, it could be a - Inconsolable crying
sign of facial nerve damage ➔ High pitch – means the baby might be
Eyes Symmetric, eyes clear, transient experiencing increased intracranial pressure
strabismus. Scant or absent tears ➔ Weak – could be a neurologic problem

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NCM 107: Care of Mother, Child, Adolescent (Well-Client)
- Inability to arouse, exceedingly sleepy - Aside from breast care
- Yellowing of the skin and breastfeeding, you
➔ It’s pathologic if it occurs in the first 24 should assist the mother
hours in positioning during
- No wet diaper in eight hours breastfeeding
- As a nurse, you should
NURSING ASSESSMENT take opportunity to teach
During postpartum, it is important to focus on the 8 about breast care and
breastfeeding
assessments presented through BUBBLE-HE acronym.
- Basically, your health
BUBBLE-HE is the acronym used to denote the teaching should start
components of the postpartum maternal nursing during the prenatal
assessment period and it goes
through postpartum
- Essential components of the nursing - In every assessment, you
assessment take advantage to do
- If you have a mother who had cesarean section, your health teaching
aside from the postpartum evaluation, the U Uterus - Firm or boggy
patient is also considered a post-op patient ➔ To understand if the
uterus is returning to
VITAL SIGNS its pre-pregnant state
- Fundal height
• 1st hour- every 15 minutes - Midline or deviated to
• 2nd hour- every 30 minutes the left or right
• 1st 24 hours- every 4 hours ➔ Could mean that the
• After 24 hours- every 8 hours bladder is full
• Vital signs should return to a normal level in - What could be the
about 24 hours after delivery possible risk if the uterus
is not firm or if it is
B Breast - Check for size, shape, boggy?
firmness, redness, ➔ Uterine atony and
symmetry could cause
- Engorgement - usually hemorrhage
occurs 72 hours after - If the mother is post CS,
birth the fundus must be
- The breast should be soft palpated gently because
and nontender after 2 of the discomfort that
days of delivery could cause by the
- The breast changes uterine incision
usually depends if the - If the uterus is not
mother is breastfeeding contracted but there is an
or not excessive amount of
- Aside from the size and lochia, it could suggest
shape, check also the laceration
areola. Observe for B Bladder - Postpartum mother may
flatness or retraction have difficulty voiding
which would make it resulting in a distended
difficult for breastfeeding bladder

POSTNATAL CARE YUSON, DREA

NCM 107: Care of Mother, Child, Adolescent (Well-Client)
- Palpation of a rounded
mass suggests bladder
distention
- If bladder is distended →
uterus will not contract
well and leads to uterine
atony and hemorrhage
10
- If it is displaced to the
right or left → bladder is
full
B Bowels - Spontaneous bowel
movement may not occur
for 2-3 days due to pain,
decrease muscle tone in
the intestines, lacerations
or hemorrhoids
- It is important to
encourage the mother to
increase fiber intake
L Lochia - Assess the color, odor
and Amount
- 3 types: (alba, serosa,
rubra)
- To assess, ask the mother
to do side lying position.
And observe on peri
pads. While also checking
the perineum
- Once the color of lochia
firm alba or goes back to
rubra or serosa meaning
having again hemorrhage
- Is there lochia in CS? (yes)
but the difference, it can
be only scanty. Compared
to SVD
E Episiotomy Assess for REEDA
and • Redness
Perineum • Edema
• Ecchymosis
• Discharge
• Approximation
- All types of postpartum
perineal hematoma
POSTNATAL CARE
- Excessive pain and
tenderness = localized
infection
- Scale from 0-15 = 0
infection 1-5 mild 6-10
moderate 11-15- severe
infection
- HOW TO ASSESS: side
lying with knees flexed
H Homan’s - Assess for sign of Deep
Sign Vein Thrombosis (DVT) by
the Homan's sign, along
with redness, or warmth
of the leg
- How to assess: dorsiflex -
Pain in the calf with sharp
dorsiflexion of the foot
- Encourage the mother to
ambulate early
- Assist the mother in
walking
E Emotions - Assess how the mother
interacts with the family,
level of independence,
energy level, eye contact
with the infant etc.
- Primipara – has higher
risk of p.p. depression
that multipara
POSTPARTUM REPORTABLE SIGNS: MATERNAL
✓ Fever more than 38 degrees celsius
✓ Foul smelling lochia or unexpected change in
color or amount
✓ Visual changes: blurred vision, headache
✓ Calf pain upon dorsiflexion of the foot
✓ Swelling, redness or discharge at the episiotomy
site
✓ Dysuria, burning or report of incomplete
emptying of the bladder
✓ Shortness of breath, DOB
✓ Depression or extreme mood swings
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NCM 107: Care of Mother, Child, Adolescent (Well-Client)
Postpartum Reportable Signs NEWBORN If mother has COVID postpartum, what are the health
✓ Temperature greater than 38 degrees celsius teachings?
✓ Poor feeding effort
1. Handwashing
✓ Vomiting or diarrhea
2. Mask while breastfeeding
✓ Inconsolable crying
3. Proper breast care
✓ Inability to arouse, exceedingly sleepy
4. If very weak – alternative ways to breastfeed
✓ Yellowing of the skin
5. Could be breast pump or bottle feed
✓ Not wet diaper in 8 hours
6. Or know somebody who is breastfeeding and
DISCHARGE INSTRUCTION ask milk
• Nutrition - adequate fluid; select food that
needs energy rather than diet.
• Rest and sleep – fatigue is common and may
continue for months. Family members will help
in taking care of the baby if possible. Take naps.
• Resumption of activities – when the mother
plans to go back to work or usual household
chores w/o too much fatigue
• Exercise – Kegel (help strengthen vaginal
muscles; like holding the flow of urine. Hold it
for 10 seconds then relax for 10 seconds).
Encourage 30 contraction a day.
o Chest exercises and knees
• Breastfeeding and breast care (keep nipple dry.
Don’t use soap when cleaning nipples)
• Different breastfeeding position
• Resumption of menstruation (depends if
lactating or not) and sexual activity
• Family Planning
• Care of the newborn (clean the cord, signs of
infection, immunization, and follow-up visits)
• Follow-ups – after 2 weeks

If COVID vaccine – would it affect mother’s

breastfeeding? → no.

Or If mother has COVID infection → it will not pass-

through milk.

POSTNATAL CARE YUSON, DREA

NCM 107: Care of Mother, Child, Adolescent (Well-Client)
How to Care for a Growing Client?
PROMOTION OF AN INFANT AND FAMILY
INFANTS
- Infants grow rapidly both in size and in their
ability to perform tasks during their first year.
- Most infants double their birth weight by 4-6
months and triple it by 1 year.
- An infant increases in height during the first year
by 50% or gross from the average birth length of
20 inches to about 30 inches
- An average infant progresses through systematic
motor growth during the first year strongly
reflecting the principles of cephalocaudal or
head to toe and gross to fine motor development
➔ Motor development is from head to toe,
gross to fine motor
MOTOR DEVELOPMENT
Shown in the picture is an example of a motor
development of an infant from birth to 1 year.
TYPE OF PLAY: SOLITARY PLAY
- Type of play for infant is what we call a solitary
play
- Solitary play, also known as independent play, is
one of the earliest stages of play where children
play alone because they have not developed
socially to be able to play with others yet
MODULE 6F: CARE OF THE GROWING CLIENT
THE NURSING ROLE IN HEALTH
PROMOTING INFANT SAFETY
- Unintentional injuries are a leading cause of
death in children from 1 month through 24 years
of age
- Most unintentional injuries in infancy occur
because parents either underestimate or
overestimate a child’s ability
Aspiration Prevention
- Aspiration is a chief injury threat to infants
throughout the first year
- Educate parents who feed their infant formula
no to prop bottles. By doing this, they are
overestimating their infant’s ability to push the
bottle away.
➔ Sit up, turn the head to the side, cuff (cough)
and clear the airway if milk should flow too
rapidly into the mouth allowing an infant to
aspirate
- Caution parents to be certain nothing comes
within an infant’s reach that would not be safe to
put in the mouth
- Use clothing without decorative buttons and
checking toys and rattles to ensure they have no
small parts that could snap off or fall out are
good steps for parents to follow
- When solid foods are introduced, encourage
parents to offer small pieces of food/ hotdogs,
not large chunks because small pieces of food is
small enough to be aspirated
➔ Children under about 5 years of age should
not be offered popcorn or peanuts because
of the danger of aspiration
- As infants become more adept(?) at handling
toys, parents need to reassess toys for loose
pieces or parts
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NCM 107: Care of Mother, Child, Adolescent (Well-Client)
Fall Prevention
- Falls are a second major cause of infant injuries
- As a preventive measure no infant, beginning
with a newborn, should be left unattended on a
raised surface.
- If the child sleeps in a crib, the mattress should
be lowered to its bottom position, so the height
of the side rails increases
- Side rails should be no more than 2 inches apart.
Narrow enough so children cannot put their
head between them.
- Be sure crib sides are raised and secure
- Make sure cords from nursing call bells or other
equipment are out of an infant’s reach
Childproofing
- Toward the end of pregnancy, parents need to
begin preparing for their infant’s arrival by
childproofing their home
- Remind parents to thoroughly check for possible
sources of lead paint such as painted cribs,
playpen rails, or windowsills before this time to
avoid lead poisoning
- If an infant is going to play on the floor, urge
parents to move furniture in front of electrical
fixtures or buy protective cups for outlets
- Parents may need to install safety gates at the
top and bottom of stairways as additional safety
measures before the infant crawls
- Urge parents to move all potentially poisonous
substances from bottom cupboards and store
them well out of their infant’s reach
- Remind parents to check play areas or areas such
as tabletops for pins or other sharp objects that
could be swallowed
PROMOTING NUTRITIONAL HEALTH OF AN
INFANT
- The best for an infant during the first 12 months
of life and the only food necessary for the first 4
to 6 months is breastmilk.
- The entire first year of life is one of extremely
rapid growth so a high protein, high calorie
intake is necessary
MODULE 6F: CARE OF THE GROWING CLIENT
- A normal full-term infant can thrive on breast
milk or a commercial iron-fortified formula
without the addition of any solid food until 4-6
months
- Delaying solid food until this time prevent
overwhelming an infant’s kidneys with the heavy
solute load
- It may also delay the development of food
allergies in susceptible infants and be yet
another way to help prevent future obesity
- Parents can tell infants are physiologically ready
for solid food when they are nursing vigorously
every 3-4 hours and do not seem satisfied or
when they are taking more than 32 ounces
formula a day and do not seem satisfied
Introducing Solid Foods
- Infants are not ready to digest complex starches
until amylase is present in saliva at
approximately 2-3 months
- Biting movements begin at 3 months
- Chewing movements do not begin until 7-9
months therefore foods that require chewing
should not be given until this age
- The extrusion reflex needs to fade before infants
accept food readily. The extrusion reflex fades at
3-4 months. At the same time, the GIT has
matured to be ready to digest food solid
Typical pattern for the introduction of solid food
beginning at four to six months includes:
Iron fortified infant cereal mixed with breast milk,
orange juice or formula
- The iron fortified infant cereal aids in preventing
iron deficiency anemia as well as the least
allergenic type of food and the most easily
digested so it's usually the First food offered
Fruits and Vegetables
- Fruit, these are the best sources of vitamin C and
a good source of vitamin A
- Vegetables are good sources of vitamin A and of
course adds new texture and flavors to the
infant's diet
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NCM 107: Care of Mother, Child, Adolescent (Well-Client)
Meat
- Meat is a good source of protein, iron, and B
vitamins
- At the end of the first-year egg yolk, a good
source of iron, can be added
Tips to help introduce solid foods to infants:
• Introduce one food at a time, waiting 3-7 days
between new items.
• Introduce the food before formula or
breastfeeding when the infant is hungry
• Introduce small amounts of a new food one or
two teaspoons at a time
• Respect infant food preferences.
➔ A child cannot be expected to like all new
tastes equally well
• Use only minimal to no salt and sugar on solid
food to minimize the number of additives
• To prevent aspiration, do not place food in
bottles to drink with formula
• Even if you don’t like the food, introduce it with
a positive “you will like this” attitude
ESTABLISHMENT OF HEALTHY EATING
PATTERNS
Weaning
The sucking reflex begins to diminish in intensity
between 6 and 9 months which makes this the time to
consider weaning from a battle.
To wean from either formula or breast milk, the parent
needs to:
• Choose one feeding a day
• Begin offering fluid by a new method at that
feeding time
- After 3-7 days, when an infant has become
acclimated to the one change, the parent then
changes a second feeding and so on
MODULE 6F: CARE OF THE GROWING CLIENT
Self-feeding
- At approximately 6 months of age, infants
become interested in handling a spoon and
beginning to feed themselves. Their
coordination unfortunately has not developed
enough for them to use a spoon without a
great deal of spilling. So they are much more
adept at feeding themselves with their fingers
- When infants play with their food by
squeezing it through their fingers or dabbing it
in their hair, it is time to end the meal.
- Infants who are hungry eat
- Those who are full play
DENTAL CARE
The first baby tooth usually erupts at 6 months, followed
by a new one monthly.
• To protect teeth enamel, a water 0.3 ppm
fluoride in water is recommended or the use of
fluoride toothpaste
• Toothbrushing can begin even before teeth
erupt by rubbing a soft washcloth over the gum
pads
• Once teeth erupt, all surfaces should be brushed
with a soft toothbrush once or twice a day
• Initial dental checkup should be made by two to
2.5 years of age and continue at 6 months
interval
TEETHING
Some infants have difficulty with teething, but some
appear very distressed by the process. Because of pain,
infants can be resistant to chewing for a day or two and
be slightly cranky possibly because they are a little
hungry from not eating as much as usual.
• Rubbing a gum line with a finger or a soft
washcloth can help a new tooth erupt
• Teething rings that can be placed in the
refrigerator or freezer provide soothing coolness
against tender gums.
➔ Cool teething rings provide soothing
coolness against tender gums
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NCM 107: Care of Mother, Child, Adolescent (Well-Client)
• Remind parents that an infant who is teething
will place almost any food on the mouth to chew
on.
➔ Parents must screen articles within the
baby’s reach to be certain they are edible or
safe to chew on
• Tylenol may be given for teething discomfort.
OTC should be discouraged.
➔ Many over-the-counter medicines are sold
for teething pain. As a rule, this should be
discouraged especially if they contain
benzocaine. If applied too far back in the
throat, this could interfere with the gag
reflex.
➔ Infants or children’s liquid Tylenol may be
given for teething discomfort after parents
check with their primary care provider for
the correct dose.
BABY-BOTTLE TOOTH DECAY SYNDROME
May occur when:
• Putting an infant to bed with a bottle can result
in decay of the teeth.
• To prevent this, advise parents never to put their
baby to bed with a bottle.
TODDLERS
- The age span from 1 to 3 years enormous
changes take place in a child and consequently in
a family
- During this period, children accomplish a wide
array of developmental tasks and change from
largely immobile and pre-verbal infants who are
dependent on caregivers for the fulfillment of
most needs to walking, talking young children
with a growing sense of autonomy
- While toddlers are making great strides
developmentally, their physical growth begins to
slow
- Toddlers tend to have a prominent abdomen
because although they are walking well their
abdominal muscles are not yet strong enough to
support abdominal contents as well as they will
be able to do later
MODULE 6F: CARE OF THE GROWING CLIENT
- They also have a forward curve of the spine at
the sacral area known as lordosis.
➔ As they become more experienced at
walking, this will correct itself naturally
- In addition, many toddlers waddle or walk with a
wide stand or stance. This stance seems to
increase the lordi curve but it keeps them on
their feet.
- Toddlers also speaks in two-word sentences
- “Baby fat” begins to disappear
TYPE OF PLAY: PARALLEL
- All during the toddler period, children play
beside other children not with them this side-by-
side play
- Is not unfriendly but is a normal mental
sequence that occurs during the toddler period
- Caution parents that if two toddlers are going to
play together, they must provide similar toys
because an argument over one toy is likely to
occur
THE NURSING ROLE IN HEALTH
PROMOTION OF TODDLER AND FAMILY
WAYS TO ENCOURAGE PARENTS TO PROMOTE
HEALTHY DEVELOPMENT OF INDEPENDENCE IN THEIR
TODDLER:
1. Listening carefully to their concerns
2. Asking questions to help separate the objective
circumstances surrounding a problem from the
parents’ possible emotional biases
3. Providing guidelines on how to handle specific
problems
PROMOTING TODDLER SAFETY
Accidents (Unintentional Injuries)
- Accident and unintentional injuries are the major
cause of death and infants through young adult
in the United States
- Unintentional ingestions like poisoning and auto
accidents are the types of unintentional injuries
that occur most frequently in toddlers
- Urge parents to child proof their home by putting
all poisonous products, drugs, and small objects
out of reach by the time their infant is crawling
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NCM 107: Care of Mother, Child, Adolescent (Well-Client)
and certainly by the time their infant is walking
to avoid these problems
- To prevent serious injury, teach parents to be
alert as to what their toddler is doing at all times
- For safety in automobiles, parents should keep
their toddlers in rear-facing seats until age 2
years or until the child reaches the maximum
height and weight for the particular seat
- Toddlers need to wear a helmet as soon as they
begin riding a tricycle or bicycle
UNINTENTIONAL INJURY PREVENTION MEASURES
FOR TODDLERS:
• Do not leave child alone in a bathtub or near
water
• Do not allow child to approach strange dogs
• Never present medications as candy
• Buy medications with child proof caps or put
away immediately after use
• Do not leave child unsupervised near hot water
• Keep electric wires and cords out of the child’s
reach. Cover electrical outlets with safety plugs.
Know whereabouts of toddlers at all time
• Do not allow the child to play outside
unsupervised
PROMOTING NUTRITIONAL HEALTH FOR
TODDLERS
- Because growth slows abruptly after the first
year of life. A toddler’s appetite is usually less
than an infant’s.
- Children who ate hungrily 2 months earlier now
may sit and play with their food
- It is important to etiquette parents that while the
child is still an infant, this decline in food intake
will occur so they will not be concerned when it
happens.
- Because the actual amount of food eaten daily
varies from one child to another, teach parents
to place a small amount of food on a plate and
allow their child to eat it and ask for more rather
than serve a large portion that the child cannot
finish.
- Growth slows and food intake declines.
- Serve small amount of food on a plate
MODULE 6F: CARE OF THE GROWING CLIENT
- One tablespoon of each food served is a good
start
- Toddlers usually prefer to eat the same type of
food over and over. This is because of the sense
of security this offers.
- Allowing self-feeding or self feeding is a major
way to both strengthen independence in a
toddler and improve the amount of food
consumed
- Offer finger foods such as pieces of chicken,
slices of banana, pieces of cheese and crackers
and allowing to choose between 2 types of food
helps promote independence while exposing
children to varied foods
Toddler Nutritional Requirement
• Sedentary children should consume 1,000 kcal
daily. Active children need up to 1,400 kcal
• Diets high in sugar should be avoided to prevent
childhood obesity
• Adequate calcium and phosphorus intake is
important. This is important for bone
mineralization.
• Toddlers need protein, carbohydrates and fats
PROMOTING TODDLER DEVELOPMENT IN
DAILY ACTIVITIES
- A toddler’s new independence and developing
abilities in self-care such as dressing, eating, and
to a limited extent hygiene presents special
challenges for parents
- Learning how to promote autonomy yet
maintain a safe and healthful environment
should be a major goal for the family
Dressing
- By the end of the toddler period, most
children can put on their own socks and
underpants.
- Parents may be reluctant to encourage
toddlers to dress themselves because it is
easier and quicker for a parent to do so
- When toddlers dress themselves, they
invariably put shoes on the wrong feet and
shirt and pants on backwards.
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NCM 107: Care of Mother, Child, Adolescent (Well-Client)
- Encourage parents to give up perfection. If
they feel the must to change the child’s
clothes, urge them to begin with a positive
statement
Sleeping
- The amount of sleep for children need
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 for
sleep declines at this time may view a child’s
disinterest in sleeping as a problem
- Some toddlers begin having night terrors or
awake crying from a bad dream and so may
receive little sleep because they are reluctant
to fall back asleep
- Other toddlers resist nap time as part of their
negativism
- When toddlers are tired, they naturally fall
asleep. They may begin to resist naps however
as well as nighttime sleep as they become
aware for the first time that activities go on
while they sleep
- As with any other activity of this period,
toddler loves a bedtime routine. Pajamas, a
story, toothbrushing, being tucked into bed,
having a drink of water, choosing a toy to
sleep with and turning out the lights
- Parents must be careful however not to let a
child maneuver them into such a long
procedure that sleep is delayed considerably
past the time initially set.
- Many toddlers are ready to be moved out of a
crib into a youth bed or a regular bed with
protective side rails or a chair strategically
placed beside it
MODULE 6F: CARE OF THE GROWING CLIENT
Bathing
- Toddlers usually enjoy bath time and
parents should make an effort to make it
fun by providing a toy such as a rubber
duck or plastic fish
- Bath time is usually so enjoyable for toddlers
that parents can use it as a recreational
activity or something to do on a rainy day
when they can find nothing else to interest
their child
- Remind parents that although toddlers can sit
well in a bathtub it is still not safe to leave
them unsupervised. They might slip and get
their head under water or reach and turn on
the hot water faucet and scald themselves.
Dental Care
- Toddlers often need between meal snacks
- To help prevent dental caries from frequent
snacking, encourage parents to offer fruit such
as banana, piece of apple, or orange slice or
protein foods such as cheese, pieces of
chicken for snacks rather than high
carbohydrate items such as cookies to limit
exposure of a child’s teeth to carbohydrate
- Remind parents not to put a child to bed with
a bottle of milk or juice to help prevent the
development of caries (?)
- Remind parents that it is better for a child to
brush thoroughly once a day probably at
bedtime than to do it poorly many times a day.
- Parents can prepare their child for this first
dental visit at 12 months of age
➔ Urge parents to schedule a dental visit at
about 12 months of age.
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NCM 107: Care of Mother, Child, Adolescent (Well-Client)
PARENTAL CONCERNS ASSOCIATED WITH
THE TODDLER PERIOD
- Parental concerns of the toddler period usually
arise because of a conflict over autonomy
Toilet Training
- One of the biggest tasks a child tries to
achieve.
- Most first-time parents ask when to start
when training should be completed and how
to go about it
- 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.
- When children have mastered defecation, it is
time to include urination. Some toddlers have
difficulty remaining dry at night until 3-4 years
old.
Before children can begin toilet training, they must
have reached 3 important mental levels:
1. Physiologic
➔ Must have control of rectal and urethral
sphincters usually achieved by the time
they walk well
2. Cognitive (other two)
➔ Understanding of what it means to hold
urine and stools until they can release
them at a certain place and time.
➔ Must have a desire to delay immediate
gratification for a more socially accepted
action.
Ritualistic Behavior
- Although toddlers spend a great deal of time
everyday investigating new ways to do things
and try activities they have never done before,
They also enjoy ritualistic patterns
- They will use only their spoon at mealtime or
only their blanket at bedtime.
MODULE 6F: CARE OF THE GROWING CLIENT
Negativism
- As part of establishing their identities as
separate individuals, toddlers go 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"
- This change indicates toddlers have learned
that they are separate individuals with
separate needs. It is important toddlers do
this if they are to grow up to be persons who
are independent and able to take care of their
own needs and desires.
- A toddler's “no”can best be eliminated by
limiting the number of questions asked. A
toddler needs experience in making choices.
However, to provide the opportunity to do
this a parent could give a secondary choice no
is not allowed for the major task so the parent
states, "It's bath time now, do you want to
take your duck or your toy boat into the tub
with you?"
- Other examples are "It's lunchtime, do you
want to use a big or little plate?" "It's time to
go shopping, do you want to wear your jacket
or your sweater?"
- Although this solution is simple it is one
parents may not arrive at by themselves
because finding a solution to a problem is
always more difficult for a person in the
middle of the problem than it is for an
objective observer.
- Once there help to practice this approach
however parents usually find it helpful in
smoothing out the friction costs by the
negativism of the toddler period.
Temper Tantrums
- Almost every toddler has a temper tantrum at
one time or another the child may kick,
scream, stomp feet, shout “no”, flail arms and
legs, bite or bang his or her head against the
floor.
- Temper tantrums occur as a natural
consequence of toddler’s development, they
occur because toddlers are independent
enough to know what they want but they do
not have the vocabulary or the wisdom to
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NCM 107: Care of Mother, Child, Adolescent (Well-Client)
express their feelings in a more socially
acceptable way
- For example: temper tantrums occur most
often when children are tired just before nap
time or bedtime or during a long shopping trip
or visit. They may be a response to an
unrealistic request by a parent such as asking
a child to comb her hair before she is
coordinated enough to do so.
In managing the toddler’s temper tantrums:
- Try to determine the reason for the behavior.
Do tantrums always occur just before
bedtime? Do tantrums occur every time you
go Shopping? Do tantrums occur whenever
you ask a child to do something?
- Be or make certain it is a tantrum not
something more. Is there a possibility you are
mistaking seizure activity for temper
tantrums? Could you be confusing neurologic
breath holding with a temper tantrum?
- Think through what you do when a child has a
tantrum. Do you give either material or
emotional bribes? Do you punish a child or do
you role model adult behavior in managing
anger or frustration?
- Probably the best approach is for parents to
simply tell a child that they disapprove of the
tantrum and then ignore it.

MODULE 6F: CARE OF THE GROWING CLIENT YUSON, DREA


PART 2: CARE OF GROWING CLIENT
NURSING CARE OF A FAMILY
WITH A PRESCHOOL CHILD:
PRESCHOOL
- period traditionally includes the
years 3, 4, and 5.
- Although physical growth slows
considerably, during this period
personality and cognitive growth
continue at a rapid rate.
 Definite change in body contour
occurs during their preschool
years:
1. Appears slimmer, taller
(ectomorphic body)
2. Vocabulary increases to 900
words
3. Growth is only 2-3.5 inches a year
4. Body contour changes to be
more childlike than babylike
5. Increased coordination.
Constantly in motion.
- bicycle
- riding
- running
- kicking
TYPE OF PLAY: in preschool
Associated play - is one of the
categories used to describe the
development of a social play by
preschoolers.
 it is generally the first stage
where social interaction is
required in children's play as
they engage in a mutual activity
though not working toward a
common goal.
 as preschoolers broaden their
horizons, safety issues must also
widen.
 PROMOTING PRESCHOOLER
SAFETY
 Children may project an attitude
of independence and the ability
to take care of their own needs
however they still need
supervision to be certain they do
not injure themselves or other
children.
MEASURES TO KEEP CHILDREN
SAFE, STRONG AND FREE:
 Cautioning a child never to talk
with or accept a ride from a
stranger
 Teaching a child how to call for
help in an emergency
 Explaining that bullying behavior
is not to be tolerated.
 Stress the important role of
wearing seat belts
 Teach the child to always hold
hands with an adult before
crossing a street
 Teach parking lot safety
 teach beginning swimming
PROMOTING THE NUTRITIONAL
HEALTH OF A PRESCHOOLER:
- like a toddler period the preschool
years are not a time of fast growth
so
 preschool children are not likely
to have ravenous appetite.
BANDIOLA, JOVELYN P.

 Most children are hungry after
preschool and enjoy a snack
when they arrive home because
sugary foods can doll a child's
appetite for dinner and it is not
too soon to begin measures to
prevent childhood obesity urge
parents to offer snacks such as
fruit cheese or milk rather than
cookies in a soft drink or juice.
 Allow child to prepare simple
foods
 Offer snacks such as fruits,
cheese or milk rather than
cookies or juice.
 Caution parents not to give
vitamins more than the
recommendation daily amount.
 As with all age groups food
selected for preschoolers should
be based on my plate
recommendations making
certain to offer a variety of food
 If parents do give vitamins
remind them that a child will
undoubtedly view a vitamin as
candy rather than medicine.
 Caution parents not to give more
vitamins than the recommended
daily amount as well or
poisoning from high doses of fat
soluble, vitamins, or iron can
result.
PROMOTING THE DEVELOPMENT
OF THE PRESCHOOLER IN DAILY
ACTIVITIES:
 the preschooler has often
mastered the basic skills needed
for most self-care activities
including feeding dressing
washing, tooth brushing with
supervision.
Dressing
 3-4 years old can dress
themselves.
 Preschool prefer bright colors or
prints.
 They need experience with
choosing their own clothes.
- many three years old and most four
years old can dress themselves
except for difficult buttons although
there may be a conflict over what a
child will wear. Preschoolers prefer
bright colors or prints and so may
select items that are appealing in
color rather than matching.
Sleep
 Go through a typical negative
phase but are aware of their
needs.
 Developmeny of fear of the dark.
- many toddlers who go through a
difficult negative phase resist taking
naps no matter how tired they are
preschoolers however are more
aware of their needs when they are
tired they often grow up on a couch
BANDIOLA, JOVELYN P.
or soft chair and fall asleep on some
occasions even though they may be
tired children in this age group may
refuse to go to sleep because of fear
of the dark and may wake up at night
terrified by a bad dream.
Exercise
 Play tends to be vigorous.
 Active games help develop
motor skills and prevent
childhood obesity.
- preschool period is an active phase
so preschool play tends to be
vigorous. Promoting types of active
games and reducing television
watching can be steps toward
helping children develop motor skills
as well as prevent childhood obesity.
CARE OF THE PRESCHOOLER’S
TEETH:
 Start of independent
toothbrushing
 Continue to drink fluoridated
water or receive oral fluoride
supplement
 Encourage to eat fruits, chicken
or cheese for snacks.
 Dental visit no later than 3 years
of age
- if independent tooth brushing was
not started as a daily practice during
the toddler years it should be started
during preschool one good tooth
brushing period a day is often more
effective than more frequent
half-hearted attempts.
- preschoolers should continue to
drink fluoridated water or receive a
prescribed oral fluoride supplement.
- encouraging children to eat apples
carrots chicken or cheese for snacks
rather than candy or sweets is yet
another way to prevent tooth decay
- a first visit to a dentist should be
arranged no later than three years of
age for an evaluation of tooth
formation because residual teeth or
what we call baby teeth must be
preserved to protect the dental arch
PARENTAL CONCERNS
ASSOCIATED WITH THE
PRESCHOOL PERIOD:
Common Health Problems of the
preschooler:
 Major cause of death:
1. Automobile accidents
2. Poisoning
3. Falls
 Minor illnesses such as colds
and ear infections are high
 Respiratory problems and
gastrointestinal disturbances.
- we have three major causes of
death: automobile, accidents,
poisoning, and falls. Minor illnesses
such as colds and ear infections are
high during the preschool years as
well as respiratory problems and
gastrointestinal disturbances.
COMMON FEAR
1. Fear of the Dark
BANDIOLA, JOVELYN P.
- because preschoolers imaginations
are so active this leads to a number
of fears such as fear of the dark the
tendency to fear the dark is an
example of a fear heightened by a
child's vivid imagination.
- a staffed toy by daylight becomes
a threatening monster at night
- children awaken screaming
because of nightmares they may be
reluctant to go to bed or go back to
sleep by themselves unless a light is
left turned on or a parent sits nearby
- if parents are prepared for this fear
and understand it is a face of growth
they are better able to cope with it it
is generally helpful if they monitor
the stimuli their children are exposed
to especially around bedtime
2. Fear of Mutilation
- fear of mutilation is also significant
during the preschool age as revealed
by the intense reaction of a
preschooler to even a simple injury
such as falling and scraping a knee
or having a needle inserted for an
immunization.
- preschoolers can be worried that if
some blood is taken out of their
bodies all of their blood will leak out.
- they need good explanations of the
limit of health care procedures such
as a tympanic thermometer does not
hurt or a finger prick heals quickly as
well as destruction techniques in
order to feel safe.
3. Fear of Separation and
Abandonment
- fear of separation is yet another
major concern for preschoolers their
sense of time is still so distorted that
they cannot be comforted by
assurances such as mommy will
pick you up from preschool at noon
- relating time and space to
something a child knows better such
as meals, television shows, or a
friend's house is most effective.
- for example stating “mommy will
pick you up from preschool after you
have had your snack “is apt to be
more comforting than “mommy will
pick you at 3 o'clock in the
afternoon”
BEHAVIOR VARIATIONS
- a combination of a keen
imagination and immature reasoning
results in a number of other common
behavior variations in preschoolers.
1. Imaginary Friends
- many preschoolers have an
imaginary friend who play with
them they tell a parent to wait for
Eric or to set a place at a table
for Lucy
- although imaginary friends are a
normal creative part of the preschool
years and can be invented by
children who are surrounded by real
playmates as well as by those who
have few friends, parents may find
them disconcerting, if so let parents
know that as long as their child has
exposure to real playmates and
BANDIOLA, JOVELYN P.
imaginary playmates do not take
center stage in children's lives or
prevent them from socializing with
other children they should not pose
a problem often live as quickly as
they come.
2. Difficulty Sharing
- sharing is a concept that first
comes to be understood around the
age of 3 years, sharing does not
come easily. However, children who
are ill or under stress have greater
difficulty with it than usual.
- as your parents that sharing is a
difficult concept to grasp and as it
with most skills preschoolers need
practice to understand and learn it.
3. Regression
- some preschoolers generally in
relation to stress revert to
behavior they previously
outgrew such as thumb sucking,
negativism loss of bladder
control and inability to separate
from their parents.
- health parents understand that
regression in these circumstances is
normal and a child's thumb sucking
is little different from the parents
reaction to stress. So it is easier for
them to accept and understand
obviously removing the stress is the
best way to help a child discontinue
this behavior.
4. Sibling Rivalry
- jealousy of a brother or sister
may be first become evident
during the preschool period
because this is the first time
children have enough
vocabulary to express how they
feel and partly because
preschoolers are more aware of
family roles and how
responsibilities at home are
divided.
- for many children this is also
the time when a new brother or
sister is born
- to help preschoolers feel secure
and to promote self-esteem during
this time reminding them that there
are things they can do that a
younger sibling is not allowed to do
and supplying them with a private
drawer or box for their things that
parents or other children do not
touch can be helpful.
- a private box serves as a defense
against younger children who do not
yet appreciate property rights.
SCHOOL-AGE
- is a relatively long time span and
even though growth is slow children
grow and develop extensively.
 Annual weight gain: 3-5lbs
 Height: 1-2 inches
 Fine motor becomes refined
 Puberty stage
 Permanent teeth erupt
 Talk in full sentences
- during this time period the average
annual weight gain for for a
school-aged child is approximately
three to five pounds the increase in
BANDIOLA, JOVELYN P.
height is one to two inches and fine
motor becomes refined during this
stage school age also will now
experience pre-puberty stage the
changes in physical appearance that
come with puberty can lead to
concerns for both children and their
parents.
- the school-aged period is a time for
parents to discuss with children the
physical changes that we look for
and the sexual responsibility these
changes dictate.
- those teeth are lost and permanent
permanent teeth erupt during the
school age period because of this
the average child gains 28 teeth
between 6 and 12 years of age.
- age children talk in full sentences
using language easily and with
meaning they no longer sound as
though talking is an experiment but
appear to have incorporated
language permanently.
TYPE OF PLAY: in school-age
Cooperative play - this play
focuses on children working
together to achieve a common goal
such as building.
- a play structure putting together, a
puzzle or engaging in dramatic play.
- it has been described as a stage
where children play in a group that is
organized for the purpose of making
some material product, striving to
attain some competitive goal,
dramatizing situations of adult and
group life or playing formal games.
PROMOTING SCHOOL-AGE
SAFETY:
 Ready for time on their own
without direct adult supervision.
They need good education on
safety practices.
 Teach to avoid unsafe areas
 Teach safety with candles,
matches, and campfires
 Teach skateboard, scooter, and
skating safety
 Wear appropriate equipment for
sports
 Help your child avoid all
recreational drugs
PROMOTING NUTRITIONAL
HEALTH OF A SCHOOL-AGE
CHILD:
 Most school-aged children have
good appetite, although any
meal is influenced by the day's
activity.
 They need breakfast
- to provide enough energy to get
them through active mornings
 Trade lunches and snacks with
friends at school
 They enjoy helping plan meals
- at school as part of fostering
industry school-age children usually
enjoy helping to plan meals they can
prepare foods such as instant
pudding jell-o salad scrambled eggs
and sandwiches they may eat meals
they have planned or prepared more
willingly than ones that are just set in
front of them
BANDIOLA, JOVELYN P.
 Boys require more calories; both
require more iron
- school-age children especially
boys they require more calories
since they are more active
compared to girls but both boys and
girls require more iron in order to
continue to of course grow and
stay active.
 Major deficit is fiber because
they dislike vegetables
- but one major deficit is the lack of
Fiber this is because most
school-aged children they dislike
eating vegetables.
PROMOTING DEVELOPMENT OF A
SCHOOL-AGE IN A DAILY
ACTIVITIES:
Dress
 Can fully dress themselves they
are not skilled at taking care of
their clothes
- until late in the school age years
this is the right age however to teach
children the importance of caring for
their own
 Teach children the importance of
caring for their own belongings
- belongings school-age children
have different opinions about coding
styles
 Have definite opinions about
clothing style
- often based on the likes of their
friends, a popular sport or a popular
musician rather than the preferences
of their parents.
Sleep
 sleep needs vary among
individual children
- younger school-aged children
typically require 10 to 12 hours of
sleep each night older ones require
about 8-10 hours, most
six-year-olds are too old for naps
but do require a quiet time after
school.
 Nighttime terrors may continue
- to get them through the remainder
of the day night time terrors may
continue during the early school
years and may actually increase
during the first grade year as a child
reacts to the stress of beginning
school
 Give up bedtime talks
Care of Teeth
- here the average child today can
expect to grow up cavity-free to
ensure this happening school is
children should:
 visit a dentist at least twice
- yearly for a checkup cleaning and
possibly a fluoride treatment to
strengthen and harden the tooth
enamel
 Remind to brush their teeth daily
 Common dental problems:
1. Dental caries
2. Malocclusion
PROMOTING HEALTHY FAMILY
FUNCTIONING:
Sex Education
- it is important that school-age
children be educated about few
brutal changes in responsible sexual
practices.
BANDIOLA, JOVELYN P.
- also preteens should have adults
they can turn to for answers to
questions about sex.
- ideally this should be their parents
but because sex is an emotionally
charged topic some parents may be
extremely uncomfortable discussing
it with their children as a result
healthcare personnel often become
resource persons.
Bullying
- a frequent reason school-aged
children sight for feeling so unhappy
that they turned guns on classmates
or commit suicide is because they
were ridiculed or bullied to the point
they could no longer take such
abuse.
- alert parents that internet or
texting, bullying are both also
possible and that a bully doesn't
have to be in fact to face contact
with their child to be harmful.
- if bullying behavior is ingrained,
therapy may be needed to correct
the behavior.
- stopping bullying helps not only the
victim but also the bully because
statistics show that children with this
type of aggressive behavior in grade
school are more apt to be
incarcerated as adults than others.
ADOLESCENT
- adolescents both grow rapidly and
mature dramatically during the
period from age 13 to 20 years.
- the major milestone of physical
development in the adolescent
period are the:
 onset of puberty at 8-12 years of
age
 Physical growth and
development of adult occur
- a cessation of body growth around
16 to 20 years between these
milestones physiologic growth and
development of adult
 Undergo sexual maturation
- coordination occur the adolescent
also will undergo sexual maturation
- a girl has entered puberty when
she begins to menstruate, a boy
enters puberty when he begins to
produce spermatozoa.
 Ability to use scientific reasoning
- secondary sex characteristics such
as body hair configuration and
breast growth are those
characteristics that distinguish the
sexes from each other but that play
no direct part in reproduction
PROMOTING HEALTH FOR AN
ADOLSCENT:
- because their judgments are still
limited adolescents still need
guidelines in reference to safety
nutrition and daily care these are
always excellent topics for
discussion at health care visits.
 Tend to eat faddish or quick
snack foods
- adolescents experience such rapid
growth that they may always feel
hungry if their eating habits are
unsupervised because of peer
pressure and when in a hurry to get
to other activities they tend to eat
fetish or quick snack foods rather
than more nutritionally sound ones.
BANDIOLA, JOVELYN P.
 Needs an increased number of
calories
- an adolescent needs an increased
number of calories over that needed
previously to support the rapid body
growth that occurs
 foods must come from a variety
of sources
- to supply necessary amounts of
carbohydrates vitamins protein and
minerals.
PROMOTING DEVELOPMENT OF
AN ADOLESCENT IN DAILY
ACTIVITIES:
* adequate sleep hygiene and
exercise are important health
education topics for adolescents as
these become an adolescent's
responsibility rather than the
responsibility of the parents.
Dress and Hygiene
 capable of total self-care
 may even be overly consensus
about personal hygiene and
appearance
- both sexes try many types of
shampoo, deodorant, breath
fresheners and toothpaste.
- they may take seriously the content
of ads showing that toothpaste or
deodorants can help win an
attractive person or gain instant
access.
 aware of how their peers dress
- when hospitalized most teenagers
seem to improve markly when
allowed to wear their own clothing
rather than a hospital gown.
Care of Teeth
 Conscientious about tooth
brushing because of a fear of
developing bad breath
 Should continue to use a
fluoride paste
- or should also continue to drink
fluoridated water to ensure firm
enamel growth.
Sleep
 May need more sleep than any
other age group.
 Sleep restlessly
- because protein synthesis occurs
most readily during sleep and adult
in are building so many new cells
this age group may need
proportionately more sleep than any
other age group.
- in addition because this is a busy
time with extracurricular activities
and also stressful period similar to
first grade.
- adolescents may sleep restlessly
as their mind reworks the day's
tensions.
PROMOTING HEALTHY FAMILY
FUNCTIONING:
- early adults may have many
disagreements with parents that
stem partly from wanting more
independence and partly from being
so disappointed in their bodies
- it may be helpful to counsel
parents to appreciate that although it
is not easy to live with a teenager it
is equally difficult to be the teenager.
BANDIOLA, JOVELYN P.
COMMON HEALTH PROBLEMS OF - initiation for street guns can require
AN ADOLESCENT: protective members to steal or
 hypertension destroy property or even kill another
 poor posture person.
 Fatigue - to help prevent this from
 menstrual irregularities happening, urge parents to be aware
 Acne of what clubs or organizations their
 obesity adulthood joins and what the
requirements for membership are.
CONCERNS REGARDING - help adolescents make sound
SEXUALITY AND SEXUAL decisions about what type of hazing
ACTIVITY: their organization advocates by
asking them about the subject at
- concerns regarding sexuality and health assessments.
sexual activity due to increasing
exposure to and acceptance of CONCERNS REGARDING
pre-marital sexual relations in SUBSTANCE ABUSE:
society
- more adulterants than ever before - this is so common among
engage in high-risk sexual behaviors adolescents that as many as 50
exposing them to sexually percent of high school seniors report
transmitted infections or conception having experimented with some
because of this as part of routine form of drug
health assessments of adolescence - use of drugs occurs in adolescence
and pre-adolescence from a desire to expand
- ask if they are sexually active or are consciousness, peer pressure or a
concerned about sexual risk desire to feel more confident and
behaviors mature
- it also can be a form of adolescent
CONCERNS REGARDING HAZING rebellion related to childhood
OR BULLYING: adversity or violence

- bullying which begun during school
age can easily continue into
adolescence and actually becomes
more serious because this can be
the time the bullied child has the
ability to regulate through
self-destructive behavior or school
violence.
- adolescents are exposed to a form
of organized bullying called hazing.
- because adolescents may not have
a large source of money the drugs
they most frequently abuse are
those they can obtain in a limited
budget and through limited contacts
- common substances or abuse
substances that they are using are
over-the-counter drugs, alcohol and
tobacco.

BANDIOLA, JOVELYN P.
CONCERNS REGARDING
DEPRESSION AND SELF INJURY:

- self-injury includes a range of

self-destructive actions from cutting
to suicide.

- cutting is found more frequently in

girls than boys and can begin as
early as grade school.

- successful suicide occurs more

frequently in males than in females,
although more females apparently
attempt suicide than males.

- adolescents need to have thorough

physical examinations at health
maintenance visits to assure them
they are in good physical health.

- assess at these visits signs of

depression such as anorexia,
insomnia, excessive fatigue, or
weight loss.

- in younger adolescence depression

may be manifested not so much by
appearing sad but by behavior
problems such as disobedience,
temper, tantrums, running away, or
self-destructive behavior or
injury-prone.

- occasionally depressed
adolescents find it so hard to be
alone that they seek constant
activity as a means of escape.

- others may withdraw from contact

with other people and become
completely isolated.

BANDIOLA, JOVELYN P.