Bachelor of Science in Nursing 2YA

NCMA217 LEC: BSN 2ND YEAR 1ST SEMESTER MIDTERM 2021

o When the level of progesterone is high and the level of four
Coverage for Midterm Exam: hormones are low, the woman will not undergo labor and
• Intrapartal care delivery.
• Labor and delivery o But when the level of progesterone is low and the level of four
• Essential Intrapartal and newborn care (EINC) homes are high, the woman will undergo labor and delivery.
• Newborn Assessment (It will start to uterus to contract) (If the 4 hormones are low
and progesterone is high, then the uterus is not contracting.)
• Postpartum care o When the end of the pregnancy, the placenta will be aging
• Postpartum complications o Oxytocin is the main hormone that is causing uterine
contraction during labor and delivery. Oxytocin coming from
posterior pituitary gland.
LABOR AND DELIVERY o Prolactin is from anterior pituitary gland.
Discussed by Prof. Francis Vasquez Remember:
- The process where in all the products of conception are - When the 4 hormones are high, and the progesterone is
expelled from the uterus (lumabas or kailangan lumabas)
low then the uterus is contracting
- Expulsion of all the products of conception.
- Then, when the 4 hormones are low, and the progesterone
- Different Products of Conception:
• Baby is low then the uterus is relax not contracting
• Placenta Premonitory Signs of Labor
• Umbilical cord • Lightening – Primi – 1-2 weeks/ Multi – 1-2 days
• Amniotic fluid - Madalas lumabas sa board exam tong lightening.
• All the products must go out during the labor and delivery - Lightening is dropping of the baby and entrance of fetal
- What will happen if one of the products of conception is presenting part. This is the earliest sign of labor
remaining the uterus? Example. The baby is out, the amniotic - Entrance of fetal presenting part into pelvic inlet. (Head,
fluid is out, the umbilical cord is out. But the portion of the buttocks, shoulder)
placenta or part of the placenta is remaining on the uterus - 9th month, wala pang lightening – yung fundus nasa
what will happen? xiphoid process.
- Prone to infection - Late 9th month may lightening – yung fundus nasa 8th
- Normal Consistency of the uterus: the uterus after the month level.
delivery of the baby and the placenta must remain - Pag nagkaroon ng lightening, SOB is relieved, napunta sa
contracted. baba yung pressure at nacocompress ung urinary bladder.
- Contracted – firm Kaya mag increase yung urinary frequency and vaginal
- What will happen if the uterus after delivery of the mother, discharge.
after giving birth relaxes? - Pag wala pang lightening, there is increase
- It begins to bleed; the uterus of the mother will bleed. infradiaphragmatic pressure. Meron pa syang SOB
- Everything must go out - Lightening occurs because of the progesterone and relaxin.
- Normally, the uterus is empty organ - Relaxin causing loosening of pelvic joints (kaya
- Length of Gestation: nagkakaroon ng broadening of the hips) Kapag multi para
• 9 months ka na, mas mabilis na ang loosening ng pelvic joints. Lalo
• 37-42 weeks na kung ang delivery ng pregnancy mo ay sunod sunod.
• 280 days - During pregnancy pelvic joint are not yet loose
- But when the woman enters the 3rd pregnancy the pelvis
Hormonal Control of Labor will become broader. Because of loosening the pelvic
joint and because of the 2 hormones
- Primi is the earliest who experience lightening.
- Multi is the fastest lightening.
• Weight loss
- Because of increased tension and fatigues and nesting
behavior.
• Increased tension and fatigue
• Cervical changes
- Effacement and dilatation
- Effacement: Internal OS (thinning)
o Progesterone is the only one hormone that prevent uterine - Dilatation: External OS (widening and opening and
contraction. softening of the cervix
o There are four hormones helping one another to start labor. • Nesting behavior – The woman is busy preparing the
Oxytocin, estrogen, prostaglandin, and fetal cortisol is the materials that baby will used.
hormones stimulate the uterine contraction.
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 CARE OF MOTHER AND CHILD AND ADOLESCENT LECTURE – BSN 2ND YEAR 1ST SEMESTER MIDTERM 2021

• Rupture of bow - Once the uterus reaches the maximum of being stretch,
• Increased Braxton hicks’ contractions the endometrium releases prostaglandin to help the uterus
- Painless irregular contraction during pregnancy. to contract, prevent uterine rupture.
- There is high estrogen level (mataas lang konti) - When the prostaglandin is released, it will cause uterine
- The contraction is painless because the progesterone level contraction; therefore, the products of the conception will
is high. (mataas si estrogen pero mas mataas si go out. The end of the pregnancy, the PPG will produce
progesterone kaya painless sya. Sana painless din kapag oxytocin causes uterine contraction.
broken hearted ka, anhirap eh huhu HAHAHA charot) • Placental degeneration theory
- Nearing labor, progesterone is decreasing, estrogen and • Progesterone deprivation theory
oxytocin is increasing. The Braxton hicks’ contractions - When the placenta is aging or degenerating the ability of
are painful and regular. Kaya nawawalan ng appetite. the placenta to produce progesterone decreases when
Nababawasan ng 2-3 pounds of weight loss prior to labor progesterone decreasing deprive then no hormone will
and deliver. prevent the uterus to contract, that is why the 4 hormones
will increase.
False VS True Labor - Lifespan of placenta is up to 9th month of pregnancy. And
• Pain originates from the abdomen (F) the main hormone that the placenta will produce is
• Pain originates from lumbosacral area (T) progesterone. Preventing contraction.
• Pain is intensified by walking (T) - Mag pinsan si placental degeneration theory at
• Pain is relieved by walking (F) (sana lahat ng pain nawawala progesterone deprivation theory.
pag naglalakad hehe)
• (-) BOW (ruptured) (T) Stages of Labor and Delivery
• Intact BOW (F)
• Sedation decreases contractions (F) – sedation is drug
• Contraction is not affected by sedation (T)
• Contractions are progressive or regular (T)
• Contractions are irregular and non-progressive (F)
• No cervical changes (F)
• With cervical changes (T) effaces/ thinning – internal os and
dilatation widening – esternal os.
• Presence of bloody show (T) – no bloody show (F)
- Cervical dilatation of 4cm, effacement of 50%, intact o Code: D E P R
BOW = true labor (woman can undergo true labor even - The stage of dilatation will start from the true labor to full
the BOW is still intact, yan minsan ung nagpapatagal ng cervical dilatation
labor nya) - Stage 2, from full cervical dilatation to delivery of the
- Spontaneous rupture of the BOW – kaya minsan kapag baby
nag poprolonged labor ka na dahil antagal pumutok ng - Stage 3, from delivery of the baby to delivery of the
BOW = Amniotomy – intentional or artificial rupturing of placenta
the BOW. - Stage 4, from delivery of the placenta to the first 2hrs
- Why amniotomy? – ang sabi natin, ung rupture of water after the delivery
will increase uterine contraction. So, kapag nirupture ni o Stage 1 dilatation is the longest duration because it is
doc ung BOW at nag increase ung uterine contraction, the measured by cm. 1 to 10 cm of cervical dilatation. it takes time
fundus pushing down faster the baby. Then the head of to cervix to dilate.
baby will compress the internal os and magkakaroon ng o Since the stage 1 is the longest duration, it is composed of 3
thinning/ effacement ang internal os. Tas papunta na sya phases. Latent, Active and Transitional
sa external os at mag da-dilate na sya. So the purpose of o The responsibility of the nurse during stage 1 is to monitor the
amniotomy is to shorten the first stage of labor by progress of labor. Using this table ↓
increasing contraction. It improves station.
Criteria
Theories of Labor Onset Latent/ Active/ Transitional/
- How will labor and delivery begin Area
Phase 1 Phase 2 Phase 3
• Prostaglandin theory Cervical
0-3 cm 4-7cm 8-10cm
• Oxytocin theory dilation
• Uterine stretch theory Uterine Contraction
- Magpinsan to sa prostaglandin theory.
- The uterus is a hollow organ. When the woman gets Duration < 40 secs 40-60" 60-90"
pregnant the uterus is filled by the products of conception.
Freq. q 5 mins > q 3-5mins 1 1/2 mins
- As the baby growing, the uterus will also grow – enlarges
- But as the uterus enlarges, the uterus is thinning because Intensity mild-mod mod-strong strong
of the uterus is being stretch
Clients less
cooperative Uncooperative
Mood cooperative

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 CARE OF MOTHER AND CHILD AND ADOLESCENT LECTURE – BSN 2ND YEAR 1ST SEMESTER MIDTERM 2021
o Sa stage 1, ang ginagawa ng nurse ay minomonitor yung vital
signs, monitoring of uterine contraction, performing IE.
o The woman is cooperative in latent phase because the intensity
is mild, the frequency is less frequent and when the uterus
contract is only short.
o During contraction in latent phase the woman is not
experiencing a lot of pain. (naka ngiti pa yan si mommy,
madaldal pa sya)
o In transitional she’s uncooperative because the intensity of
a) Oxytocin
uterine contraction is already strong. (Masakit na bhi3, ikaw
kaya, pag heartbroken ka. Nalaman mo may iba na syang
mahal, syempre masakit yon diba. Kahit daldal ng daldal ung
katabi mo, wala kang pake (uncooperative) kasi nga masakit
ung puso mo, gusto mo mag emote or magwala. Ganern
HAHAHHA sorri heartbroken kase nagtype neto hehe)
o The uterus will contract for 90 seconds occurring every 1 and
half minutes – If the uterus contracts now and happen again in
2 minutes.
o For duration – seconds; frequency – mins and seconds
o Latent phase is the best time to teach the mother about the
proper pushing because she is still cooperative.
o The maximum duration of one contraction during transition is
90 secs only. Dapat ung intensity is strong, hindi very strong.
o Kapag lumalagpas sa 90 secs yung one contraction, the baby is
fetal distress. Pag ganon, notify the doctor agad.
o You need to monitor the fetal heart rate, fetal movement, and
color of amniotic fluid to know if there’s a possibility of fetal
distress.
5 Ps of Labor and Delivery
• Power
• Passageway
• Passenger
• Psyche
• Placental Factor
Drill:
1) COC/ companion of choice – Psyche
2) Cervix – passageway
3) Maternal pushing – power
4) Uterine contractions – power
5) Attitude – passenger
6) Multiple pregnancy – passenger
7) Vaginal canal – passageway
8) Prenatal check-up – psyche
9) Abruption – placental factor
Power
- Forces that push the baby out
2 Sources of Power During Labor
1) Uterine contraction fundus
- Main source of power
- Contraction originates from fundus, myometrium of the
fundus in the upper uterine segment.
- 2 groups of drugs that will affect the uterus whether to
contract or relax:
a) Oxytocic – drug that stimulates the uterine
contraction (pamhilab)
b) Tocolytic – drug that prevent or stop the uterine
contraction. It is relaxing the uterus (pang patanggal
ng hilab) (sometimes the midwife prescribes the
tocolytic drug as pampakapit)
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- Don’t take it literally that the baby is hanging on the
uterus
Oxytocic Tocolytic
Syntocinon Duvadilan
Pitocin Dactyl OB
Oxytocin - EINC Yutopar
Methergine Bricanyl/Terbutline
• Syntocinon and Pitocin
- Given via IV incorporation (naka mix sya sa IV bottle)
- Masyado pinalalakas ang contraction.
- So, ang tendency ng uterus after delivery, ay mag relax.
Kasi nagamit na yung muscle tone
- Side effect: vasoconstriction and hypertension (sa
postpartum – uterine atony effect)
• IV corporation
- You do not administer the drug in the white port or
piggyback kase kapag ininject mo yung drug sa
piggyback mag da-direct yung gamot sa pasyente,
rather ang ginagawa mo sa drug is mini mix mo sya
doon mismo sa laman ng IV bottle.
- Particularly, the syntocinon, Pitocin, and oxytocin are
not given to IV push
- Ex. 1 ampule of Syntocinon has 10 units, a total of
2mL or 2cc and u have 1L of IV fluid.
- 1L = 1000mL
- You incorporated the drug in the bottle. The mother
consumes all the 2mL Syntocinon, when the mother
already consumes the 1L IV fluid kase minix mo sya
doon. Meaning the nurse dilute the drug very well.
- If you push the 2mL syntocinon IV push, the nurse
administered pure drug
- Ex. The woman is undergoing pre-mature labor 28
weeks pregnant (pre-term labor). Then when the baby
is delivered, it is pre-term baby.
- If the doctor can still stop the uterine contraction and
save the pregnancy, then the drug that will prescribe is
the Tocolytic drug to relieve the uterine contraction.
- Diba kase ang full term is 40 wks.
- But when the woman is in true labor the woman
cannot receive tocolytic drug
- The origin of the uterine contraction: Myometrium,
Fundus, Upper uterine segment
• Oxytocin – EINC
- Essential intropartal in newborn care. Oxytocin is not
given in IV incorporation; it is given by IM (intra-
muscular injection) to the mother 1 min after the baby is
out or delivered. (Placenta is still inside)
• Methergine
- Given after the placenta is out.
- Nowadays the most common drug that is given is
oxytocin no more methergine.
- Pag hindi mo ninotify ung nurses’ station, hindi sya lalapit
sa pasyente para magbigay ng Methergine IM.
- After placenta is out, promote contraction and prevent
postpartum bleeding.
- The different between the oxytocin and methergine:
o Oxytocin promotes rhythmic uterine contraction
o Methergine sustained contraction
 CARE OF MOTHER AND CHILD AND ADOLESCENT LECTURE – BSN 2ND YEAR 1ST SEMESTER MIDTERM 2021

o Rhythmic uterine contraction – the uterus will dedefecate sya, kasi baka yan ung ulo ng baby, lumagpas
contract, rest/relax. (vice versa) na ung ulo ng baby sa anal sphincter.
o Sustained contraction – the uterus will continue to - Panting relaxes abdominal muscles.
contract
- If you will use methergine and accidentally administered
the methergine before the placenta is out: C1 C2
o The placenta will not go out because the cervix will
close.
o When u accidentally administered the methergine by
intramuscular to the mother before the placenta is out o Increment – start of the contraction
it will promote sustained contraction. The uterus will o Achme – peak of the contraction
continuously contract, and the cervix closes, and the o Decrement – end of the contraction
placenta is trap on the uterus.
- Between oxytocin and methergine which one has a higher Assess Uterine contraction as to:
chance of causing hypertension to the mother: 1) Duration –increment to decrement
o Both can cause hypertension or can elevate the blood 2) Interval – decrement to increment
pressure of the mother. But the higher chances that 3) Frequency – increment to increment
could cause is the Methergine, because it sustained 4) Intensity
uterine contraction
o If it sustained uterine contraction the blood vessels o What do you call A to B? – Duration (tagal ng hilab)
are constricted. o Decrement to Increment? – Interval (pagitan ng hilab)
o Therefore, before u will administered oxytocin or o Increment to increment? – Frequency (dalas ng hilab)
methergine u have to check the blood pressure of the
mother is less than 140/90 Situation:
o If the blood pressure is reaches 140/90 and above. Do Mrs. Smith started to feel the contraction at 7:01 am that lasted for
not administer both drug. U must notify physician 45 sec. This was followed by another contraction at 7:07 and 15
b) Tocolytic sec. What is the duration, interval, and frequency of her
- They stop the uterine contraction. contractions?
- Bricanyl / terbutline – bronchodilator na, ticolytic drug pa.
They relax the smooth muscle of the uterus and that is
myometrium.
- It is given when u want to save the baby.
- Ex. The woman is undergoing pre-mature labor 28 weeks
pregnant (pre-term labor). Then when the baby is
delivered, it is pre-term baby.
Solution for Duration:
- If the doctor can still stop the uterine contraction and save
7:01/ 45 – 7:01 = 45 seconds
the pregnancy, then the drug that will prescribe is the
Solution for Frequency:
Tocolytic drug to relieve the uterine contraction.
7:07 / 15 – 7:01 = 6 mins 15 seconds
- Diba kase ang full term is 40 wks.
Solution for Interval:
- But when the woman is in true labor the woman cannot
receive tocolytic drug, the woman can receive oxytocic.
- Example: A Pregnant woman is experiencing threaten
abortion. The doctor ordered bricanyl subq, the patient
ask u, what is the action/effect of this drug? – it relaxes
the smooth muscle of the uterus. Hindi na isasama ung
o 15 – 45 hindi pwede, so mag boborrow ka doon sa 7. Ung 7
bronchodilation kasi wala naming asthma si nanay.
magiging 6 na.
2) Ability of the mother to bear down or push. (kakayahang
o Binawasan natin ng 1min yung 7 kaya ang mapupunta sa 15 ay
umire)
60 secs. Bali 15 + 60 = 75 secs.
- No coach pushing.
- Dapat fully efface (100%) and fully dilate (10cm) na sya, Situation:
saka mag push. Mrs. Kent is on her 9th month of pregnancy. She is complaining of
- Example: cervix 8cm dilated, 100% efface, rupture BOW, pain originating from her back that becomes intense whenever she
positive 2 station – engaged na sya, do not push walks. Her bow broke 2hrs ago. Upon IE, the nurse noted 6 cm
- 8cm dilated at 100% efface – bawal pa sya ipush pero ung cervical dilatation. Her uterine contractions are occurring every 4-5
nanay napapaire na (uncontrollable urge to push during mins strong in intensity.
contraction) so para mawala ung urge to push, mag
o True labor
papanting na sya.
- Kasi the pain is originating from the back.
- Example: the woman undergoing through labor, she is
- The pain is intensified by walking
8cm dilated and 100% effacement. During contraction,
- Rupture of the bag water
she feels the urge that she’s going to defecate. – ask the
- Presence of cervical dilatation.
woman to do panting first. Nafifeel ng nanay na mag
o Stage 1 – active phase
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Situation:
Mrs. Troy is at term and undergoing labor. She started to feel
contractions at 9:55 am and ended at 9:56' 10". This was followed
by another contraction at 9:57' 40'' and ended at 9:58' 55"am. Her
cervix is 8cm dilated, (-) bow, +2 station. Examination reveals a
vertex presentation with the back at the right side of her abdomen.
She had 1 abortion and a stillbirth at 35 weeks. She left home her
twin sons born on the 39th week of pregnancy.
o GPTPALM
- Gravida 4 – parity 2 – term 2 – preterm 1 – abortion 1 –
living 2 – multiple pregnancy 1
- G4P221121
o Stage and Phase of Labor
- Stage 1 – transitional phase
o Duration, frequency, interval of Ucs
- Duration in 1st contraction – 70 secs
- Duration in 2nd contraction – 75 secs
- Frequency – 2mins and 40 secs
- Interval – 1min and 30 secs
o Presentation, presenting part, lie, attitude, and position
- Presentation – cephalic
- Presenting part – vertex/ occiput
- Lie – longitudinal
- Attitude – flexion
- Position – right occiput anterior
o Auscultation site of FHR
- Right lower quadrant
Passageway
- This pertains to the birth canal
1) Pelvis – types and diameters
2) Cervical canal – effacement and dilatation
3) Vaginal canal – ability to distend
- The best type of the pelvis – Gynecoid and anthropoid
- The AP diameter of the inlet – 11 diameters, Transverse – 13,
Outlet – 13
Passenger
The fetus
- Number: 1 baby/preg
- If there is multiple pregnancy magkakaroon ng additional
problem malpresentation
- One baby is in cephalic, one baby can be in breech
presentation
- Size: 2.5kg; Ave: 3kg – 4kg
- Attitude: flexion
- Presentation: cephalic
- PP: vertex/occiput
- Position: LOA, ROA, OA
- Common position: LOA, Lie: longitudinal
Psyche
- The mental, psychological, and emotional preparation of the
woman to undergo labor and delivery
- COC: companion of choice
- To provide continues maternal support.
- Allowed to enter labor room
- Allowed to be with the delivery woman inside the
delivery room.
- The husband is the best companion of choice
- Remember: a woman can carry normal delivery is allowed to
choose to bring one companion during delivery. the husband is
the best companion of choice.
- Regular prenatal check up
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- The woman can undergo normal delivery is she have regular
pre-natal checkup. Because she knows that there is no problem
during labor and delivery. So, it could boost the confidence of
the woman during delivery
Placental Factors
• Placenta previa – problem is in the location of the placenta.
• Abruptio placenta – problem is the timing of separation.
ESSENTIAL INTRAPARTAL NEWBORN CARE
Discussed by Prof. Francis Vasquez
- Goal of ENC – To decrease both maternal and neonatal
morbidity and mortality rates by 40%.
- Maternal morbidity – sickness or illness of the pregnant
woman. During pregnancy, during labor and deliver, and after
delivery.
- Maternal mortality – deaths of the woman related to pregnancy,
labor and delivery, and after delivery.
- Neonatal morbidity – illness of the newborn in the 1st 28 days
of life.
- Neonatal mortality – death of the infant in the 1st 28 days of
life.
- Ung neonatal morbidity and motality hindi naachive ng ENC
ung 40%, 20% lang. Kaya inimprove nila ng EINC
- ENC was the answer of the WHO, DOH to Millennium
development goals (MDG) Nos 4 & 5.
- From MDG to Sustainable development goals
- MDG No. 4 – child health
- MDG No. 5 – maternal health
Pre-pregnant Updates for Childbearing age Women:
- Childbearing age women – married, sexually active. Mga
capable na mabuntis.
- Healthy lifestyle – exercise, avoid smoking and alcohol.
- Smoking – vasoconstriction, low oxygen, and nourishment
supply of the baby. Small gestational age, maliit ung baby,
maliit din ung utak at mababa din ang IQ (undeveloped brain)
- Alcohol – neurologic impairment – irreversible; cognitive
impairment – affects the brain, the ability of the baby to
process ideas to think.
- Health teachings on:
• STD prevention, family planning and contraception
• Nutrition requirements:
o Calories – 2,000/ day
o Iron – 30 mg/ day
o Use of iodized salt (iodine supports brain
development of your future baby)
Antenatal Updates
- Buntis na sya dito.
- Prenatal Checkup – facility-based checkup (4)
- Facility-based checkup – health center.
- Minimum of 4 checkups – before the 4th month, 6th, 8th and 9th.
- Healthy lifestyle – exercise (walking), avoid smoking and
alcohol
- Health Teachings on:
• STD prevention
• Family planning & contraception (ituturo mo yan:
antenatal, pre-pregnant and Postpartum)
• Newborn Screening – assessment test that will determine
if the baby has metabolic disorder because this can cause
cognitive impairment.
 CARE OF MOTHER AND CHILD AND ADOLESCENT LECTURE – BSN 2ND YEAR 1ST SEMESTER MIDTERM 2021

• Nutritional requirements: Inside delivery room:

o Calories = 2,300 - 2,500/day Prepare DR environment:
o Iron = 60 mg/day • Set temperature of DR between 25-28 C
o Folic Acid = 400 mcg/day (prevents neural tube • Eliminate air drafts (mag hawak ng tissue paper sa loob,
defect, spina bifida – may kulang ng parte ng buto sa kung malakas ang uga, meron pumapasok na hangin from
likod) the outside, it can reduce the temp, ang baby pwede ma-
o Calcium = 1,200 mg/day hypothermia)
o Protein = 60 gm/day • Turn off AC unit just before baby is out
o Vit A 10,000 iu (binibigay sa 2nd trimester 4th month) Safe delivery techniques:
(not on the 1st trimester because of teratogenic • Semi-upright position
effects) • No more routine amniotomy (kasi pag masyadong maaga,
o Elemental Iodine = 250mg 1 cap/ pregnancy (4th baka magkaroon ng infection) amniotomy – artificial
month) intentional rupturing of the bag of water. Purpose –
o Increase fiber & fluid – to prevent constipation. increase uterine contraction.
- Exercise during pregnancy: • No more routine episiotomy (kung tingin ni doctor ung
• Walking size ng baby can pass through the birth canal without
• Pelvic rocking – relieves backache creating episiotomy, then don’t do episiotomy)
• Tailor sitting – makes perineum supple • With COC
• Squatting – strengthens perineal muscles • No coached pushing
• Kegel’s exercise – strengthens perineal muscle • No fundal pushing
• Perform Ritgen's Maneuver (is done to deliver the head of
The administrator of antenatal steroid to a pregnant woman
the baby to prevent lacerations)
- Use: to improve fetal lung maturity by increasing the
production of surfactant. • Check for cord coil
- When: 24 – 28th week of pregnancy (6th – 7th months kasi ang • Oxytocin IM 1 min after baby is out
fetal alveoli will produce surfactant starting 6th months) • Active management of the 3rd stage labor
- Surfactant lubricates the alveoli. • No more Brandt-Andrew's Maneuver
- Who: 4 criteria – • Controlled Cord Traction with Counter-Traction
1) With history of preterm birth (22 -36th weeks) • No Cord milking
2) At risk of preterm birth (hypertension, diabetes mellitus, • No more Methergine IM
Anemia) • Perform 4 Newborn Protocols
3) with history of vaginal bleeding during the present 4 newborns protocols
pregnancy 1 30 secs
st
Dry the baby Hypothermia
4) Experiencing actual preterm labor (1 dose is enough kaya Hypoglycemia and
ang ibigay benta na higher dose) Next 30secs Skin to skin contact
infection
- What: Timely cord
• Dexamethasone = 6 mg IM q 12 hrs x 4 doses (ilan araw 1-3 mins p birth Anemia
clamping cutting
makompleto ung dexa – 12 x 4 = 48 hours/ 2 days) Encourage Breast
• Betamethasone (Celestone) = 12 mg IM q 24 hrs x 2 1st 90 mins p birth Skin to skin contact
feeding
doses (ilan araw makompleto ung beta – 24 x 2 = 48
houts/ 2 days)
ESSENTIAL INTRAPARTAL NEWBORN CARE
Intrapartal updates
Discussed by Prof. Jhal Espinosa
At labor room:
- It is a package of evidence-based practices recommended by
• Admit at active phase (2 signs of that the woman had enter the
the DOH and PhilHealth.
active phase of labor: 4cm CD or 2-3 UC in 10 mins pero ang
- It was initiated by the WHO.
common na gnagamit ay 4cm of cervix dilation)
- Considered to be standard of care in all births.
• With COC companion of choice – continues maternal support. - Hindi lang gnagamit to sa government to, ginagamit din to sa
• Any upright position (standing, walking, sitting, squatting) private hospital, specifically doon sa mga baby friendly
(advantage: gravity pulls the baby down) (purpose: shorten the hospitals.
1st stage of labor) - Worldwide
• No more NPO – early digested food (more on carbohydrates – - It is also considered as a comprehensive strategy design to
for energy to push) lower down the rate of mother and child mortality and
• No more IV fluid morbidity.
• No more IV incorporation of oxytocic
• Perform IE <5 (gaano kadalas every 4 hours) (gaano pinaka Essential Intrapartal Newborn care
madalas every 2 hours) Primi – 12-14-16, Multi – 6-7-8 hours) - An evidenced based standards for safe quality care of birthing
• Bladder emptying – promotes fetal descent (offer bed pan) mothers and their newborns within 48 hours of intrapartum
• No more shaving period and a week of life for the newborn. (so, may follow up
• No more enema – enema may increase BP checkup dapat.)
• Use of partograph
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 CARE OF MOTHER AND CHILD AND ADOLESCENT LECTURE – BSN 2ND YEAR 1ST SEMESTER MIDTERM 2021
- Administrative order (2009 – 0025) – December 2009 –
institutionalize the policies and guidelines for the government
on the private hospitals as well as all birthing centers.
- WHO – ang tawag natin dito EINC
- Pero sa pilipinas – Unang yakap
EINC Practices
1) Continuous maternal support, by a companion of her
choice, during labor and delivery.
- COC – dati walang ganto, mag-isa lang si mami
(anshaket), ngayon pwede sya sa big hospitals.
2) Mobility during labor – the mother is still mobile, within
reason during this stage.
- Dati, kapag naadmit ka na sa hospital, you are bed bound
already. Nakahiga ka na agad. Pero ngayon sa EINC,
pwede na sya lumakad lakad konti sa bed side.
- Pinapalakad natin si mami onti because walking facilitates
the descend of the fetus and shortens labor process.
3) Position of choice during labor and delivery.
- Prior to EINC walang position, nakahiga lang.
- Pero ngayon, the client can request the obstetrician for a
specific position of comfort during labor and delivery.
Kaya lang, karamihan sa nag lalabor, gusto nila nakaluhod
sa may bed side. Kasi yung feeling nya parang dudumi
sya. May challenge dito, kapag cephalic ang baby at
nakaluhod si mami at napalakas ung push nya derederetso
yon at baka umontog ung ulo ng baby sa floor.
- Although we are allowing a position of choice for our
client, we still need to be ensured the safety of our baby.
(kaya ingatan nyo baby nyo ah “sanaol may baby, ako
kasi iniwan ee </3*)
4) Non-drug pain relief, before offering labor anesthesia.
- Does who receive pain medications are only those who
undergoes cesarian sections. And also who cannot tolerate
the pain.
- All of them will have to experience normal spontaneous
vaginal delivery without pain medication.
- Good side: feel na feel nya na mami sya.
- Nursing responsibilities: we need to teach them breathing
techniques. Para kahit papano mapahinga sya, hindi ung
push lng ng push.
- Panting breathing or for sleep breathing
- As nurses, we should be constant communication.
5) Spontaneous pushing in a semi upright position
- Semi fowler to high fowlers position. Pero mas ginagamit
ung semi fowler’s kasi kapag high parang umiipit na rin
ung tyan ni mami.
- Dati naka higa lang, lithotomy position.
- Ngayon medyo ine-elevate yung head, para by force of
gravity. Pag push ni mami, tutulong ung gravity para
bumababa si baby.
- Fundal push is not allowed. (ito ung dinadaganan ung tyan
sa may fundus) ginagawa sya dati in order to help out in
the descent of the fetus. Pero kapag hindi marunong ung
mag fu-fundal push, minsan nag rurupture ung uterus.
- Kaya dapat tuturuan nlng natin si mami na mag push.
(When to push, when not to push)
- The client will have to push hard kapag fully cervical
dilatation at kapag andon na sya sa delivery table.
- Pushing:
o Lithotomy position
o Nakahawak sa bakal
J.A.K.E 7 of 21
o Hinga malalim, hold ur breath, close ur mouth
o Pag sinabi ni nurse ng go, PUSH!!
o And ikaw mag coconut ng 10secs habang nag pupush
si mami tas hinga uli ng malalim.
o Kaya dapat 10 secs ung haba ng push.
6) Episiotomy will not be done unless necessary.
- Deemed necessary – doctor mag dedecide.
- We perform Ritgen’s maneuver – naka support tayo sa
perinium ni mami para paglabas ni baby, hindi ma la-
lacerate ang perinium.
- Pero minsan kahit mag perform ka ng ritgen’s maneuver,
nag la-lacerate ung perinium, kaya ung iba nag e-
episiotomy nlng.
- Kapag na lacerate, crooked sya at mahirap tahiin.
7) Active management of 3rd stage of labor
- 3rd stage of labor – placental stage
- We’ll wait for a maximum of 30 mins for the placental to
separates spontaneously from our uterus.
- Curettage – Pinapasok nya ung kamay nya sa vaginal
canal para icheck kung merong placental fragments na
naiwan sa loob.
- There are doctors who prefer to do episiorrhaphy (yung
pagrerepair ng episiotomy) even before the placenta is
delivered. Disadvantage of curettage: the sutured
episiorrhaphy baka mabuksan uli at mas masakit yon.
- Ang gnagawa dati ay Brandt Andrew maneuver.
o Nakahawak ung isang kamay sa fundus then ung isa
may hawak na Kelly forceps – iniikutan ng umbilical
cord.
o Up down right left (side to side, up down)
o Ginagawin natin to para matulungan natin sya mag
detach agad.
o Most of the time gnagawa to kasi nagmamadali tau.
And to shorten the delivery time of placenta.
- EINC – controlled cord traction with counter traction –
nakahawak pa rin sa Kelly forceps and fundus. Dahan
dahan lang. ididiin ung fundus at dahan dahan lang ung
paghila.
- But still we need to wait for the 3 signs of placental
separation:
o Calchine sign – The fundus become firm and globular.
(biglang bumibilog ung fundus at tumitigas)
o Lengthening of cord (lumalapit na sya sayo kaya
nakaka-roll ka na ng cord sa Kelly forceps)
o Sudden gush of blood
8) Monitoring the progress of labor with the use of
partograph
- Being utilize once the client is already in the active phase
of labor.
Purpose of EINC
• Assess and evaluate the newborn as he or she transitions from
intrauterine life to extrauterine life.
- Paano sya nagrereact from being inside of the mother and
now she is delivered.
• Evaluate and monitor the newborn, system by system for
normal versus abnormal functioning, providing maintenance
of normal and potential treatment of abnormal findings.
- If u discovered something abnormal, then we will have to
discuss that with pediatricians. And we need to find ways
to assess the baby.
• Foster bonding between infant and parents.
 CARE OF MOTHER AND CHILD AND ADOLESCENT LECTURE – BSN 2ND YEAR 1ST SEMESTER MIDTERM 2021

- Priority – skin to skin contact. Some flexions of Well flexed

Activity None, flaccid
• Always provide a safe environment. arms and legs arms and legs
< 30 wear, >30 strong
4 core steps of EINC respirations 0
irregular cry vigorous cry
Immediate and thorough drying
1) Call the time of birth Interpretation Nursing intervention
- Once na lumabas na si baby, sisigaw si nurse na
“MAHAL KO PA RIN SYA” ay joke, HAHAHA I mean. 0-3 Severely depressed Immediate resuscitation
Sisigaw si nurse ng “BABY GIRL ESPINOSA, TIME 8
AM” 4-6 Guarded Suctioning
2) Using a clean dry cloth, dry the newborn thoroughly for at Proceed to routine
least 30 secs. 7-10 Good prognosis
newborn care
3) Wipe the eyes, face, head, front and back, arms and legs. o Immediate resuscitation – CPR, bigyan ng epinephrine or
- Hindi natin tatanggalin ung vernix caseosa kasi ito ay other medications.
thermo-regulator. Hindi sya madaling matanggal kung o Suctioning – doctors order
hindi mo sya irurub or forceful ung pagpunas mo. When to do the APGAR scoring?
4) Remove wet cloth.
• 1 minute – to assess the general condition of the newborn
st
- Ung towel dapat na expose sa radiant warmer para
mapainitan. • 5th minute – to assess newborn’s adaptation (adaptability –
- Kasi kapag dry ung towel, mag chi-chill si baby. paano sya nakakapag adapt sa environment ngayon.)
- Ung delivery room, between 25-28 C, yung lamig. Dapat • 10th minute – if the 5th minute APGAR is core is less than 4
walang air drop. Itaas mo ung tissue, at dapat d sya (hindi na sya regularly ginagawa, ginagawa lang natin to
gumagalaw. Pag gumagalaw sya ibigsabihin may hangin kapag may something wrong sa 5th minute)
sa loob. - Dr. Virginia Apgar (1952)
- Pero hindi nakapatay ung aircon, controlled temperature - This test checks a baby’s heart rate, muscle tone, and
lang. hindi sya mainit at hindi rin sya malamig. other sign to see if extra medical care or emergency care
- Lahat ng ididikit natin kay baby should be prewarmed. is needed.
- Kailangan punasan maigi para matanggal ung secretions. - Health care professionals use this assessment to quickly
Lalo na ung ilong, use bulb suction. Pipindutin natin ung relay the status of a newborn’s overall condition.
pinaka bilog tas ipapasok natin sa ilong ng baby then - Low apgar scores may indicate baby needs special care,
irerelease mo ung bilog para isuction ung ilong ng baby. such as extra help with their breathing.
- Ilong muna i-susuction bago bibig kasi ang baby natin ay Don’ts in immediate and thorough drying
an obligatory nose breather. (hindi nya pa alam kung • Do not wipe off vernix caseosa (because it help maintain body
paano sya huminga sa bibig. temp)
- Make sure the baby is always in side lying position for all • Do not bathe the newborn (until maging stable ung
the secretions will drain out itself. And preventing temperature ni baby, papaliguan na natin sya with baby soap)
aspiration. • Do not do foot printing
- To stimulate to cry – niru-rub natin ung likod ng baby. Or • No hanging upside-down
minsan nirurub natin ung foot ni baby para umiyak . • No slapping
- Lalagyan din ng bonnet si baby kasi ung hypothalamus ay • No squeezing of chest
nasa ulo at sya ang nagreregulate ng body temp. • Do not suction unless the mouth or nose is blocked.
- In 30 secs, dapat naka-administer tayo ng 10 units of Early skin to skin contact
oxytocin IM deltoid doon sa mother to promote uterine • Cover the newborn’s back with dry blanket.
contractions and prevent bleeding. (1 ampule only)
• Cover the newborn’s head with bonnet (to prevent
- Pwede macircumcised at birth kung nirequest yon ni
hypothermia)
mami.
• Place identification band on ankle
- Earrings: choice din to ng mader kung gusto nya ipabutas
tenga ng baby. • If newborn is crying and breathing normally avoid any
5) Do a quick check of breathing while drying (APGAR 1st manipulation
minute) - Dapat prewarmed ung blanket. At ipapatong sa dibdib ni
- 1st min, 5th min, 10th min mami ung baby.
- Dr. Virginia Apgar – 1952 - Nag skin to skin contact para maprevent yung
- Perfect score – 10 hypoglycemia. It promotes an increase in colonization of
0 1 2 protective bacterial flora from the skin of the mother that
is being transferred to the skin of neonate and that helps
Acrocyanosis
Blue/ pale all fight against infection.
Appearance circumoral PINK all over
over the body - Kapag nakadikit na si baby kay mami, maya maya
cyanosis
hahanapin na nya yung breast ni mami, kasi dalawang
Pulse 0 <100 bpm >100 bpm
kulay lang nakikita ni baby. Bright and dark, eh ung
No cry to nipple ni mami, dark yon kaya hahanapin nya yon at
No reaction
Grimace stimulation weak Strong cry makakainitiate na tayo ng breast feeding.
to stimulation
cry / grimace

J.A.K.E 8 of 21
 CARE OF MOTHER AND CHILD AND ADOLESCENT LECTURE – BSN 2ND YEAR 1ST SEMESTER MIDTERM 2021
- Kangaroo method – nilagay ung baby sa loob ng gown ni
baby. This promotes safety.
- Wag kakalimutan ung ID band or ankle band.
- Kapa ung parents hindi kasal, gagamitin muna ung
surname ni mami.
- We do not perform suctioning and oxygenation.
- Pinupunasan muna ung baby bago mag skin to skin
contact.
Property timed cord clamping
• Remove the first sets of gloves.
• Hold the cord and feel the pulsation.
• Cut the cord close to the plastic clamp.
- We remove the 1st sets of gloves kasi naka double gloving
ang doc. Kasi magiging unsterile ung 1st gloves kaya
tatangalin yon, then after non pwede ka na mag perform
ng cord clamping.
- Nakapatong si baby side lying doon sa tyan ni mami.
Hahawakan natin ung umbilical cord and wait for 1-3mins
until the pulsation inside the cord stops. Kasi nagsisimula
na sya mag detach sa uterus. Kapag na-detach na yan,
wala ng blood flow at hihinto na un pulsation. At mag
cocord clamping na tau.
- You measure 2cm, doon ikakabit ung plastic cord clamp.
Then measure uli, from the navel measure 5 cm then
Kelly clamp. And the from the plastic cord clamp, 1cm
doon icucut.
Non-separation of newborn from mother for early
breastfeeding
• Observe the newborn and feeding cues (baka unti unti na
gumagapang si baby kay mami)
• Counsel on positioning
• Initiate breast feeding
Anthropometric Measurement
Head HC: 33-35cm (1finger breath from the eyebrow)
Chest CC: 31-33 cm (nipple line)
Abdomen AC: 31-33cm (umbilical level)
BL: 47-54cm (posterior fontanel up to the heel of the
Length
foot following contour of newborns body.
WT: 2.5 – 4 kg or 5.5 – 8.8 lbs or 2500 – 4000
Weight
grams
Medications
• Crede’s prophylaxis
• Erythromycin ophthalmic ointment – from inner canthus of
the eye to outer canthus. (Prevents ophthalmia neonatorum or
neonatal blindness. May possibility sila na magkaroon ng
ophthalmia neonatorum kasi may possibility na may STI si
mami)
• Teramycyin
• Vitamin K – to promote blood clotting, prevents bleeding and
hypofibrinogenemia (IM left Vastus lateralis)
- Full term – 0.1 cc
- Post term – 0.1 cc
- Preterm – 0.05 cc
• Hepa B – dosage 0.5 ml, IM, right Vastus Lateralis
• BCG (Bacillus Calmette Guerine) – for tuberculosis
(binibigay ito kapag for discharge na si baby) (d pwede
imassgae, pisilin or hawakan)
J.A.K.E 9 of 21
o This should be done after the 1st full breast feeding is
completed. (matutulog si baby pagtapos nya mag breast feed
and that is the time na gagawin mo ung mga measurement at
medications)
o Wag itatapon or isasayang ung colostrum. This carries anti-
bodies.
o Hindi tayo nagbibigay ng glucose water. Deretso breast lng tau
o Do your physical assessment for a possible malformation,
injuries, or defects.
o Yung paliligo ni baby, pinopause natin ng minimum of 6
hours to day or 2.
o As much as possible, hindi narin minamanupulate si baby kasi
mababawasan ung remaining energy nya. Gusto nya lang
matulog ng matulog (huhu ako rin usto ko matulog nlng at
wag gawin ung mga tasks HAHA)
o 3 ways in measuring the length:
- Posterior fontanel until foot
- Foot until posterior fontanel
- Or naka side lying si baby.
o Body temperature: 36.5 – 37.4 (less than that hypothermia,
greater than that hyperthermia)
o Heart rate: 180 bpm (pero pag nag stabilize na sya in 1st hour
of birth 120 -160 bpm)
o RR: pag umiiyak si baby – 80 pero pag hindi, 30-60
o We don’t usually measure the BP unless ordered by the doctor.
(Neonatal cough) systolic :60-80, diastolic: 40-50.
Ethico-Legal Considerations
• Administrative Order No. 2009-0025
- December 1, 2009
- A protocol was first mandated in public and private
hospitals in the Philippines in 2009. It provides specific
details on care during birth until first 6 hours of life, as a
guide for healthcare workers as well as clarify the
importance of public health units in the implementation of
the protocol.
- "The UNANG YAKAP Act of 2020" An Act
Institutionalizing the unang yakap Campaign. adopting
the protocol on Essential Newborn Care. H8 6103. Jan.
29.2020
• Executive Order No. 51
- Philippine milk code of 1986
- The National Code of Marketing of Breastmilk
Substitutes, Breastmilk Supplement and Other Related
Products.
- The aim of the Code is to contribute to the provision of
safe and adequate nutrition for infants by the protection
and promotion of breastfeeding.
• Republic Act 10028
- The Expanded Breastfeeding Act of 2009
- Nagpoprovide incentives doon sa mga hospitals na
nagpoprovide ng rooming in para kay mami and baby.
- Mother – baby friendly hospitals
• Department Circular No. 2011-0365
- The Mother – Baby Friendly Hospital
- DOH launched 1992
• Republic Act (R.A.) 7600
- The Rooming-In and Breast-feeding Act of 1992.
- The State adopts rooming-in as a national policy to
encourage, protect, and support the practice of
breastfeeding.
 CARE OF MOTHER AND CHILD AND ADOLESCENT LECTURE – BSN 2ND YEAR 1ST SEMESTER MIDTERM 2021

Every newborn has needs - We would like to provide the parents some information
• To breath normally regarding newborn care, lalo na ung first child (parang first
• To be warm love mo yan tamang adjust ganurn madami kang pagdadaanan
• To be protected so dapat maging handa ka ganern)
• To be fed. - Immediate initiation of respiration and changes of circulatory
patterns are essential for extrauterine life.
NEWBORN ASSESSMENT - Mabilis ang respiration ni baby dahil bagong labas lang sya.
Discussed by Prof. Jhal Espinosa Nagkakaroon sya ng transient nasal flaring – lumalaki ung
- Newborn experiences complex biophysiological and butas ng ilong.
behavioral changes resulting from the transition (from the
intrauterine and now to the extrauterine life) 0 1 2
- First few hours of birth represent a critical adjustment, kasi Acrocyanosis
Blue/ pale all
baka hindi kayanin ni baby yung mga changes na ma- Appearance circumoral PINK all over
over the body
eexperience nya. cyanosis
- The moment that baby is born, we have to immediately care Pulse 0 <100 bpm >100 bpm
for this baby. No cry to
No reaction
Grimace stimulation weak Strong cry
Indications to stimulation
cry / grimace
- A comprehensive knowledge of the pregnancy is essential in Some flexions of Well flexed
our understanding. The significance of physical findings of our Activity None, flaccid
arms and legs arms and legs
newborn. < 30 wear, >30 strong
- Systematic approach helps to ensure the pertinent data are not respirations 0
irregular cry vigorous cry
overlooked. (kaya meron tayong system na finofollow kasi
para mas systematic or sunod sunod ang ating assessment sa
Interpretation Nursing intervention
bata.)
1st examination 0-3 Severely depressed Immediate resuscitation
- Monitoring the baby inside the womb of the mother before.
The delivery and 2 hrs after birth 4-6 Guarded Suctioning
- Habang naglalabor until the baby is delivered ina-assess mo Proceed to routine
both mother and the baby. 7-10 Good prognosis
newborn care
2nd examination - Doing an APGAR scoring lend 30 seconds dapat mabilisan
- Before discharge (Elay: para di ka maunahan galaw galaw naman dyan preee emzz, Aki:
- Assess pa din si baby if there is any complications or yung inunahan ko na nga pero mas pinili nya pa ung bagong dating ouch)
mga health teaching for the both parents. - Acrocyanosis – nagiging bluish ung extremities ni baby at
- Kapag wala naman problema, 24-48 hours minsan naaffect oral cavity.
- Cesarean – 5days - For fast assessment of APGAR just think the total score “10” then
3rd examination minus lang kapag may nakita ka habang inaassess si baby. Any
division from the norm (2pts), minus 1 ka lang ng minus 1.
- After 6-8 weeks of neonatal life
- Severely depressed: 0-3
- Babalik na for follow up check up
- Moderate depressed: 4-6 (baka ung baby super sedated, kasi si
- Announcement of the doctor about the vaccines.
mami ayaw nya makaexperience ng pain kaya si baby ay tulog
4 Phases of Assessment na tulog. Kaya ang gnagawa, sina-suction nlng si baby para
Initial Phase mastimulate natin sya to cry.) pero hindi na to ginagawa by
- Establish and maintain patent airway and support respiration. EINC, kapag kailangan lang, minsan kapag cesarean, hindi na
- Kailangan makahinga sila from their nose so need mong e compress si baby doon sa vaginal canal kaya hindi nailabas ni
suction agad after the baby delivered kase nasal breather ang baby ung mga secretions nya kaya minsan kailangan mag
mga babies. suction para mailabas ung secretions na yon.
- Maintain their temperature not too high, not too low - Excellent condition: 7-10 (just continue the newborn care)
- 25 degree C to 28 degree C temp of the delivery room or the - CPR – two fingers lang.
ICU. - 1st minute of assessment – how the baby tolerates the delivery
- We also need to ensure safety and preventing injury and process. (gaano nya nakayanan ung pag process
infection. We need to be able to know the actual and potential pagkakapanganak sakanya)
problems: - 5th minute of assessment – how is the baby outside the uterus
• Actual – during the assessment u can see the existing (extrauterine life) how the baby accepting the outside of uterus
problems. - 10th minute of assessment – if APGAR is good in 5th minute
• Potential – the baby is at risk to develop a problem. assessment pwedeng hindi kana mag continue sa 10 minutes of
Transitional Phase assessment tuloy tuloy mo na pag aalaga sa baby.
- Continuation of care (tuloy tuloy lang) - Transitional assessment:
- Nursing goal: is continuously protect the newborn. We also - 1st stage: last for 6 – 8 hrs, first 30 min. awake and remaining
facilitate a development of a close relationship specifically hours the newborn will be sleeping.
with mother. - 6 – 8 hrs the baby will show gestational age, Nature of the
birth, Effect the birth on the baby
J.A.K.E 10 of 21
 CARE OF MOTHER AND CHILD AND ADOLESCENT LECTURE – BSN 2ND YEAR 1ST SEMESTER MIDTERM 2021
- Sleep face – relax and fall asleep – this usually occurs within
the 1st two hours of life
- 2nd stage: 6 – 12 hrs observation should be made until the vital
signs are established
- 6 – 12 hrs hyperresponsiveness, nagugulat na sila,
nagrerepond agad sila sa extrauterine life. (Parang ikaw, nag hi
lang sayo si crush, kilig na kilig ka na dyan. Be hindi ka nya
gusto, nagchachat lng sayo yan kapag kailangan HAHA ouch)
- Hal. Naag BP ka sa mother tapos nasa dibdib yung baby naka
higa natutulog, pumipisik yung baby kapag nakakarinig ng
tunog kahit mahina
- Skin color changes. Una pinkish sya nung pinanganak tapos
after an hour nagsh show sya ng cyanosis. (minsan dahil sa
surroundings. Room temp)
- Kapag nawala na ung regular suppy of oxygenated blood
kailangan na mag effort si baby, Nag de-decrease oxygenated
blood and pH level nya at nag increase ung carbon dioxide .
- Transitory asphyxia – resulting from deprivation of O2 to
newborn infant
- As we stimulate to cry the baby, mag oopen lahat ng alveoli ng
lungs nya and then ma-ooxygenated si baby regularly.
Assessment of Gestational Age
- A systematic assessment of physical sign and neurological
traits help establish the newborns gestational age.
Ballard Scoring Criteria
- By Doc. Jeanne L. Ballard
- One of the commonly used criteria for assessing the newborn
infant
- Assess the posture of the baby
- Kapag kiniliti ang paa dapat mag wa wide sya
- The baby could flex the legs para makakuha ng score na 4
Dubowitz Maturity Scale
- Extensive and mahirap gamitin so hindi na sya ginagamit
- Dati nung ginagamit ito kapag maganda ang G.A assessment
sa Dubowitz Scale that means the APGAR score will be
perfect
J.A.K.E 11 of 21
Assessment of Gestational Age
1) Small for gestational age (SGA)
- The newborn is less than 10% of the ideal weight at the
time of birth (2, 500 grams)
- Usually sa mga smoker or alcoholic drinker si mami.
2) Large of gestational age (LGA)
- The newborn is more than 90% of the ideal weight at the
time of birth (4,000 grams)
- Macrosomia – babies that delivered by the mother who
has gestational diabetes
- Kapag malaki ang baby iniisip na may gestational
diabetes na kaya need talaga i-check si mother
- What if the mother is pumunta nalang na manganganak na
without any prenatal check-ups? You don’t have
information. So mahirap sya.
- The doctor usually orders for glucose test. Dapat 0
glucose ang lumabas.
- Kapag diabetic si mother nasanay ang baby tendency is
magchi-chill si baby after cut yung umbilical cord kase
dependent sya sa glucose ni mother
3) Appropriate for gestational age (AGA)
- The newborn is within the ideal range of birth weight
(2,500 to 4,000 grams – normal weight of the bay)
- If there is disproportion on measurement. Iisipin na agad
na there is something wrong w/ the baby
- You will think that the bay has gigantism or dwarfism
- Hal. Si mahal at mura dwarfism hindi na sila lumaki
• Full term – pregnancy that reached 37 to 42 weeks AOG or
beyond the post term
• Pre-term – pregnancy that reached 28 to 36 weeks AOG
• Post-term – pregnancy that has extended to or beyond 42
weeks AOG
General Physical Examination
Vital Sign
• Based on the EINC we could conduct assessment of the baby
after the full breastfeeding and skin to skin contact with the
mother bef. You touch the baby again
• General appearance – check for the posture of the baby
• Skin condition – sometimes pinapanganak sila may rashes na
• Skin turgor
• Crinkles
• Lanugo
• Birth mark
• Respiratory effort – ginagawa mo para makahinga ang baby
• Temperature – can be take through rectal (to check also for the
patency of the anus) or axilla
- EINC – hindi na pwede ung rectal temp kasi they
considered that as an invasive procedure, and it may cause
of problem in terms of traumatizing the rectal mucosa of
the baby.
- Normal temp: 36.5 to 37. 4C
- Hypothermia: less than 36C (so dadagdagan natin ng
covering si baby or hinaan ung aircon)
- Hyperthermia: more than 40C
- Accurate temp is the anal temperature
- To check the patency of the anus if may butas ang pwet ni
baby (minsan walang butas ang pwet ni baby)
- Ngayon sa tempanic nalang or axilla temp ang ginagamit
 CARE OF MOTHER AND CHILD AND ADOLESCENT LECTURE – BSN 2ND YEAR 1ST SEMESTER MIDTERM 2021

- Kapag lumabas na si baby papahinaan ang aircon and get - Teach the mother to make sure the area is dry (kaya di
a tissue dapat hindi gumagalaw yung tissue or walang air pumapayag na gumamit ng bigkis na sinasabi para
drop na mangyayari. sumexy at hindi lumaki ang tyan shanolll charrr)
- Poikilothermic – madali sya mag respond sa temp change. - Bawal i-submerge sa bathtub kase prone to infection
• Assessing the patency of the Anus - Kapag stabilize na ang extrauterine ni baby you can have
- Wait for the meconium to pass sponge bath. (Warm water)
- It happens on the first 24 hours of life • Body length: 47 – 54 cm
- It tells us the anus of the baby is patent - 1st style: posterior fontanelle (diamond shape). Next,
• Respiration – count by observing the abdominal movements contour of the body to heel (alakalakan) then pwede mo
and count in one full minute for accuracy na makuha ang LENGTH.
- Gaano ka effort para makahinga si baby - 2nd style: start from the heel, down to the contour of the
- Assessing rise and fall of the abdomen kasi si baby ay body and to posterior fontanelle then read the
abdominal and nasal breather. measurement (pabaliktad)
- Normal respiration: 30 to 60 cpm - 3rd style: wooden ilalagay lang si baby then mame
- Tachypnea: more than 60 cpm measure na yung haba, then mamarkahan ang reading
- Bradypnea: less than 20 cpm • Body weight 2500 – 4000 gms
- Hindi pwedeng 25 seconds lang ang ita-time mo dapat 1
FULL MINUTE kase newborn infant. Kapag hindi na Head and Face
sunod hindi mo ma a-assess na yung baby is humihinto Normal Abnormal
hinto ang breathing that could lead to Apnea.
- Assessment of respiration: physical aspect, sensory aspect, - Microcephaly – Hc <33cm/< 12.5
- Newborn’s head
and chemical factors in (maliit)
appears
o Physical factors – kakayahan ng lungs to expand. - Macrocephaly – HC > 35cm/ >
disproportionately
o Chemical factors – nalelessen ung oxygenated blood 14in (malaki)
large because it is ¼ or
nya tas nagiincrease ung carbon dioxide. - Widely separated sutures:
25% of the total body
- Newborn infant breath to their nose. Hindi pa sila preterm, hydrocephalus, cerebral
length
marunong huminga sa bibig edema
- Head circumference is
- 3 weeks pa bago nila ma-realize na they could breathe - Bulging fontanelle: subdural
33 –35cm
through their mouth hemorrhage, hydrocephalus, CHF
- Fontanelles
• Pulse – you may use the apical pulse which is located on the - Delayed closure: rickets,
- Anterior fontanelle –
midclavicular bet. 4th and 5th inter coastal space left. Count in hypothyroidism, down syndrome
soft and closes
one full minute for accuracy - Caput succedaneum –swelling or
- 9–18 months, diamond
- Normal PR: 120 -160 bpm edema or a bump on newborn’s
shape
- Bradycardia: less than 120 bpm head shortly after delivery
- Posterior fontanelle –
- Tachycardia: more than 160 bpm - Cephalhematoma – a collection
soft and 2– 4 months,
• Blood pressure – BP monitoring is not routinely done. The of blood between a newborn’s
triangular
average of systolic and diastolic pressure is 60/80 or 40- scalp and the skull.
50mmHg at 1-3 days of age.
o Molding can be observed kase kaka deliver palang ni baby
Anthropometric Measurement o Anterior fontanelle – 3-4cm long; 2-3cm wide
• To assess the body size, shape, and the composition of the o Posterior fontanelle – slightly smaller than the anterior
newborn’s baby fontanelle (mas maaga nagc close)
• To compare the size with estimated period of gestation o Fontanelle: bulging that can create intracranial pressure
o Kapag nakalubog, possible na gutom ang baby kaya pwede
• To identify if there are abnormalities in newborn
painumin ng gatas para ma rehydrate ang baby.
• Head circumference:
o Hydrocephalus – there is a lot of water or fluid in the head
- 33-35.5 cm (biggest size of the body)
causing compression of the brain
• Chest circumference: o Paano ire-release ang fluid or para ma-decompress and head?
- 31 – 33 cm (nipple line) - By inserting VP shunt (ventriculoperitoneal shunt) brain
- Mas malaki ang head kesa sa chest surgery. (craniotomy)
- 2 to 3 cm smaller than the head - Ilalagay sa loob ng brain ang manipis na tubo going down
• Abdominal circumference: to the neck (inside) then going down to peritoneum (para
- 31 -33 cm (same w/ the chest circumference) syang straw) bumaba ang fluid pababa sa excretory duct
- Level of the umbilicus. para iihi ni baby ang fluid
- The abdominal contour is rounded, protruding bec. of - Kapag si baby lumaki, bibitin na ang tube sa loob ng
weak abdominal musculature (baby fat) katawan so kailangan palitan yung tube.
- Note: remember the baby is still has umbilical stump - Hanggang hindi nareremedy yung situation ni baby ng
(pusod). Take care of it, just little above from the navel hydrocephalus just keep changing the tube until you reach
ang measurement. the full height of the baby to help excrete the fluids
- The umbilical stump will fall off after 1 – 3 weeks - Toxic (parang relasyon nyo toxic na emmzzz)
- 7 – 10 days healing of the navel

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o Caput succedaneum – normal lalo na kapag di marunong

umere si mother. Nagiging cone shape kase lalabas papasok si
baby during the power stage of the mother.
o Mareresolve sya in couple of days
o Anencephaly – absence of the brain and skull. Day die after a
days They don’t survive for long time.

Hair and Eyes

Normal Abnormal
Mouth and Neck
- Preterm – fuzzy hair Normal Abnormal
- Fine and silky hair
- Turner’s Syndrome – low
hairline - No deviation
- Intact palate
- Eye movements are not yet - Upper slant eye would - Epstein Pearls are one or two small - Excessive salivation
coordinated indicate down syndrome round well circumscribed cysts are - Cleft lip
- Eyelids maybe edematous for - Cataract is a sign of rubella present in the palate, a result of - Cleft palate
2 days and others extra load of calcium that was
- Sclera may be pale in color - Conjunctivitis deposited in the utero (benign bec.
- Iris is round - Nystagmus of the extra calcium)
- No tears because lacrimal - Corneal reflex should be - Webbing of neck
ducts are not yet fully mature checked - Newborn’s neck are usually short
would indicate
(linisan din to check also the
o Strabismus – eyes hindi masyado pantay. Hindi align sa bagay turner’s syndrome
baby’s neck baka hindi ma
na tinitigan nya kase di pa naman sya nakakakita - Swelling of the neck
detached)
o Nystagmus – involuntary movement of the eyes. Kapag hindi maybe due to tumor
- Head should be extended when
agad na remedy it could cause affect balance coordination of and other
examined
the baby abnormalities
o Dolls eye – kapag tinurn ang head ni baby naiiwan ang mata o You put a sterile gauze around your glove finger, tas papasok
o Lacrimal ducts – form after 3 months nyo sa bibig ni baby, then ififeel nyo yung palate sa taas kung
o Down syndrome – or mongoloid babies in colloquial term. may butas.
Their eyes are slightly slant and their ears are flat o Turner’s syndrome – usually mga babae ito.
o Cataract – caused by the mother who has congenital rubella.
o Conjunctivitis – ophthalmic ointment Skin
o Corneal reflex – magpa pass ka ng light dapat may reaction Normal Deviation
- Pink in color, ruddy
- Pallor would indicate anemia,
Ears and Nose or reddish in color
edema, shock hypoxia, and
Normal Abnormal - Skin turgor:
hypotension
sensation of fullness - Cyanosis
- Top portion of the external ears should be derived from the
at the level of the eye • Central Cyanosis
presence of hydrated
- Ear cartilage: pinna is firm, cartilage can • Peripheral Cyanosis
- Low set ears subcutaneous tissue
be felt at the edges - CHD – Severe respiratory distress
would indicate - Elasticity: when the
- Instant ear recoil (kapag finold ang ear - Jaundice (Pathologic/Physiologic)
genetic skin is pinched and
dapat bumabalik) - Petechiae would indicate infection
syndrome release, it will go
- Tympanic membrane is grey - Edemas indicate over hydration,
back again to normal
- Normal infant can hear sound and can renal failure, coronary heart disease,
- Lanugo
stimulate moro reflex due to sudden noise anemia
- Vernix caseosa
- Forceps mark (dalawang bakal na
- Mongolian spots –
- Neonates are also nose breathers - Obstruction of parang tongs) Kapag na cocompress
only Asian people
- Noses are usually flattened after birth mucus plugs nagkakaroon ng neurological
- Millia – white spot
- Patency of the nasal passages should be - Flaring of problem causing seizure
assessed nares
o Acrocyanosis – bluish or purple discoloration of the hands and
o To assess the patency of the nose ang gawin is takpan ang isa feet of the baby including the mouth (nawawala naman sya
then check if the baby still could breathe in one nose (may air after 24 hrs. nakakabawas nga lang sa perfect score of the
na lumabalas) then ganun din ang gawin APGAR scoring)
o Kapag hindi mo naramdaman ang paghinga ni baby (grabe o Jaundice - occurs w/ in 24 hrs of life (masama ito) ibig sabihin
naman po kamanhidan mo kung ganun charoooott) get a tissue the baby has the hemolytic disease. Pathologic jaundice – Hal.
paper then itapat mo sya sa nose to check kung gumagalaw Merong RH incompatibility or RBO incompatibility ang blood
yung tissue or hindi ng parents hindi compatible
o Hemangioma – not life threatening but prone to bleeding kase o Neonatal Jaundice – lumalabas ang paninilaw after 3 to 5 days
nga highly vascular ang area. Once the area punctured it will so ang gagawin is papaarawan (sunlight). It lasts for 10-12
days. The doctor will order a serum bilirubin and he will check
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bilirubin level. Then kapag Nakita na nya yun he will compute

and order for photo exposure or Bili light exposure
o Bili light exposure – nursing care: cover the eyes and genital.
o Until 9am only wag masyadong ibilad sa araw
o Problema dito sa pilipinas – ung mga mami, nag eexpose sila
ng araw pero doon sila sa gitna ng kalsada, maraming smug
and smoke kaya baka magkaroon ng respiratory problem si
baby.
Chest and Abdomen
Normal Abnormal
- Normal and absence of retractions
- Proportion to the body - Chest retractions Spine and Anus
- Normal circumference is 31 –33cm - Crackles sounds Normal Abnormal
- Heart rate is 120 –160bpm during Spine - Spina bifida – neural tube
- Nipple size 5 -10 mm auscultations - No mass or nodules defects
- Witch’s milk - Normally straight - Meningomyelocele
- Abdomen is protuberant
- Distended Anus - No opening
- Abdominal circumference: 31 –33cm
abdomen (malaki - Patent
- Liver can be felt at 1 –2cm below the
ung tyan) - Passes of meconium within
right coastal margin
- Prominent liver 24hours after birth
- Bowel sound is present.
- Umbilical hernia
- Umbilical cord two artery and one vein
o Make sure mag auscultate ka muna bago ka mag palpate ng
abdomen. Kasi pag inuna mo ung palpate, iiyak na agad si
baby.
o Make sure ung diaphragm ng stethoscope na prewarmed mo.
o Witch’s milk – nag sesecrete ung chest ni baby ng milk.
o Yung liver ni baby, pinapalpate natin sa side
o AVA – importante na makita natin to kasi minsan kapag si
baby may problem at birth, baka kailangan natin gamitin ung
umbilical blood vessels or umbilical catheterization. Extremities
o Umbilical hernia – lumabas ung AVA nya sa pusod Normal Abnormal
o Omphalocele – birth defect sya sa abdominal wall. May butas Hands - Simian usually presence of
ung abdominal wall. - Creases one straight crease in the hand
- Complete Fingers and can be seen in client with
Male and Female Genitalia Feet down syndrome
Normal Abnormal - Creases - Syndactyl – the fingers or toes
Male - Phimosis – hindi sya ma- - Full term – creases are webbed or joined and that
- Prepuce covers the glans penis retract. Masyadong tight covering the entire the condition was present at
- Scrotum with rugae and - Hypospadias - sole birth
descended testes - Epispadias - Post mature – deep - Polydactyl – when a baby is
- Urinary meatus should be at the - Cryptorchidism – creases over the born with an extra finger on
tip of glans penis undescended testes - foot the hand or an extra toe on the
Female - Premature – no creases or foot.
- Labia majora covers the labia partially - Clubfoot is a congenital foot
- Labia majora does not - covering the upper 2/3 of deformity that affects a child's
minora and urethra
cover the labia minora the sole bones, muscles, tendons, and
- Pseudo menstruation (blood na
indicate that the newborn - Complete fingers-no blood vessels
lumalabas, that is part of the
is preterm abnormal curvature
maternal hormones being
present in the baby)
- Clitoris – prominent

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Reflexes POSTPARTUM CARE

- Are involuntary movements or actions. Some movements are Discussed by Prof. Jhal Espinosa
spontaneous and occur as part of the baby’s normal activity. - Refers to the medical and nursing care given to a woman
Others are responses to certain actions. during the puerperium. Approximately 6 weeks after the
- Tonic neck reflex – fencing reflex delivery of the neonate beginning from the time that you have
terminated the labor. (hanggang sa mabalik ung mga
reproductive organs sa non-pregnant state)
- This period constitutes a physical and psychological
adjustment.
- 4th trimester of pregnancy
Principles
• Puerperium
- Postpartum period 6 weeks
- Period of adjustment after the delivery of the baby when
the anatomic and physiologic changes of our body is
being reverse to the normal non pregnant state.
• Involution
- Uterus goes back to the prepregnant state (pagliit ni
uterus)
• Post-partum care
- Immediate care of the mother and neonate after delivery.
• Post-partum goals
- Aim to help the mother in the healing of the process.
- To provide emotional support.
Post-partum Goals
1) Promote normal uterine involution and return to the
nonpregnant state.
2) Promote comfort and healing of pelvis, perianal, and perineal
tissues.
3) Prevent or minimize postpartum complications.
4) Assist in restoration of normal body functions
5) Increase understanding of physiologic and psychological
adjustment and changes
6) Facilitate newborn care and self-care by the new mother (baka
mamaya di pa marunong baka primi palang so kailangan e-
assist talaga ng malala sizt)
7) Promote the newborn’s successful integration into the family
unit
8) Support parenting skills and parent newborn attachment
9) Provide effective discharge planning

Physiologic Changes of the Postpartum Period

The uterus
- the sealing of the placenta site is accomplished by rapid
contraction of the uterus immediately after the delivery of the
placenta. With time, thrombi form w/ in the uterine site and
permanently seal the area
- Once na madetach ung placenta, ung attachment ng placenta
sa placenta site is exposed already. There are blood vessels
that is exposed in the area which can bleed. Then the uterus
will start to contract, and this contraction will pinch the blood
vessels, so that it will stop bleeding. And because of that
pinching effect, there will be thrombi formation, and this will
permanently seal the openings left by the placenta. So, the
uterus will no longer bleed, and we won’t have any problem
with hemorrhage.
- The uterus contracts firmly after delivery of the newborn and
reducing the size of the uterus. The uterine contraction allows
it to involute para sya ay mag return sa normal size.

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- Pagnailabas na si baby, biglang bababa yan hanggang sa level Lochia Duration Color Amount
ng umbilicus. Mag stay sya doon for about 2 days and after
Moderate in
that, every day it will go down by one finger breadth (1cm). Rubra 1-3 days Red
amount
- Then after 10-14 days or 2 weeks, the uterus should not be
palpable anymore. Because the uterus is already inside the Pinkish to brown 4-
Decreased in
pelvis. Serosa 3-10 days 6th day pinkish
amount
- Healing nun pinagiwanan ng placenta in the endometrium, that 7-9th day brownish
will take approximately 6-7 weeks to permanently heal. 10-21 days Minimal in
Alba Cream white
- Endometrium starts to regenerate – 6 weeks (up to 6wks) amount
- May pain si mami kapag na iinvolute kasi nag cocontract.
Discomfort. The Cervix
- Analgesic drug e.g paracetamol to reduce the pain - It becomes thicker and firm. Childbirth results in a permanent
- Nursing care: continue breastfeeding, because as the baby change in the cervical os from round to elongated
sucks on the breast, more oxytocin is being produce. And - Complete cervical involution may take approximately 3-4
because of that the contraction will go into a normal months. (cervical involution – going to go back to non-
contraction and it will hassle the involution. pregnant state but it will not take the same form during the
time na hindi pa sya nabubuntis)
- Ung hindi pa nabubuntis ung babae, bilog pa ung butas ng
cervix nya, pero after delivery of the baby, it will shrink, up to
1cm but the shape is elongated. It has experience tremendous
trauma because of the passing baby.
- Cesarian – may changes din sya pero hindi lng sya masyadong
elongated. Kasi may mga nag ta-trial labor before cesarian
section.

The Lochia
The Vagina
- Uterine flow consisting of blood, fragments of decidua, white
- It is smooth and swollen,
blood cells, mucus, and some bacteria w/ poor tone after delivery
- Last for 3 weeks after the baby is born. - Rugae re-appear by 3-4
- Kung normal spontaneous delivery si mami, the mother and
weeks
baby will stay in the hospital 1-3 days. Pero kapag cesarian, 5-
- Hindi na bumabalik sa
7 days.
original na itsura kasi
- Rubra: the reason of being dark red color is it contains
there will be scar
epithelial cells, erythrocyte, decidua, odor – characteristic formation bcz of the
human odor. (parang regla ung amoy). Makikita sya in 1st – 3rd episiotomy.
day.
- There is a surgical
- Serosa: pinkish – contains serosanguinous discharge
procedure to repair a
containing decidua, erythrocytes, leukocytes, cervical mucus
vagina sa mga gusto pang
and microorganism. May mga microorganism na sya kaya mother na maayos yung
malakas na ung odor nya kaysa nun rubra. part.
- Alba – albicans, nag eextend pa sya ng 6 weeks. It contains
The Perineum
leukocyte, decidua, epithelial cells and fats (kaya light color
- It appears edematous and bruised after delivery
sya). No odor or very slight odor. Slight bacteria.
- Episiotomy or laceration may be present.
- The mother and father should wait until the secretions or
- There will be pain.
discharges of the lochia stop before doing sexual intercourse. - Nursing care: position her sims position. Nakadapa na
And you must also consider the healing of episiotomy. 21 days nakagilid, put a pillow under the flex leg so that lalabas ung
or maximum of 6 wks.
isang paa, mas mababa ung extend ng paa, so magkakaroon ng
- 6 weeks after birth the woman will menstruate, that is for non-
gap or space in between the legs, so there will be more space
lactating mothers. While for lactating mothers, it will take
for the perineal area.
approximately 24 weeks or 6 months for menstruation to
- Nursing consideration: engorge breast, kaya it’s kind of
return. difficult to position the mother in sims, kasi madadaganan ni
- Kapag hindi agad bumalik ang mens ng mother pero hindi mami. Kaya dapat mag pa breast milk muna si mami bago sya
nagla lactate its normal lalo nap ag regular yung mother but in
mag sims position.
nursing care kailangan kapag ganun is mag family planning
- After 24 hrs u can give ice pack for the edema
sya kase baka hindi nya alam na hindi sya nagme mens but
nago ovulate na pala sya tendency na pwede sya ulit mabuntis.

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The Abdomen
- It remains soft, and flabby for some time after delivery
- Striae remain but lightens to silvery white
- Assessment of the rectus abdominis muscle.
- During the pregnancy, the muscle separated from each other
and that is normal.
- It can take several months to heal the muscles and move close
to each other.
- Diastasis recti – the abdominal muscles getting stubborn. ayaw
nyang bumalik sa kanyang original form. Ayaw nya mag dikit
uli. (Aki: kaya wag ng pilitin ibalik ung dati. Kasi kahit anong
effort mo kung ayaw nya bumalik. Edi wag. HAHA jk leng
nemen. Elay: wag na balikan ang past wag marupok owkieee
emzz) so, nagiging weak ung core ng body, it leads to back
pain. And ung belly nya name-maintain nya ung laki ng belly.
- S&S – there is indentation in between, and the color becomes
bluish to purplish. Nursing care is to recommend that the client
performs exercises. (light – moderate exercises for abdominal)
The Breast
- During the 1st week after delivery, as the colostrum is
changing to mature milk, your breast will become full.
- This normal postpartum fullness usually lessens w/ in 3 to 5
days, if feeding or pumping does not adequately remove all the
milk your body produces, engorgement may develop.
- Prolactin – hormone responsible in stimulating milk
production. This are being stimulated by rapid rack of the
estrogen and progesterone level.
- Breastfeeding mother – ung posterior pituitary gland ay mag
sesecrete din ng oxytocin hormone para maka initiate ng let
down reflex or milk ejection reflex.
- She should regularly breast feed the baby, so that there will be
increasing amount of prolactin and oxytocin production para
tuloy tuloy ung production ng breastmilk.
- Colostrum is present kailangan ni baby na makuha yan
- Breast engorgement – may occur in nursing and non-nursing
mothers. Specifically, in 2nd or 3rd day because of vasodilation.
Ipabreastfeed nya lng si baby or minsan apply warm compress
para ma alleviate ng pain.
- 1st day, there is a present of milk but not that much. Kase the
bby is still not yet know how to suck well kaya kailangan e-
assess and breastfeeding teaching so kapag natuto na si baby
mas madami na yung pag labas nung milk.
Systematic Changes of the Postpartum Period
The Renal/Urinary System
- Overdistention of the bladder is common due to increased
bladder capacity, swelling, bruising of tissues around the
urethra and diminished sensation to increased pressure
- parang kakulangan ng pakiramdam sa bladder {alam mo
pakiramdam ng namanhid ka ng ilang minute kase di ka
crinushback awts ganurn}, kahit puno na yung bladder nya
hindi pa din umiihi that could cause urinary retention kase
hindi pa nga ene excrete
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- The glomerular filtration rates remain elevated for about 5-7
days postpartum
- Dilated ureters and renal pelvis return to their nonpregnant
state within 6-10 weeks after the delivery
- Diuresis occurs within the 2nd to the 5th day after delivery.
- Gumigilid si uterus. That can soften or make uterus baggy and
that can lead to bleeding. Hindi sya makacontract dahil wala
sya sa position nya.
- If the bladder is always distended, that can lead to urinary
retention then it can lead to urinary tract infection.
- Adequate bladder emptying resumes 5-7days.
- Kapag ung babae umiihi ng madalas pero trickles lng, may
problema yon. Dapat ang normal, unang ihi ni mami 100-150
ml.
- May also complain of dysuria – because of the damage in the
trigone in the bladder.
- Normal delivery – we catheterize the woman before delivery,
so that we can release the urine in bladder, so mag shishrink
ung bladder and it will facilitate the passage of the descent of
the fetus.
- Catheterization is a dependent nursing function. (orange). One
time big time ang pag gamit sa orange, while the yellow kase
it uses for C-section.
- Nursing intervention: to encourage urination, offer a bed pan
and u can alternately pour warm and cold water. That can
stimulate micturition. Also, kung ready to ambulate na sya at
hindi nahihilo (make sure there’s no orthostatic hypotension)
Samahan nyo sa CR, and mag run kau ng water, ng patak
patak lng, and this sound will also stimulate the mother to void.
(make sure u do not flash the toilet while naka upo si mami
kasi ung splash ng water from the toilet, that can have
microorganism which can go to the perineal area and infect the
episiotomy)
- Kapag wala tlg taung makuhang urine output, we need to
notify the physician right away.
The Circulatory System
- The usual blood loss w/ a vaginal birth is 300 to 500 mL.
- With cesarean birth, it’s up to 500 to 1000mL.
- A 4-point decrease in hematocrit (proportion of RBC to
circulating plasma) and a 1-g decrease in hemoglobin value
occur w/ each 250mL of blood lost.
- Para malaman natin na 500 ml ung lumalabas na blood, use
regular size of kidney basin because that can accommodate
500 ml of blood. Cesarian – silver kidney basin.
- Women usually continue to have the same high level of
plasma fibrinogen during the 1st the postpartal week. Because
it is protecting the woman from hemorrhage. (Plasma
fibrinogen – nag cacause sya ng blood clotting) but because of
clotting effect, the woman is prone to thrombus formation.
Babara sa blood vessels.
- Plasma level 1000 ml
- Once u found out the patient has thrombus formation, DO
NOT MASSAGE kasi if u massage, gagalaw ung thrombus
formation and this will travel in the blood vessels. Dumadaan
ung blood vessels sa mga main organs. And if the thrombus
formation travels to the main organs, babara yon doon at
magkakaproblem.
- The client will experience an elevated pulse during labor and
delivery. It will decrease in about an hour after delivery.
- Hematocrit drops during the 3-4days, but it will stabilize by 2
months postpartum.
 CARE OF MOTHER AND CHILD AND ADOLESCENT LECTURE – BSN 2ND YEAR 1ST SEMESTER MIDTERM 2021
- WBC mag eelevate. Normal: 2500-1100. Pero sa bagong
panganak 25,000. Kumbaga nagready lang ung katawan ni
mami, just in case there’s an infection.
The Gastrointestinal System
- Digestion and absorption begin to be active again soon after
birth unless a woman has had a cesarean birth. Almost
immediately, the woman feels hungry and thirsty, and she can
eat without difficulty from nausea or vomiting during this time.
- Gastrointestinal motility and tone. Peristaltic movement will
return to non-pregnant state in 2 weeks. So, because of that, it
is expected, that the patient will experience constipation.
- Dahil magkakaroon sya ng constipation, decrease muscle tone,
perineal discomfort, the mami will refuse to defecate. Pag
pinipigil nya mag move ng bowel that can lead to constipation
- Mag kakaproblema tau kapag na constipate si mami kasi hindi
sya allowed to exsert effort to move the bowel. Hindi sya mag
pass out ng hard stool kasi it will damage the episiotomy.
- The client may return to pre-pregnant weight in 6 to 8 weeks.
- Normally, Magkakaroon si mami ng hemorrhoid because of
the pressure of the descent of the fetus.
- Nursing intervention: we cannot allow the patient to remain
constipated kasi madadamage natin ung episiotomy. So, we
need to increase fiber intake such as vegetables and increase
fluid intake both water and citrus juice (fresh). Citrus juice
will have vitamin C and it will aid in the healing process in
episiotomy.
- kapag ginawa mo na lahat ng effort pero wala nangyari, we
need to notify the physician. (kaya hanap ka nlng ng iba kung
ayaw nya tanggapin lahat ng effort mo HAHAHA) and seek
an order for stool softener or laxative.
The Integumentary System
- Profuse puerperal diaphoresis is evident on the first 24 hours
postpartum (sobrang pagpapawis) nursing intervention:
punasan at patuyuin, palitan ng dami para comfortable sya.
- Melanin decreases gradually, causing a decrease in
hyperpigmentation
- Visible vascular changes of pregnancy disappear as estrogen
levels decrease.
- 1st 24 hours she will experience profuse diaphoresis.
- During the pregnancy, she was able to incur a lot of
pigmentation. And now, she has delivered the baby, the
melanin pigment that cause of all hyperpigmentation will
gradually decrease and this will start the hyperpigmentation
lighten up.
- During pregnancy, the woman experiences vascular changes,
nag increase sya kasi gusto ng katawan ng maraming blood
vessels for more blood supply for the baby. So, this will lead
to the presence of varicose veins. (malalaking ugat).
The Immune System
- A slight increase in maternal body temperature may occur
without apparent cause following childbirth
- It is normal for 1st 24 hours postpartum, for the mother to
experience slight hyperthermia up to 37.9 C. so, we give TSB
(tepid sponge bath), nag lalagyan tayo ng towel sa noo.
- But if the mother experiences hyperthermia in the next 48
hours or 2nd and 3rd day postpartum, temperature increase 38 C
and above then that can be sign of having an infection. So, u
need to notify the physician.
The Respiratory System
- Pulmonary functions return to nonpregnant status by 6 months
after delivery.
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- When the baby is out, there is no longer a pressure in the
diaphragm, so it is allowed to expand properly, and it will go
back to nonpregnant state.
Musculoskeletal System
- Most women ambulate 4-8 hrs after delivery, early ambulation
is encouraged to avoid complications, promote uterine
involution, and improve emotional outlook
- Relaxation and increased mobility of pelvic articulation occur
6-8 weeks after delivery.
- Encourage mother to do early ambulation pero u need to check
the orthostatic hypotension. So, the nurse assists the mami in
the first ambulation. (pa upuin muna, then iharap nyo sa side
ng bed, pagalawin ung paa. After a few mins, wala nangyayari
or hindi na nahihilo si mami, make her stand the bed side.)
- Teach the significant other do not let the mother to lock the
door. Kase once na mag collapse si mother hindi mo agad
maagapan and possible na pwede tumama head nya kung saan.
Endocrine System
- Prolactin levels will remain elevated if the woman continue to
breastfeed
- If not breastfeeding, prolactin level will return to normal levels
by 3 weeks postpartum
- Without breastfeeding, ovulation may return as soon as 45
days. However, ovulation may be delayed by as much as 6
months if the mother is exclusively breastfeeding every 2-3
hours. (Lactation amenorrhea)
- More than 3 months, pwede wala pa syang menstruation pero
baka nag oovulate na si mami kasi after 3 months, the baby
sleeps longer. Kaya humahaba na ung interval ng
breastfeeding then baka magkaroon na sya ng ovulation. That
is why we encourage her that she needs to use another family
planning on the 3rd month.
- The LAM not guaranteed in 6 months
Postpartum Maternal Assessment
B.U.B.B.L.E. – H.E. maternal assessment
B – breast side, shape, and engorgement
- Palpation
- If may nodule, make sure to assess that by breastfeeding.
Make sure that she empties the breast then if there’s still a
nodule, u need to notify the physician.
- Pero kapag nawala ung nodule, most probably curdle milk.
- So, we need to palpate the breast kasi minsan sumasabay
ung breast cancer sa postpartum period.
- Nursing intervention: instruct the mother to clean her
breast every day. (she can soak it with warm water) she
just needs to wash it with warm water. Kailangan linisin
lagi kasi ung drips ng breastmilk contains glucose at yun
ay makaka irritate sa skin ni mami, it can lead to irritation
and break of skin that can cause infection.
U – uterus: firm or boggy?
- Palpate the uterus, u must ensure that the uterus is firmed,
contracted and globular. And it is following the proper
uterine involution pattern.
B – bladder: tender or distended?
- As checking the height of the fundus.
- We have to talk to the mother about proper perineal care,
explain that she should wipe from front to back. Because
the back near the anus is considered contaminated.
- Distention – it needs to be emptied so that it will not be
dispelled the position of the uterus.
 CARE OF MOTHER AND CHILD AND ADOLESCENT LECTURE – BSN 2ND YEAR 1ST SEMESTER MIDTERM 2021

- The first 3 postpartum voiding should be measured and Postpartum Complications

should be at least 150 cc. Postpartum hemorrhage
- If there is burning sensation during urination, then that is Predisposing Factors Management
reportable matter to the doctor that may indicate infection Uterine atony - Over distention of - Vigorous fundal
or urinary retention. (exhaustion of the uterus (na-over massage
B – bowel movement? muscle) stretch) - Bimanual uterine
- Ask ur patient when was the last time she move her bowel. - Most - Multiple pregnancy compression
Kasi expected natin that she will be constipated. So, if common - Caesarean section - Ice compress
she’s not able to move her bowel by the 2nd postpartum cause of post- - Chorioamnionitis - Modified
day, we are going to perform all our independent nursing partum (infection of a Trendelenburg
intervention such as we will increase fluid intake and give hemorrhage chorion) - Fast drip of IV
her high fiber diet. wherein the - Macrosomia (large fluids
- Pero kapag wala pa rin, we need to seek to physician to uterus fail to for gestational age) - Oxytocin
give the mother a mild laxative. contract and - Rapid or prolonged administration
L – Lochia: amount, odor, color, clots becomes labor - Let the newborn
- Vaginal discharge. We must check the peripad that she is more relaxed - Deep inhalation suck the nipple
using. We need to see if there are clots. That could be sign and boggier anesthesia of the mother
of impending bleeding or hemorrhage. - Hysterectomy
- Make sure ung number of postpartum days nya ay tama sa o Uterine atony – lumambot ung uterus, it refuses to contract
kulay ng lochia. because of exhaustion of muscle.
E – episiotomy location, stiches, edema, and redness. o Magpaalam muna kay mami bago mo sya i-fundal massage.
- Inspect – u position her in dorsal recumbent position. And Wag ung biglaan. (ung bigla ka nya iniwan na wala syang
u need to provide privacy. And use a penlight. snasabi </3 )
- Check also for rectal area, kung may hemorrhoids. o Bimanual uterine compression
- Check also for episiotomy, for proper wound healing,
walang signs of infection or inflammation. And make sure
to touch the sides of labia majora, if it is warm to touch
then that is a problem.
H – Homan’s sign – positive?
- Papahigain si mami and itataas ung isang paa. Tas ung
paa i-dorsiflex then ung isang kamay mo, pipindutin or
ipepress ung cuff area ng paa. If there is pain and redness,
o Modified Trendelenburg (para si uterus ay by gravity aakyat
that is positive hooman’s sign. So, there is possible
sya)
thrombus formation.
o U can use ice packs for contractions
- Do not massage, kase pwede sya mag travel and mapunta
o Fast drip of IV fluids (for replace, incase bleeding or
sa mga major organs.
hemorrhage then we need to immediately replace the fluids in
E – emotional status and bonding.
the body, to prevent hypovolemic shock)
• BUBBLE HER Sa ibang book may R sa dulo – Respiratory
o Oxytocin – 10 iu
changes.
o Kapag nagawa na natin lahat ung management at hindi pa rin
• BUBBLE SHE – meron namang S – skin integumentary nawawala, we need to notify the physician.
system. o Hysterectomy – surgical removal of the uterus.
DVT and Homan’s Sign
Laceration
• A positive homan’s sign is indicative of DVT
- Profuse bleeding w/ contracted uterus
• The patients. leg is positioned at a 90-degree angle (either
- Degrees of Laceration
while in supine or sitting)
a) 1st degree – extends only through vagina and perineal skin
• Dorsiflexion of the foot reveals pain in the calf if positive
b) 2nd degree – extends deeply into perineal soft tissue and
• Other signs of DVT: Redness, Sudden sharp pain, Warmth in perineal muscles
the leg c) 3rd degree – extend through perineum and anal sphincter
d) 4th degree – extends through the perineum, anal sphincter
and extends through the rectal mucosa
- Management:
• Assess the perineum
• Surgical repair
• Assist the physician during repair
• Low residue diets
• Stool softener
• Sitz bath, Peri light therapy, Perineal hygiene – to
promote wound healing by heating the area to promote
vasodilation.

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 CARE OF MOTHER AND CHILD AND ADOLESCENT LECTURE – BSN 2ND YEAR 1ST SEMESTER MIDTERM 2021

• Exogenous Sources: pathogens introduced from external

resources. Organism most frequent responsible for post-
partum infections: Anaerobic streptococci (from outside)
5 signs of Inflammation
1) Redness (rubor): caused by increased blood flow
2) Hotness (calor): caused by increased blood flow
3) Mass (tumor) oedema: caused by leakage of fluid and cells
4) Pain (dolor)
Management
5) Loss of function
Hematoma – purplish discoloration - Remove hematoma - Nursing management: to ask her to go in to complete bed
of the subcutaneous tissue of the - Cold compress rest. Improve nutrition, increase fluid intake. Take
vagina or perineum vitamins c. and we perform proper wound care. (sakit ng
- There is blood underneath kalingkingan sakit ng buong katawan)
Disseminated Intravascular - Blood transfusion - Cold compress
Coagulation (DIC) - Hysterectomy
- Hypofibriginemia – failure to
coagulate
- Predisposing factors – abruptio
placenta, amniotic fluid embolism
and still birth

Uterine inversion - Repositioned vaginally

- Blood and IVF Perineal Infection
replacement (to • Endometritis – inflammation or infection of the lining of the
prevent hypovolemic uterus specially the endometrium
shock) • s/s: abdominal tenderness, uterus not contracted and painful to
- Administer oxytocin touch, dark brown, foul-smelling lochia.
- Minsan nahihila ung placenta at after repositioning - Di pa nahahawakan umaaray na
nasasama si uterus. (kasi kapag nasal abas - Nagiging dark brown yung red na color of Lochia
pa sya at nagbigay ka • Management – fowlers position, so we can localize the
ng oxytocin, mag infection. Pababain ung infection. Doon lang sa vulva area. To
cocontract na yan at drain secretion and probably the physician will order for
mahirapan tau ibalik atibiotics.
ung uterus.) R.E.E.D.A – for New Mamma Care
o Severe uterine prolapse – need to have vaginal surgery to • R – redness
remove the uterus
• E – Edema
• E – ecchymosis
Late Postpartum Hemorrhage
Retained placenta fragments • D – discharge
Risk factors: • A - approximation
• Abnormally trophoblastic invasion Always check:
Management - Episiotomy
- Tearing
• Dilatation and curettage
- Hematoma
• Manual extraction of the placental fragment
- Formation
• Uterine massage REEDA Scale
• Late postpartum – After a couple of days saka sya nag
manifest ng hemorrhage because of the retained placental
fragments then she will have to go back to the hospital
and perform dilation and curettage or DNC. (raspa)
Sources of infection
• Endogenous (primary) Sources: bacteria in the normal flora
become virulent (tumapang) when tissues are traumatized, and
general resistance is lowered. (because of the trauma during
labor and delivery it becomes virulent and causes infection.)
- Sometimes the infection causes dahil sa nurses kase it’s
either na cut or nabutas yung gloves then nag internal
examination
- Sexual intercourse bef. The mother delivers the baby
humirit pa si dadii nagt trigger ng infection
- Premature of membrane
- APGAR like scoring
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 CARE OF MOTHER AND CHILD AND ADOLESCENT LECTURE – BSN 2ND YEAR 1ST SEMESTER MIDTERM 2021

• Redness – need flashlight to check the the perineal assessment o Experience of childbearing can help to a transitional phase to
• Edema adapt being a mother
• Ecchymosis – discoloration of the skin o Reva Rubin – nurse theorist who formulated the theory of
• Discharges – pus coming out maternal identity 1977
• Approximation – check for the edema approximation o Nursing Care: do not disturb the mother after delivering the
baby. Let the mother rest kase pagod pa. That time she joined
Postpartum Fever her child in resting phase tapos kapag gising na saka mon a e-
Predisposing Factors Progression render lahat ng care para hindi irritable ang si mother.

- Caesarian section – baka - Day 0: atelectasis – Psychological Changes

nagka infection sa wound nya collapsed of the lungs - Postpartal Blues during the pstpartal period, as many as 50%
- Prolonged labor – yung - Day 1-2: UTI of women experience some feeling of overwhelming sadness
pagod ni mother - Day 2-3: Endometritis – (Buultjens & Liamputtong, 2007). They may burst into tears
- Premature rupture of inflammation of the lining easily of feel let down or irritable. This temporary feeling after
membrane – ascending of the uterus birth has long been known as the "baby blues"
infection - Day 4-5: wound infection - Manifestation in mood changes
- Multiple vaginal exam – kaka - Day 5-6: Septic - It resolves after 2 weeks
IE ni doc na trauma na si thrombophlebitis – do not - Nagkakaroon sila ng mood changes kase yung mga hormones
mother massage bumabalik na sa normal
- Meconium - Day 7-21: infectious - The significant other should know about its para magkaroon
- Manual placental extraction – Mastitis – breast colostrum ng mas madaming patience to understand his wife. Baka kase
na pwersa (still can breastfeed the baby isipin kapag bigla bigla umiyak yung mother is akala ayaw
- Anemia sa kabila na walang nya yung baby hindi sya masaya sa family.
- Poor nutrition infection) - The mother also should know about it kase para di nya isipin
na nababaliw na sya
Postpartum Psychosocial Adaption - This phenomenon may be caused by hormonal changes,
Reva Rubin’s Psychological Responses Postpartum particularly the decrease in estrogen and progesterone that
occurs w/ delivery of the placenta. For some women, it may be
Dependent phase:
a response to dependence and low self-esteem caused by
- Mother is passive (hindi masyado
exhaustion, being away from home, physical discomfort, and
concern kay baby) and cannot make
the tension engendered by assuming a new role, especially if a
decision (focus on self-need after the
woman is not receiving support from her partner.
Taking delivery)
1 -3 - Postpartum psychosis – need the immediate care kase
in - She verbalizes her feelings of recent
days sometimes pag hindi naagapan ito yung nagiging dahilan na
phase delivery (ang hirap nung pinagdaanan
nasasaktan nila yung mga anak nila.
nya sa during the delivery)
- Focus of nursing care and proper
Nursing Care
hygiene (sleep deprivation can cause
irritability which is dapat iwasan) • Provide pain relief for after pains.
Dependent to Independent Phase: • Relieve muscular aches
- Mother is active and can make decisions • Administer cold and hot therapy
(nakaka pag change na ng diaper, nag be • Promote episiotomy care
breastfeeding na in short may pake na sa • Administer sitz baths
Taking kanyang baby, naol may pake charoottt) • Provide perineal care
4 -7
hold - 4 -5 days: post-partum blues or baby • Promote rest in the early postpartal period
days
phase blues (an overwhelming feeling of • Assess peripheral circulation
sadness or depression characterized by • Prevent/alleviate breast engorgement
crying, dependency, inability to sleep • Promote breast hygiene
and lack of appetite related to hormonal • Teach methods to promote uterine involution
changes)
Independent Phase:
- Mo. Redefines her new roles and begin
interdependence with the other members
7 days
Letting of the family (pages set up ng bahay
and Basahin din ung modules sa canvas ah! Mas bumabase doon ung mga prof
go para may space ang baby, mag a alter na
above pagdating sa exam. Itong reviewer, galing lng to sa mga tinuro ni Sir V
mga routine sa bahay hal. Mahilig sa
and Mam Jhal, so parang additional info na to. Good luck sa exam guys!
mga party party ayun hindi na pwede) Konti nlng matatapos na tong 1st semesterrr, rawr – Aki
- May extend as the child grows
o Emotional or psychological stress for the new mother. The
changes that occur after delivery.
o Paano magiging successful and transition nya from pregnancy
to being a mother? Support of the family and friends
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