CEPHALIC BREECH SHOULDER

Labor HEAD at the lower Sacrum / Internal examination shows

 The process by which the fetus, placenta, and amniotic pole of uterus. feet/knee that the ACROMIUM of the
membranes are expelled from the uterus is called labor ( FHT at lower is at the baby lies on the birth canal. –
 Parturient - woman in labor abdominal lower (CBQ)
quadrant) –(CBQ) pole of
6 P's of labor(CBQ) uterus Shoulder presentation:
P assenger Vertex – most FHT at
P assageway common (occiput or upper Most common sign:
P ower the small triangular abdomina “TURTLE SIGN”
P osition portion of head l  retraction of the
P syche or perception comes first) quadrant. baby's head back
P arity into the vagina
Passenger 1. TAKE NOTE:
A. Vertex Complete Fundal height measurement
Fetus: 2.5kg – 4 kg or 5.5lb-8.8lb. (CBQ) presentation: most breech may not reflect the baby's
Placenta: 400g or 1 lb ( 500 at term) common, fetal head fetal growth if the presentation is
Amniotic Fluid: 2 lbs is completely flexed knees SHOULDER. –(CBQ)
Amniotic fluid volume: 500 to 1000 ml onto chest, and the and hips
 Less than 500 ml is Oligohydramnios(CBQ) SMALLEST are both Shoulder dystocia
 More than 2000 ml is Polyhydramnios(CBQ) diameter of the flexed, Method of delivery:
fetal head presents thighs are Cesareansection. –(CBQ)
Normal presentation : CEPHALIC(CBQ) to pelvis on the
Normal position: OCCIPUT ANTERIOR ( LOA) *occiput is abdomen
Normal lie: LONGITUDINAL / VERTICAL(CBQ) presenting part , and the Assist delivery via
Normal attitude: VERTEX ( complete flexion) (CBQ) ( triangular portion calves McRobertsmaneuver; involves
Cephalic prominence: Suboccipitobregmatic (9.5cm) of head is palpated) are on hyperflexing the mother's legs
the tightly to her abdomen to
FONTANELS: B. Sinciput posterior widen pelvis–(CBQ)
Anterior fontanel: structure located between FRONTAL and presentation: fetal aspect of
PARIETAL bones. (CBQ) head is neither the thighs
B regma flexed nor
A nterior fontanel extended, the 2. Frank
D iamond shaped occipitofrontal breech-
diameter presents the fetal
Posterior Fontanel: structure located between PARIETAL and to the maternal hips are
OCCIPITAL bones. (CBQ) pelvis flexed,
L ambda *top of head is and the
P osterior presenting part knees are
T triangle shaped extended
Cranial sutures – lines connecting cranial bones. C. Brow 3.
1. Metopic- connects the 2 frontal bones presentation: fetal Footling
2. Coronal- connects 2 frontal to 2 parietal bones(CBQ) head is partially breech-
3. Sagittal - connects 2 parietal bones extended, the the fetal
4. Lambdoid- connects 2 parietal bones to 1 occipital bone occipitomental hips and
diameter, the legs are
FETAL HEAD DIAMETERS: largest extended,
anteroposterior and the
Anteroposterior diameter (APD) of Fetal Head diameter, is feet of
presented to the the fetus
1. mento-Vertical: 14 cm- ( BROW) - partial maternal pelvis present
extension(CBQ) * Sinciput is the to the
2. SUB-mento-Vertical: 11.5 cm - ( FACE) - incomplete presenting part maternal
extension(CBQ) pelvis
3. sub-mento-Bregmatic: 9.5 cm- ( FACE) D. Face either
4. occipito-Frontal: 11.5 cm ( VERTEX) presentation: the one or
5. SUB-occipito-Frontal: 10.5 cm ( VERTEX) fetal head is two feet
6. sub-occipito-Bregmatic: 9.5 cm (VERTEX) - complete HYPEREXTENDE present
flexion. D, the
submentobregmatic
Transverse diameter of head: diameter presents
bi-Mastoid: 7.5 cm to the maternal
bi-Temporal: 8 cm pelvis
bi-Parietal: 9.5 cm(CBQ) * FACE is
presenting part
Fetal presentation
 part of the fetus that is leading/ presenting to the pelvic
inlet of the birth canal Fetal lie
 Cephalic- most common ( 95% ) - relationship of long axis of fetus to long axis of uterus /maternal
 Breech- 4 % of cases spine
 Shoulder - 1 % of cases
1. L ongitudinal - parallel to one another
 3. BROW - poor flexion/partially extended ( face in birth
canal) widest diameter of the head enters the pelvis
first.
4. Mentum - completely hyperextended * chin or face is
presenting part(CBQ)

Fetal station - relationship between fetal presenting part to the

ischial spine

Ischial spines – the ANATOMIC FIXED REFERENCE POINT to

determine the station of the fetal head. –(CBQ)

Above the ischial spines is referred to as NEGATIVE station ( -1

 ELONGATED shaped abdomen. to -5 )
2. O blique - diagonal lie( 45° angle to one another) The ischial spines is zero (0) station. – head is engaged.
3. T ransverse - fetal long axis is perpendicular to maternal Below the ischial spines is referred as POSITIVE STATION ( +1
long axis ( 90° angle to one another) to +5)
 TRIANGULAR shaped abdomen.
 Associated with placenta previa. Each station is measured by “cm or centimeter”
Fetal position -5 station means 5 cm above the ischial spines
 relationship of the fetal presenting part to the four -4 station means 4 cm above ischial spines
quadrants of the maternal pelvis. -3 station
 *OA / Occiput anterior are the most favorable normal means 3 cm
position. above ischial
spines
4 Quadrants of pelvis: -2 station
R ight means 2 cm
A nterior - symphysis pubis (upper) above ischial
L eft spines
P osterior – sacrum (lower) -1 station
means 1 cm
3letters: above ischial
1st letter -which side of the pelvis the fetus reference point is on spines
(R for right, L for left). 0 station
2nd letter -what reference point on the fetus is being used means at
(Occiput-O,Mentum-M, Breech-S, Shoulder-Sc or A). level of the
3rd letter -which half of the pelvis the reference point is pointing ischial spines (Engagement)
in / near of (anterior-A, posterior-P, transverse or in the middle-T). +1 means 1 cm below the ischial spines
+2 means 2 cm below the ischial spines – (CBQ)
EXAMPLE: +3 means 3 cm below the ischial spines – (CBQ)
1. During an internal examination, the nurse palpated the posterior +4 means 4 cm below the ischial spines
fontanel to be at the leftside of the mother at the upperquadrant. +5 means 5 cm below the ischial spines
The interpretation is that the position of the fetus is:
__________________. – (CBQ) Sample: (CBQ)
A. LOA B. ROP C. LOP D. On internal examination, the leading portion of the fetal head is 3
ROA centimeters above the ischial spines. This means that the
presenting part is _____________
FETAL POSITIONS: A.Station plus 2 B.Station zero C. Station
Most common and NORMAL plus D. Station minus 3
positionMALPOSITIONS( ABNORMAL)
LOA - left occiput anteriorLOP - left occiput posterior
ROA - right occiput anteriorROP- right occiput posterior Passageway

Take note: LOP / ROP may cause severe backache during labor.  The birth canal that is composed of the bony pelvis,
SEVEREBACKACHE during labor : position mother to cervix, pelvic floor, vagina, vaginal opening.
SQUATTING– (CBQ)
4 Types of pelvis
LOCATI Cephalic/vertex: The FHR Breech: The FHR will Gynecoid The genuine female pelvis- most
ON OF will be located below the be located above the common/ prevalent type
FHT umbilicus on R or L side umbilicus or ROUNDbrim– (CBQ)
(same side as reference UPPERFUNDALQUAD pear-shaped pelvis – (CBQ)
point) or at the RANT. – (CBQ)  most favorable pelvis
LOWERABDOMINALQUA for vaginal delivery
DRANT
– (CBQ) Ischial Spines: blunt NON
prominent
Pubic Arch: more than 90 degree
angle wide arch
Fetal Attitude ( degree of flexion or fetal habitus)
 the relationship of the fetal body parts to one another Anthropoid APE - like pelvis
2nd most favorable for vaginal
1. Vertex - complete flexion - SOB/occiput is presenting delivery
part It allows and favors passage of
2. MILITARY- moderate flexion- sinciput is presenting OP fetus
part Has an OVALbrimand a slightly
 narrow pelvic cavity. – (CBQ)
Anteroposterior diameter( APD) :
WIDE
Transverse diameter: Narrow
Android Male pelvis
HEART shaped brim / APPLE
shaped pelvis– (CBQ)
TRIANGULAR inlet with
CONVERGENT side walls
poor prognosis for vaginal
delivery
Ischial Spines: usually prominent
and encroaching
Pubic Arch: <90 degrees and
narrow
Plattypelloid RAREST/Least type of pelvis–
(CBQ)
FLAT pelvis
APD: narrow/short
Transverse diameter: WIDE
KIDNEY BEANshaped brim –
(CBQ)
Anteroposterior Diameters (APD)
The anteroposterior (or "conjugate") diameter is the
distance between the pubic symphysis and the sacral
promontory.
Three distances are:
 D iagonal conjugate
 O bstetrics conjugate
 T rue conjugate
1. Diagonal Conjugate
 Measured between the sacral promontory and the lower
edge/ INFERIOR margin of the pubic symphysis– (CBQ)
 can be clinically evaluated by I.E
 *used as baseline to get OB and True conjugate
average of 12.5 cm
2. Obstetrics conjugate
 Measured from the sacral promontory to the point
bulging the most on the back of the symphysis pubis,
located about 1 cm below its upper border.
 AVERAGE of 10.5 cm or more
 MOST critical measurement and SHORTEST
Anteroposterior diameter of the pelvis. – (CBQ)
 The obstetrical conjugate is computed by subtracting
1.5 to 2.0 cm from Diagonal conjugate
3. True conjugate
 Also known as Conjugate Vera and Anatomical
conjugate
 Measured between the sacral promontory and the upper
edge of the pubic symphysis and average of 11.0 cm
 CANNOT CLINICALLY EVAUATED or NOT measured
by I.E – (CBQ)
Oblique Diameter
distance between the arched line near the sacroiliac
joint posteriorly and the pubopectineal line. ( measures
12 cm)
Transverse diameter
distance between the two innominate lines at their
widest point and measures approximately 13 cm.
Transverse Diameters of pelvic outlet:
1. Bituberous diameter/ Intertuberous diameter
 between 2 ischial tuberosities.
 May be measured by placing a close fist
against perineum (4 knuckle)
 measures: 11 cm
2. Bispinous/Interspinous diameter
 between 2 ischial spines (smallest
pelvic diameter)
 measures: 10.5 cm – (CBQ)
FALSE PELVIS TRUE PELVIS
 known as the  known as LESSER
GREATER pelvis pelvis
 ABOVE the linea  BELOW the linea
terminalis– (CBQ) terminalis
  superior and is  Inferior and is to ESTROGEN) (CBQ)
surrounded by iliac surrounded by the
fossa portions of the pubis and ischium WOF: Cord prolapse
coxal bones and the portions of the *when there is prolapsed cord
upper portion of the coxal bones 1staction: Position mother to knee chest or
sacrum. Trendelenburg(CBQ)
* contains the inlet, cavity 2nd action: Relieved cord compression and
and outlet prevent drying of cord.
3rdaction: Cover the cord with sterile gauze wet
with NSS(CBQ)
Powers of Labor * you can push the fetal head back to pelvis BUT
1. Primary power: involuntary power- uterine contraction NEVER PUSH BACK THE CORD IN VAGINA.
( FERGUSON REFEX) (CBQ)
2. Secondary power: voluntary power- maternal bearing down
efforts ( Valsalva maneuver) Braxton Hicks Practice Labor contractions
contractions False labor contraction
Assessment: - intermittent, irregular and painless contractions
1. Increment/Crescendo – INCREASING force of
contraction Bloody show  Sign of cervical effacement and
2. Duration – length of uterine contraction , measured from dilation.
the beginning of a contraction to the end of the same  Mixture of thick mucus and pink or
contraction(CBQ) dark brown blood vaginal discharge
3. Intensity – STRENGTH of uterine contraction  It occurs as a result of the softening,
4. Acme/Apex – PEAK of uterine contraction dilation, and effacement (thinning) of
5. Decrement/Decrescendo – DECREASING force of the cervix
contraction  Bloody show will continue and will
6. Interval – measured from the end of contraction to the increase during labor as the cervix
beginning of the next contraction continues to dilate and efface.
7. Frequency – rate of uterine contraction, measured from
the beginning of a contraction to the beginning of the
next contraction(CBQ) False Labor True labor
Contraction: Contraction: regular
irregular/intermittent Pain: painful
PREMONITORY SIGNS OF LABOR Pain: painless Origin: lower back to
Origin: abdomen only abdomen(CBQ)
Lightening EARLIEST sign of approaching labor(CBQ) Sedation: rest and medication Sedation: intensified by
also known as "Baby drops" / engaged Bloodyshow: negative walking(CBQ)
Engagement occurs: Cervicaldilatation: no cervical Bloodyshow: positive
Primigravida: 10-14 days before onset of changes cervicaldilatation: progressive
labor(CBQ)
Multigravida: at the onset of labor
Childbirth Preparation Methods

Signs/Symptoms: Dick-Read Fear-Tension-Pain Cycle

1. Lower Fundic height Method *Pain during childbirth was caused by FEAR
2. Ease of breathing Bradley Method HUSBANDcoached(CBQ)
3. Easier eating. Partner plays an active role.
4. Return of urinary frequency Healthy diet, exercise, and use focal points
5. Return of leg cramps6. back pain Lamaze method Psychoprophylactic method

Nesting “BURST of ENERGY” Childbirth method with controlled breathing/

instinct mothers seems energetic cleansing breaths to CONTROL PAIN,
due to a surge in adrenaline in the final months position, massage and relaxation
or weeks of pregnancy. *effleurage massage(CBQ)
The hormones most likely to influence nest
building are beta-estradiol and progesterone limited medical interventions like limited use
of analgesia.
ADVISE MOTHER TO TAKE REST TO Leboyer method Childbirth WITHOUT violence.
CONSERVE ENERGY! (CBQ) Odent method WATER BIRTH
Sheila Kitzinger Experience of Childbirth and Psychosexual
Leukorrhea expulsion of mucus plug philosophy
leukorrhea is a thick, whitish or yellowish vaginal Link between jaw & peri tension
discharge. 1. The nurse asked for the personal data of the patient which, to
some, Carlita did not like to She asked: “Why do you need to
Due to increasing level of ESTROGEN, the know if I am married? “What should be a good response of the
mucus plug thins and dislodged as nurse? “I asked your marital status because ________.
leukorrhea(CBQ) A. “if you do not have a husband, then that can pose a big
problem for you.”
Ruptured MOST common reason for admission (rupture of B. “if you are married then your husband will also suffer
membrane bag of water) from discomforts like you.”
Priority: Place the mother in bed and CHECK C. “you need your husband to accompany you every
FHT(CBQ) prenatal check up.”
Note the: Color, Odor, Amount, Time of rupture. D. “your husband is your best support system during your
(C.O.A.T) pregnancy.”
ConfirmROM : FERNTEST(ferning pattern is due
2. Kevin asks what possible contributions he could give for the  FHT more than 160 (10 mins. or more) is known as
normal development of the baby . Nurse Elsie agreed that his PERSISTENT TACHYCARDIA
BEST contribution would be the following EXCEPT____.  Fetal tachycardia is early sign of fetal distress(CBQ)
A.Stroke Jane’s abdomen and talk to babyC.Join wife during  Fetal bradycardia is late sign of fetal distress
prenatal check-up
B. Provide Jane nutritious food and drinksD. May smoke once in a
while

THE FOUR STAGES OF LABOR

First stage Cervical dilatation /Preparatory stage.

begins: onset of true labor
ends: fully cervical dilation (10cm) (CBQ)

Second FETAL EXPULSION STAGE

stage begins: fully cervical dilation ( 10cm) (CBQ) COLOR OF LIQOUR ( recorded every 4 hours )
ends: complete fetal delivery
Plotting in partograph:
Crowning of Fetal head – signals second stage of “B” – bloody
labor (CBQ) “I” – Intact

Third stage PLACENTAL EXPULSION STAGE “M” – meconium /green stained

begins: complete fetal delivery “A” – absent / ruptured
ends: complete placental delivery “C” – Clea

Fourth stage RECOVERY STAGE/IMMEDIATE POSTPARTUM Fetal Moulding ( Every 4 hours) (CBQ)
Begins: complete placental delivery to FIRST 1 - 2 0 - Bones are separated and the sutures can be felt
hours after delivery. easily.
+1 - Bones are just touching each other.
+2 - Bones are overlapping but can be separated easily
THE FIRST STAGE OF LABOR with pressure by your finger.
FIRST STAGE +3 - Bones are overlapping but cannot be separated
 Cervical dilatation stage easily with pressure by your finger. ( uterine obstruction-
 Longest stage of labor REFER!)

3 Phases: PROGRESS OF LABOR

Phase I - latent phase ( 0 - 3 cm )  Cervical dilation - every 4 hours (CERVICAL DILATION
Phase II - active phase ( 4 - 7 cm, Early active: 4-5cm, Late IS PLOTTED AS “X”) – (CBQ)
active: 6-7cm)  Progress of labor – hallmark is cervical dilation– (CBQ)
Phase III - transition phase ( 8 - 10 cm ) Primigravida – 1 cm/hour
Multigravida – 1.5 cm /hour
NON – ROUTINE procedures: (CBQ)
M aternal shaving TAKENOTE: 1 cm effaced cervix means 50%(CBQ)
O xytocin to augment labor
T otal restriction of fluids and food ( NPO)
H aving an artificial rupture of membrane ( amniotomy)
E nema Duration of STAGE 1 of labor:
R outine IVF insertion PRIMIGRAVIDA: 8-12 hours
MULTIGRAVIDA: 6-8 hours
Partograph is a graphical presentation of the progress of labour,
and of fetal and maternal condition during labour. L atent - 0 - 3 cm
A ctive - 4 - 7 cm(CBQ)
Maternal Wellbeing T ransitional - 8 -10 cm
Pulse - recorded every 30 mins.
Temperature - recorded every 2 hours ACTIONS:
Blood pressure - measured every 4 hours B reathing exercise & relaxation.
Urine output - every voiding E ncourage ambulation / walking.
* Encourage mother to EMPTY BLADDER every 2 hours– (CBQ) D o not place patient in NPO.
TAKE NOTE: Height of the uterine fundus, maternal height,
weight , intake and outout are NOT recorded in the partograph – NO MATERNAL PUSHING IN FIRST STAGE OF LABOR OR
(CBQ) UNTIL CERVIX IS FULLY DILATED.
Fetal Well being:
FHT - monitored every 30 minutes in Active phase of labor LATENT PHASE: ACTIVE PHASE TRANSITION
NORMAL FHT : 120 - 160 bpm. (CBQ)
 FHT less than 120 ( 10 mins. or more) is known as Primi: 6 hours Primi: 3 hours Primi: 1 hour
PERSISTENT BRADYCARDIA Multi: 4-5 hours Multi: 2 hours Multi: 30 mins.

Phases Consistenc Intensit Duratio Interva Dilatio

y y n l n
Latent Like nose Mild 20 – 40 5 – 10 0–3
secs. mins. cm
Active Like chin Modera 40 – 60 3–5 4–7
te secs. mins. cm
Transition Forehead Strong 60 – 90 2–3 8–1 After 30 seconds
al secs. mins. cm  Initiate Skin to skin contact ( prone in mother's
abdomen.) (CBQ)

Transfer of woman from labor room to delivery room. Within 1-3 minutes or until cord pulsation stops
Primis – cervix fully dilated  Clamp and cut cord
Multips – cervix is 8 cm dilated  Cord clamp : 2 cm above base(CBQ)
 2nd clamp: 5 cm above base
Position during transport: Left lateral  NO MILKING OF THE CORD(CBQ)
 NO TO ANY SUBSTANCES IN THE CORD ( maintain it
Delivery Position DRY and CLEAN) (CBQ)
1. Lithotomy – used when forceps delivery & episiotomy  OOZING BLOOD IN CORD – Apply firm pressure.
are to be performed ( with stirrups)  CUT with sterile scissor to prevent tetanus infection of
 Lift the patient's legs slowly and place legs the cord(CBQ)
simultaneously into the stirrups to prevent
lumbosacral strain. (CBQ)
Third Stage of labor
2. Dorsal Recumbent – head of the bed is 35 – 45˚
elevated, knees are flexed & feet flat on bed. This DELIVERY TIME: 10 - 30 minutes.
position facilitates the pushing effort of the mother. Technique: WATCHFUL WAITING ( Do not hurry placental
delivery.)

THE SECOND STAGE OF LABOR 1. EXPECTANT MANAGEMENT OF THIRD STAGE OF

Fetal Expulsion Stage
Primies: 50 minutes
Multips: 20 minutes
FHT monitoring: every 5-15 minutes.
CARDINAL/ MECHANISM of LABOR: E - D - F - IR - E - ER- E
E ngagement - settling of the head in pelvic brim(CBQ)
D escent – entrance of BPD of fetal head to inlet
F lexion – the chin of the fetus touches his chest
I nternal Rotation – baby head rotates from transverse diameter to
AP diameter
E xtension – the head of the fetus extend towards the vaginal
opening.
* CROWNING occurs. ( encirclement of head to vulva)
E xternal Rotation – when the head comes out, the body turns
from transverse to AP diameter ( RESTITUTION)
E xpulsion – when the head is born, NEXT is the anterior shoulder
then posterior shoulder & the rest of the body follows without
much difficulties.
Common board questions:
Cardinal movement of labor that precedes flexion is
DESCENT(CBQ)
Mechanism of labor to follow internal rotation is
EXTENSION(CBQ)
LABOR.
Wait for Signs of placental delivery:
 Calkin’s sign – uterus is firm, globular (round)
& rising to the level of umbilicus(CBQ)
 Sudden gush of blood from vagina
 Lengthening of the cord
 SHULTZE mechanism ( placenta in vagina)
 FIRM and contracted fundus.
2. ACTIVE MANAGEMENT OF THIRD STAGE OF
LABOR (AMTSL)
Three main components of AMTSL
1. Injection of oxytocin after delivery of baby to
lessen bleeding (CBQ)
2. Controlled cord traction to deliver placenta
3. Massage uterus to keep it contracted after
delivery
PRIORITY: CHECK the completeness of placental cotyledons
and fetal membranes after delivery, any missing fragment can
result to bleeding or infection. ANY PIECE OF PLACENTA is
missing, REFER! The woman to the doctor. (CBQ)
WARNING: DO NOT pull the umbilical cord, the cord may break
or the uterus may turn inside out (UTERINE INVERSION). (CBQ)

Take note: precede means before, to follow means after. FAILURE TO DELIVER placenta more than 1 hour, REFER the
woman to hospital – (CBQ)
The available injectable uterotonics are Oxytocin 10 “u” and
FETAL DELIVERY: methylergometrine 0.2 mg.
 Instruct mother to push DURING CONTRACTION and OXYTOCIN is the FIRST CHOICE drug because it is FAST
REST IN BETWEENS. (CBQ) ACTING ( EFFECTIVE 2 – 3 minutes after injection) and has
 NO TO FUNDAL PUSHING or Kristeller maneuver. minimal side effects. (CBQ)
(CBQ)
 FACILITATE and ASSIST head delivery by Modified TAKE NOTE: CHECK Blood pressure FIRST before giving
RITGENS maneuver. uterotonic drugs. (CBQ)
 Modified Ritgens maneuver preserves the perineum to
prevent massive perineal laceration.
METHODS OF PLACENTAL DELIVERY
* IMMEDIATELY AFTER DELIVERY: SHULTZE DUNCAN
Head comes out: CHECK neck for any cord coil(CBQ)  Fetal side comes  Maternal side comes
WIPE mucus or secretions in face ( NO ROUTINE FIRST FIRST
SUCTIONING!!!)  SHINY, SMOOTH  DIRTY SIDE,
Your FIRST ACTION IS TO DRY the baby NOT suctioning (CBQ) portion(CBQ) MEATY
 GRAYISH WHITE PORTION(CBQ)
AFTER CALLING OUT the time of birth and sex of newborn  DELIVERED LIKE A  DARK RED
1st 30 seconds FOLDED  RISK FOR
 FIRST ACTION: DRY the baby immediately ( dry, warm UMBRELLA(CBQ) RETENTIONS
towel) (CBQ)
 NO WIPING OUT OF VERNIX CASEOSA(CBQ)
THE FOURTH STAGE OF LABOR
FOURTH STAGE: A ssess proper latching on and positioning
FIRST 1-2 HOURS after delivery S upport breastfeeding ( give NO other than
Most DANGEROUS STAGE(CBQ) breastmilk even water) (CBQ)
DANGER FOR: POSTPARTUM HEMORRHAGE T each on how to care the breast – ALWAYS
wash hands before handling breast.
INTERVENTIONS:
M aintain Firmness/ contracted uterus Everted, Flat, inverted
A ssess for a soft and boggy uterus ( uterine atony)
M assage fundus(CBQ)  Instruct to perform Hoffman's maneuver.
A dminister uterotonic drugs  Roll nipples to toughen. (CBQ)
* OXYTOCIN - FIRST CHOICE to prevent  Use breast shells and nipple shield.
P.P.H. (CBQ)  Express breast-milk ( manual or pump)
 Do not stop breastfeeding(CBQ)
POSTPARTUM CARE
Priority in FIRST 6 – 12 hours AFTER DELIVERY SORE/ CRACKED NIPPLES
 Blood loss /bleeding(CBQ) C orrect latching on and positioning(CBQ)
Postpartum Assessment: (CBQ) R ecommend to continue breastfeeding
 every 15 mins for 1st hour A dvise to use the least sore breast first(CBQ)
 every 30 mins for 2nd hour C ream: lanolin ointment
 every 4 hours for 1st 24 hours K eep the breast air dried after feeding(CBQ)
 After 24 hours every 8 hrs. E xpress milk or colostrum and apply to nipples(CBQ)
Involution D o not use SOAP, silk bra, bra with plastic straps.
 Process of RETURN of uterus and other reproductive (CBQ)
organ to non-pregnant state. (CBQ) Engorgement
 Happens by 3 – 4 weeks AFTER delivery or until 6 H eavy and tight
weeks postpartum. (CBQ) E rythema (redness)
A warm to touch breast
Two process of Involution: V ery firm or hard, painful and tender(CBQ)
1. Retrogressive changes: Y es! It is shiny and swollen
 Involution of the uterus ( shrinking and
descent) ONSET: FIRST 3-5 days postpartum
 Lochia discharges Management:
F requent breastfeeding
2. Progressive changes: U seengorged breast FIRST(CBQ)
 Production of milk for lactation L atchthebabyproperly
 Restoration of normal menstrual cycle L etmother massage, express milk and air dry the
breast(CBQ)
Watch out for: SUBINVOLUTION or non returning of uterus to
normal state like TAKE NOTE:
 Non shrinking of uterus.  Apply warm packs 15-20 minutes
 Bright red/lochia rubra at 6 days postpartum. BEFOREfeeding(CBQ)
(CBQ)  Warm compress during feeding-cold compress between
 Most common cause is RETAINED feeding-pump milk * use cabbage leaves. (CBQ)
FRAGMENTS OF TISSUES. (CBQ)  Try a warm shower before breastfeeding. (CBQ)
 Use the last use breast First in your next feeding. (CBQ)
AFTERPAINS  NEVER STOP BREASTFEEDING(CBQ)
 NORMAL(CBQ)  MASSAGE AND MANUALLY EXPRESS MILK IN A
 Painful uterine contractions CUP(CBQ)
 Breastfeeding stimulates oxytocin release which cause Mastitis
powerful & painful uterine contractions
 More acute in and common among: Inflammation of the breast, can be infective or non-infective
Breastfeedingmothers(CBQ) Most common: at 2-3weeks postpartum
Multiparouswomen(CBQ)
CesareanDeliverymothers Non infectious type – MILK STASIS
INFECTIOUS type – Staphylococcus aureus bacteria(CBQ)
Priority action: Give ANALGESIC or pain reliever as ordered.
(CBQ) Signs and symptoms:
Post partum Assessment: I nflamed
N ursing discomforts ( painful)
B reast F lu like ( chills) (CBQ)
U teurs E levated temperature ( fever) (CBQ)
B ladder C ontinuous burning sensation
B owels T ender and swollen
L ochia E rythema or redness
E pisiotomy and perineum D ischarge ( pus) – for incision and drainage.

H omans sign Management:

E motions A lternating warm & cold compress(CBQ)
Breast: B reastfeed on demand(CBQ)
B reastfeed immediately after delivery initiate C orrect position and latching on(CBQ)
within FIRST 1 hour (CBQ) D o not use soap in breast
R ooming in up to 24 hours (CBQ) E xpress milk and massage
E xclusively breastfeed the baby up to 6 F ree the breast to Air. (CBQ)
months(CBQ)
 Time occurrence: Time Occurrence: 4-
Proper Breastfeeding Attachment(CBQ) within 24hours after 10 days Time occurrence:
delivery up to 1 –3 11-21 days
C hin of baby touching days(CBQ) Color: pink or Or until 6 weeks
mothers breast(CBQ) Color: Dark brownish(CBQ) postpartum
A reola is more visible RED(CBQ) Odor: odorless Color: yellow –
above Odor: fleshy, creamy white(CBQ)
L ower lip is turned musty, stale odor Odor: slightly stale
OUTWARD(CBQ) that is non- Composition: serum, odor
M outh widely open(CBQ) offensive. erythrocytes, shreds
S ucking is SLOW, DEEP with some pauses. of degenerating
(CBQ) Composition: blood decidua, more in Composition:
w/ small amounts leukocytes, serous leukocytes,
Regulatory Laws: of mucus, shreds of fluid cervical mucus, decidual cells,
E.O 51 - MILK CODE(CBQ) decidua, epithelial numerous bacteria epithelial cells,
RA 7600 - Rooming In and Breast feeding Act of 1992(CBQ) cells, leukocytes; fat, ,cervical
RA 10028 - Expanded Breastfeeding Promotion Act of 2009 may contain fetal mucus, cholesterol,
meconium, lanugo, bacteria
or vernix caseosa
Uterus
REMINDER: LOCHIA should be:
Height - Fundus descends 1cm or 1 fingerbreadth each day(CBQ)  NO CLOTS larger than 1 cm. (CBQ)
 FOUL ODOR FREE
Location of fundus  PROGRESSIVE Color changes ( Red to pink/brown to
 Immediately after delivery - just below umbilicus yellow/white) (CBQ)
( midline and palpable halfway between the symphysis  Lochia with a foul smell or green tinge may indicate
pubis and the umbilicus. ) (CBQ) infection. (CBQ)
 One hour after delivery, the fundus is firm and at the
level of the umbilicus. Lochia amount measurement:
 By 10 days postpartum, uterus cannot be palpated  scant: less than a 2.5 cm (1 inch) stain on the peripad
already.  light: less than 10 cm (4 inch) stain
 moderate: less than 15 cm (6 inch) stain
Position of UTERUS:  heavy: saturated peripad in 1 hour
 Fundus should be MIDLINE near the umbilicus(CBQ)  excessive: saturated peripad in 15 minutes
 A full bladder may push the fundus to the R or L of the
umbilicus ( deviated/ displacement suggest FULL TAKE NOTE:
BLADDER) (CBQ)  WEIGHING pads is the BEST way to measure amount
of lochia or bleeding. (CBQ)
Tone of Uterus:  Orcounting the number of saturated pads
 FIRM/HARD means CONTRACTED uterus and it is  1 milliliter of blood weighs approximately 1 gram(CBQ)
GOOD!! (CBQ)  The normal amount of lochia may vary with the
 SOFTandBOGGY means relaxed / atony and it is NOT individual but should NEVER exceed 4 to 8 peripads per
GOOD!! (CBQ) day. (CBQ)
 Uterine atony - increases risk of PPH  The average number of peripads is 6 per day.
 Gently massage the uterus to help the muscles to
contract Peri Care
W ipe vulva from front to back/ anterior to posterior
patting gently(CBQ)
Bladder
A fter each voiding, change the peripads
T ucks application 1 – 2 (witch hazel) pads to peripad
P alpate for distention above symphysis pubis.
with each pad change.
E ncourage the patient to pass urine
C onsume a high fiber diet(CBQ)
E nsure passage of urine 6 – 8 hours after delivery. (CBQ)
H ave sitz bath 24 hours postpartum per Doctor’s order
TAKE NOTE: MOTHERS should Voided within 6-8 hours after
for 20 min 2 – 3 x a day especially if patient had a 3rd or
delivery.
4th degree laceration(CBQ)
Bowel
B owel sound assessment every shift Use of Perilight:
O bserve any fecalith passing in vagina ( REFER!!) –  Perilight 25 watts – distance : 12-18 inches
Sign of rectovaginal fistula(CBQ)  Perilight 40 watts – distance: 18-24 inches(CBQ)
W ipe FRONT TO BACK ( anterior to posterior) in care
of vulva to prevent infection. (CBQ)
E ncourage patient to eat digestible foods. Episiotomy
L eafy green vegetables and fruits in diet. Widens the vaginal opening (CBQ)
I t is commonly done at second stage of labor(CBQ)
TAKE NOTE: First Bowel movement usually occurs on or after D octors practice ONLY
2nd postpartum day. ( 2 – 3 days postpartum) (CBQ) E pisiotomy shortens the second stage of labor
N ote and assess for the R.E.E.D.A(CBQ)
R=redness
E-edema
Lochia discharges E=ecchymosis
-Lochia is the vaginal discharge after giving birth, containing D=discharge
blood, mucus, and uterine tissue. Lochia discharge typically A=approximation
continues for 6 weeks. (CBQ)
Lochia Rubra Lochia Serosa Lochia Alba Midline episiotomy – less bleeding, fast healing.
R or L mediolateral – more bleeding, longer healing.
  Monitor for any adverse signs and symptoms like:
Watch out for: PERINEAL HEMATOMA(CBQ) hematuria, ecchymosis, epistaxis.
 patient complains of rectal pressure and increasing
perineal pain
 INITIAL ACTION: Apply cold packs for 15 – 20 minutes Emotions
every 4 hours. (CBQ) Taking In phase Taking Hold Letting Go
 Application of ice packs helps reduce pain and swelling,
and is the most appropriate initial action for a vaginal  Immediate  Preoccu  About 7
hematoma. ly after pied with days after
 Cold sitz bath of 20 – 30 minutes delivery till the delivery
up to 2 present  Adaption
DEGREES OF PERINEAL LACERATIONS: days  2–5 to
1. First Degree postpartu days parenthoo
 Tear of fourchette, vaginal mucous m postpart d
membrane, perineal skin(CBQ)  Focus to um  Abandon
 Still intact muscles self  Intereste ment of
 Sense of d in self- fantasized
2. Second Degree wonderme care image of
 Tear that extends from fourchette, vaginal nt when  Optimal neonate
mucous membrane, perineal skin, and looking at time for and
MUSCLES OF PERINEAL BODY. (CBQ) the teaching acceptanc
 Still intact anal sphincter neonate  Focus e of real
 Contempla on image
3. Third Degree tion of caring 
 Tear that extends from skin and vaginal birth for baby Assumpti
mucosa, subcutaneous tissues, fascia and experienc on of
MUSCLE SPHINCTER ANI. – (CBQ) es responsibi
 Still intact rectal muscles ( relives lity and
events of care for
4. Fourth Degree Labor and the
 fourchette, vaginal mucous membrane, Delivery) neonate.
perineal skin, muscles of perineal body, anal PSYCHOLOGICAL PROBLEMS IN POSTPARTUM PERIOD
sphincter & mucous membrane of RECTUM Postpartum blues Postpartum Postpartum
(CBQ) depression psychosis
AKA: Maternity baby More than 2 weeks Develops within the
Watch out for: blues, maternity of blues first 2-3 weeks
blues or baby blues postpartum.
1. Rectovaginal fistula- *Treatable with
 abnormal connection between vagina and MOST COMMON: antidepressant Women with a
rectum allowing feces and flatus to escape in PRIMIGRAVIDA drugs.(SSRI) history of bipolar
vagina. – (CBQ) (80%) disorder have
 The number 1 cause is obstetrical trauma Decreased higher risk.
such in obstructed labor Onset: 2 – 3 interest(CBQ)
 The number 2 cause is Crohn's disease days(CBQ) Extreme anxiety or Paranoia
 And Failure to suture EXTERNAL/INTERNAL Peak: 5th day Panic attacks Self harm or
ANAL SPHINCTER muscle such in 3rd or 4th Resolves: 10th day ( Restlessness and harming infant.
degree laceration – (CBQ) not more than 2 irritability Yes! SAFETY is the
weeks) Emotionally priority
2. Vesicovaginal fistula down&ISOLATION Confusion an
 abnormal connection between vagina and *NORMAL MILD Suicidal thoughts disorientation
urinary bladder– (CBQ) MOODINESS. or attempts Hallucinations,
Due to hormonal Sleeping problems delusion and
Homan's Sign influences. ( Irritable sad & have illusion.
Watch out for: Phlegmasia alba dolens or Milkyleg ( DVT) (CBQ) decrease estrogen no energy Obsessive
+ Homan sign is elicited by passively dorsiflexion of the foot at the and progesterone) Obsessive thoughts behaviors
ankle with the knees extended (CBQ) N o appetite /Do not
* Painful calf or popliteal area = + Homan sign(CBQ) want to eat REFER! for
HALLMARK SIGN: treatment
Prevention: Ambivalence/mixed
 Early ambulation after delivery (CBQ) emotion. Treatment:
 Use of support stocking in women with varicosities to CRY and Hospitalization
promote circulation & prevent stasis – put on stocking GETANGRY easily Antipsychotic
before rising from bed in the morning(CBQ) medications (e.g.
 NEVER MASSAGE any swollen and painful area. Blue emotion haloperidol)
(CBQ) (sadness) Mood stabilizers
Labile instability (lithium).
Anticoagulant medications to prevent further clot formation. Usually cries with
 Heparin – not passed to breastmilk (SAFEST No reason
anticoagulant) (CBQ) Episodes of
 ProtamineSulfate – antidote of heparin toxicity(CBQ) headache,
 Monitor laboratory values of activated partial insomnia, irritability,
thromboplastin time (aPTT) (CBQ) poor appetite and
 Avoid SALICYLATE drugs because it can aggravate anger(CBQ)
bleeding. (CBQ)
ABNORMAL OBSTETRICS the vagina and the uterus is firmly contracted suspect
for : LACERATIONS (CBQ)
Maternal death Active Management of Third Stage of Labor (AMTSL)
 defined by WHO as the death of a woman while  Injection of oxytocin after fetal delivery
pregnant or within 42 days of termination of pregnancy.  Controlled cord traction
(CBQ)  Massage uterus (DO NOT OVER massage)

Direct Maternal Indirect Maternal Coincidental death Fluid replacement: Uterotonic drugs: Position for shock:
death deaths Ringer lactate or 1st choice: Modified
death of a woman death of a woman death due to 0.9% sodium Oxytocin (10 u) Trendelenburg(CBQ)
that results from caused by non- coincidental causes chloride ( normal 2nd choice:
obstetric obstetric conditions or other death is saline) (CBQ) methylergometrin
complications of the or diseases that death during e IM: 0.2mg
pregnant state, may exist before pregnancy, misoprostol SL:
which includes pregnancy, but is childbirth and the 800 mcg
pregnancy, labor, aggravated by the puerperium due to
and puerperium. physiologic effects coincidental
of pregnancy. causes, e.g. Oxytocin Methylergometrine
Examples: (CBQ) suicide. Action Rhythmic uterine Sustained (Tonic)
H emorrhage Examples: contraction (CBQ) uterine contraction
O bstructed labor Diabetes mellitus Onset of action 2 – 3 minutes 6 – 7 minutes
U nsafe abortion Heart disease
S epsis IM injection action
E clampsia Malaria and HIV last for 2 – 3 hours
Anemia (IDA) (CBQ)
Tuberculosis
Hypertension
Side effects Act as Antidiuretic Headache, vomiting
( water retention) Hypertension
Postpartum hemorrhage (PPH) Hypotension(CBQ)
 defined as blood loss of 500 mL or more following a Contraindication Low blood pressure High blood pressure,
normal vaginal delivery (NVD) or 1,000 mL or more Myocardia
following a cesarean section within 24 hours of delivery. infarction(CBQ)
 PPH is the leading cause of maternal mortality in low- Angina pectoris
income countries.
 More than 10 – 11 mothers die daily due to pregnancy Priority CHECK BP before CHECK BP before
and delivery complications (UNFPA, 2016) (CBQ) assessment administration(CBQ) administration
 Hemorrhage is the leading cause of maternal mortality.

Predisposing factors: (CBQ) Puerperal Sepsis – “Childbed fever”

Tone – uterine atony ( relaxed uterus)  Infection of the genital tract after delivery.
Trauma – uterine rupture cervical and vaginal  a temperature rise above 38.0°C (100.4°F)
lacerations; uterine inversion. maintained over 24 h or recurring during the period from
Tissue – retained placental fragments the end of the first to the end of the tenth day after
Thrombin – coagulation disorders childbirth or abortion. (CBQ)
Early postpartum hemorrhage Late postpartum hemorrhage  MOST COMMON POSTPARTAL INFECTION IS
Primary postpartum Secondary postpartum ENDOMETRITIS (CBQ)
hemorrhage hemorrhage
Occurs WITHIN 24 hours of Occurs AFTER 24 hours to 6 Predisposing factors:
delivery(CBQ) weeks after delivery  PROM (CBQ)
MOST common cause is  Retained placental  Prolonged labor
UTERINE ATONY fragments (tissue)  Postpartum hemorrhage and tissue retention
 Uterine atony may  Dilatation/
occur due to Completion Signs and symptoms:
overstretching of curettage Fever and chills (Above 100. 4 °F) (CBQ)
uterus like in Odorous foul lochia
Maternal Hydramnios Unwell feeling (body malaise)
Macrocosmic baby Lack of appetite
(LGA)
Multiple pregnancy Treatment: ANTIBIOTICS (as per doctors order)
(twins/triplets)
Molar pregnancy (H- Prevention
mole)  Good prenatal nutrition (IRON AND FOLIC)
Maternal infection  Good maternal hygiene
(chorioamnionitis)
Maternal anesthesia Urinary Tract Infection
 Prolonged labor Most common during puerperium due to bladder trauma, urinary
retention, & overdistention of the bladder due to anesthesia
COMMONLY ASKED IN THE BOARD EXAM: WOF: CAUTI – catheter associated urinary tract infection.
 First action when uterus is relaxed, soft and boggy is to
MASSAGE IT GENTLY. (CBQ) Escherichia coli (E.coli) Bacteria is the MOST COMMONLY
 If uterus is DISPLACED to right or left side above ISOLATED agent causing UTI. (CBQ)
umbilicus – empty the bladder since a full bladder
interferes with effective uterine contraction(CBQ) Signs and symptoms:
 When bright red blood continue to gush or trickles from  Burning/painful urination and hematuria
  Urinary frequency and urgency DIFFERENT TYPES OF ABORTION
 Flank pain Types Characteristics Management
 Fever
Threatened Vaginal bleeding Bed rest(CBQ)
Management(CBQ) WITHOUT cervical Ensure fetal wellbeing
Regular bladder emptying to prevent urinary stasis dilatation.(CLOSE) Do not engage sex for
Increase fluid intake ( 3,000cc/day) to flush away (CBQ) 2 weeks
infection from the bladder.  Mild abdominal Save all pads(CBQ)
Collect urine specimen ( clean catch) for examination cramping
Analgesics for pain, antibiotics for infection.  With +FHT

DANGER SIGNS DURING PREGNANCY ( needs referral) Inevitable Vaginal bleeding WITH
cervical dilatation. Hospitalization for
S wollen feet, fingers and face (preeclampsia) (CBQ) (OPEN cervix) (CBQ) – D&C
H eadache with visual disturbances (preeclampsia) (CBQ)  Moderate to – Oxytocin
A bdominal pain profuse Bleeding after D & C
V aginal bleeding no matter how slight. (CBQ)  Moderate to – Emotional
E scape of watery discharge in vagina (premature rupture of severe cramping support
membrane)  Membranes
D ischarges, foul odor with fever and chills. (Sepsis) rupture

DANGER SIGNS DURING POSTPARTUM PERIOD. ( needs Complete Expulsion of ALL Psychological support
referral) products Emotional support
 Moderate bleeding Avoid being
B leeds heavily (hemorrhage)  Mild uterine judgmental.
L ooking very ill and convulsions. (CBQ) cramping
O liguria ( less than 30 cc urine per hour), fast HR, fast RR, LOW  Passage of ALL
BP (Hypovolemic shock) tissues(CBQ)
O dorous lochia with fever and chills and scanty lochia flow
(puerperal sepsis and retention) (CBQ) Incomplete SOME products are Dilation and curettage
D yspnea, diaphoresis with chest pain and confusion. (Pulmonary expelled(CBQ) Oxytocin after
embolism) (CBQ) passage of some curettage
S evere headache, epigastric pain (Postpartum preeclampsia) “MEATY” tissues. Comfort
(CBQ) (CBQ)
 Profuse vaginal *COMPLETION
TAKE NOTE: bleeding CURETTAGE(CBQ)
Thirst, fatigue and a temperature up to 100.4°F (38°C) are  Severe uterine
NORMAL within the FIRST 24 hours. cramping
(Instruct to increase fluid intake for hydration) (CBQ)  Open cervix
 Other products are
retained
BLEEDING DISORDERS DURING PREGNANCY PERIOD.
First trimester Abortion: termination of pregnancy before age Missed RETENTION of all CONFIRM by
of viability – most common products of conception ultrasound FIRST
Ectopic pregnancy: pregnancy outside uterine after the death of the D&C
cavity fetus in the uterus. Oxytocin
 WITHOUT FETAL Emotional support.
Second Hydatidiform mole: benign gestational CARDIAC
trimester trophoblastic disease. – most common ACTIVITY(CBQ)
Incompetent cervix: premature cervical dilation.
Habitual Three (3) or more If the underlying cause
Third trimester Placenta previa: ABNORMAL implantation of consecutive pregnancy is incompetence of
placenta at lower uterus losses before 20 weeks cervix, do a cerclage
Abruptio placenta: sudden premature of gestation. (CBQ) procedure. (CBQ)
separation of NORMALLY implanted placenta.
Also known as:
FIRST TRIMESTER BLEEDING DISORDERS RECURRENT
pregnancy loss or
ABORTION /MISCARRIAGE recurrent miscarriage.
 EXPULSION OF THE PRODUCTS OF CONCEPTION
BEFORE THE AGE OF VIABILITY ( FETUS CAN Septic Abortion complicated Treat abortion
SURVIVE EXTRAUTERINE LIFE) by infection. • Antibiotics
 Less than 20 weeks or less than 500 grams fetus  Foul smelling
vaginal discharge
Chromosomal aberration/abnormality – MOST common cause of  Uterine cramping
abortion(CBQ)  Fever and chills
(CBQ)
Other causes:
S tress and substances like cytotec drug Ectopic pregnancy
T rauma  a fertilized egg implants itself outside uterus, usually in
I UD, lack of progesterone, infection/illnesses one of the fallopian tubes
 Diabetes mellitus
 Venereal diseases or STI Tubal pregnancy – is the MOST common form of ectopic
( AMPULLA portion) (CBQ)
 symptoms BEFORE 20 weeks. (CBQ)
RISK FACTORS: H yperthyroidism
C igarette smoking(CBQ)
A dhesion, tumor, scars in oviducts/fallopian tube Hallmark sign: BROWN Vaginal bleeding(CBQ)
P elvic inflammatory disease in the oviducts(CBQ) Characteristic: GRAPELIKE/MULBERRY/BERRY LIKE/ Sago like
I UD contraceptive discharges. (CBQ)
T ubal pregnancy history WARNING: For any berry – like discharges go to the clinic
immediately. (CBQ)
Signs and symptoms:
E vident signs of pregnancy: Amenorrhea, Morning Diagnosis: Ultrasound shows “SNOWSTORMS” appearance.
sickness, + Pregnancy test (CBQ)
C ul de sac mass
T ender abdomen Treatment:
O ne sided /unilateral lower quadrant abdominal pain  Methotrexate (CBQ)
P alpable adnexa mass(CBQ)  Folinic acid (leucovorin) is used to decrease the toxic
I rregular vaginal bleeding “SPOTTING” effects of methotrexate.
C ullens sign – bluish discoloration of navel/umbilicus  SUCTION ASPIRATION/SUCTION CURETTAGE –
( blood accumulation in peritoneal cavity) MOST preferred treatment method in molar pregnancy.

Signs of tubal rupture: DISCHARGE INSTRUCTIONS:

 Sudden severe sharp knife like stabbing pain in the
lower quadrant of the abdomen radiating to shoulder or
neck. (CBQ)
TAKE NOTE: Most sensitive sonographic sign of ectopic is the
presence of ADNEXAL MASS(CBQ)
M onitor HCG titer for one year ( should be negative 2-6 weeks
after removal of H-mole.) (CBQ)
O lder than 40 years old may undergo hysterectomy. (CBQ)
L aboratory and diagnostic exam like Chest X-ray(CBQ)
A void getting pregnant for at least 1 year(CBQ)
R ecommend the use of contraception

PRIORITY: PAIN (CBQ) TAKE NOTE: Chest X-ray every 3 months for 6 months. (CBQ)
The LUNGS are the MOST COMMON site of metastasis of
Diagnostic test: choriocarcinoma(CBQ)
C uldocentesis – aspiration of bloody fluid from Cul de
sac of Douglas CHORIOCARCINOMA – MOST DREADFUL complication of H-
U ltrasound reveals presence of the gestational sac mole(CBQ)
outside of the uterine cavity. (CBQ)
T rans-vaginal ultrasound examination is the best way to
diagnose an ectopic pregnancy
INCOMPETENT CERVIX
Treatment  PAINLESS CERVICAL EFFACEMENT & DILATATION
If not yet ruptured: in early mid trimester.
GIVE METHOTREXATE (STOPS the growth of embryo) (CBQ)
GIVE MISOPROSTOL ( TO ABORT ectopic) – principle of TWO REMEMBER: It is the MOST COMMON CAUSE of habitual
FOLD EFFECT. abortion.
Salpingostomy and salpingotomy– removal of a conceptus
manual, forceps or gentle suction CAUSES:
Cervical trauma (history or repeated D&C, cervical
If ruptured: Surgery lacerations)
Salpingectomy – removal of the OVIDUCTS (CBQ) Congenital maldevelopment of cervix
Management: Cervical conization or cone biopsy.
T reat or prevent hemorrhage ( hemorrhage is the Cervical infections (Trichomoniasis)
MOST common complication)
U se modified Trendelenburg position for shock Signs and symptoms:
B lood transfusion Presence of backache
A dvise use of contraception upon discharge. Pelvic pressure
L oss is present, provide emotional and psychological Pinkish vaginal bleeding.
support Premature labor contractions
Premature rupture of bag of water
SECOND TRIMESTER BLEEDING Painless cervical dilatation.
Hydatidiform mole / molar pregnancy
 Gestational trophoblastic disease. Management: CERVICAL CERCLAGE
Risk factors:  Cerclage should be placed during second trimester
M ultiparity before 24 weeks. (13 – 14 weeks)
A dvance maternal age (greater risk if more than 35  Uses local anesthesia by spinal block.
years old) (CBQ)  Outpatient procedure, position patient
L ow protein intake(CBQ)
A sian women Mc Donald's cerclage Shirodkar cerclage
L ow socioeconomic status Temporary suturing of cervix. Permanent suturing of cervix
A previous molar pregnancy Nylon suture 5 mm Mersilene tape or silk
Most Commonly done thread.
Signs and symptoms: (5H) (CBQ) 'purse-string' stitch Delivery by cesarean section.
H igh HCG Instruct to come back for
H yperemesis gravidarum removal around 36-37 weeks
H yperenlargement of uterus WITHOUT fetal of pregnancy, before the onset
heart tone(CBQ) of labor for vaginal delivery.
H ypertension and edema or PIH signs and (CBQ)

THIRD TRIMESTER BLEEDING DISORDERS
Placenta previa
 ABNORMAL implantation of the placenta
Types of placenta previa
1. Low lying – placenta is 2 cm from the marginal os(CBQ)
2. Marginal – marginal portion of placenta at the edge of
cervical os
3. Partial – part of placenta is partially occluding the
cervical os
4. Totalis/Complete – placenta is totally occluding the
cervical os
RISK FACTORS:
P arity (Multiparity)
R ace
E ndometrial tumors, lesions/scars ( previous CS and
D&C) (CBQ)
V ellamentous cord insertion
I llicit drug use
A dvance maternal age ( over 35 years old)
S moking ( Cigarette smoking)
Signs and Symptoms:
Bleeding: BRIGHT RED vaginal bleeding(CBQ)
Uterus: SOFT and NON TENDER
Contraction: NO uterine contraction(CBQ)
Pain: PAINLESS
Diagnosis: ULTRASOUND – BEST confirmatory test. (CBQ)
Management:
P lace woman on complete bed rest WITHOUT
bathroom privileges.
R eplacement of loss fluid – Ringers Lactate solution or
normal saline(CBQ)
E nsure fetal well-being (monitor FHT)
V ital signs assessment (watch out for SHOCK)
I nternal examination must be AVOIDED! (CBQ)
A nticipate cesarean section delivery.
Position: Left side lying (left lateral) (CBQ)
- To ensure adequate oxygenation and blood supply to
mother and fetus.
R igid abdomen
U terine apoplexy or couvelaire uterus
P AINFUL(CBQ)
T ender abdomen
I n COVERT type bleeding is concealed.
O vert type bleeding is external.
N O internal examination (AVOID I.E.) (CBQ)
Common Board Questions
 SHARP PAIN IN THE FUNDAL AREA (Abruptio
placenta) (CBQ)
 PAIN is present in abruptio placenta, and absent in
placenta previa
 The presence of PAIN will differentiate Abruptio
placenta against placenta previa.
 PAINFUL DARK RED vaginal bleeding in COVERT type
(concealed) (CBQ)
 HARD, RIGID, FIRM,BOARD-LIKE ABDOMEN caused
by accumulation of blood behind placenta. (CBQ)
 Woman involved in a VEHICULAR ACCIDENT with
vaginal spotting and abdominal cramps MOST LIKELY
DIAGNOSIS is Abruptio placenta (CBQ)
DIAGNOSIS: Ultrasound – the ONLY BEST way to diagnose
placenta abruption(CBQ)
Management:
R equires hospitalization – bedrest in side lying or
LATERAL position.
I nitial action: Assess vital signs and FHT, then 2 large
bore IV's
G ive oxygen mask if fetal distress is present.
I f there is NO SIGN OF FETAL DISTRESS, deliver via
normal vaginal delivery.
D istress is present, bleeding is severe – cesarean
delivery.
Complications:
1. COUVELAIRE UTERUS OR UTERINE
APOPLEXY(CBQ)
 HARD, and COPPER/Bluish/Purplish uterus
 INFILTRATION of blood into the uterine musculature.
2. HEMORRHAGE and SHOCK – treated by BLOOD
TRANSFUSION
3. DIC – managed by FIBRINOGEN and
CRYOPRECIPITATE

ABRUPTIO PLACENTA/ABLATIO PLACENTA PLACENTA PREVIA VERSUS ABRUPTIO PLACENTA(CBQ)

 ABRUPT separation of a NORMALLY implanted
placenta AFTER 20 weeks. (CBQ) Placenta previa Abruptio placenta

TYPES: Bleeding Bright red Dark red

1. MARGINAL ( OVERT) Uterus SOFT and NON HARD and TENDER
 Separation begins at the edges of placenta TENDER
resulting blood to escape from the uterus Contraction WITHOUT WITH CONTRACTION
 EXTERNAL bleeding CONTRACTION
Pain Painless PAINFUL
2. CENTRAL ( COVERT)
 Separation begins at the center resulting in Disseminated Intravascular Coagulation (DIC)
blood being TRAPPED BEHIND placenta. Other name: Consumptive Coagulopathy
 INTERNAL bleeding
RISK FACTORS D isorder in blood coagulation
H ypertension, preeclampsia and eclamptic I NAPPROPRIATE widespread coagulation within the
seizure(CBQ) blood vessels
A buse of cocaine and cigarette smoking C auses are the following:
R upture of membrane with short fetal cord Chorioamnionitis infection
D anger in auto, motor vehicular accidents (trauma to A bruptio placenta and placenta accreta
abdomen) (CBQ) Usual cause is massive hemorrhage
Septicemia and preeclampsia (HELLP) (CBQ)
GREATEST AT RISK: Increased maternal age (35 years old Embolism (amniotic fluid
above)
REMEMBER THIS! Signs and Symptoms(CBQ)
A buse of COCAINE can cause abruptio placenta. B ruising, hematuria, bleeding in IV insertion
(CBQ) sites (early signs)
B oard like abdomen(CBQ) L ow fibrinogen levels
 E cchymosis using the sphygmomanometer to predict pregnancy-
E asy bleeding: oozing from venipuncture induced hypertension starting at 20 weeks age of
D ental gum bleedings gestation (AOG).
 Position mother to SIMS (LEFT LATERAL) then check
PRIORITY MANAGEMENT: monitor PT, PTT, and Hct, protect BP, then rolls over to a supine position where her blood
from injury; NO IM injections. (CBQ) pressure is taken immediately and in 5 minutes. (CBQ)
Supportive measures: blood transfusions, platelet transfusion,
cryoprecipitate, fresh frozen plasm. RESULT: An increase in blood pressure of 30 in systolic and 15
mm Hg in diastolic over baseline on two (2) occasions at least 6
HYPERTENSIVE DISORDERS IN PREGNANCY hours apart accompanied by edema and albuminuria after 20
weeks gestation is POSITIVE PREECLAMPSIA (CBQ)
Chronic hypertension hypertension BEFORE pregnancy or
develop before 20 weeks gestation in the
absent of H-mole persisting BEYOND ECLAMPSIA
THE POSTPARTUM PERIOD.
AURA OF IMPENDING SEIZURE:
Gestational Develops DURING PREGNANCY or C ontinuous elevation of BP
Hypertension during the first 24 hours AFTER U nusual smells, tastes, sounds, or sensation (CBQ)
DELIVERY which is NOT accompanied E pigastric pain(CBQ)
by edema, proteinuria and convulsion S evere headache WITH visual disturbances (halos
that may disappear within 10 days around lights, double vision) (CBQ)
AFTER delivery.
HAVE EMERGENCY EQUIPMENT AVAILBLE: Suction
Pregnancy Induced hypertension apparatus, oxygen,MgSO4, calcium gluconate
PREGNANCY INDUCED HYPERTENSION (PIH)
Old name: TOXEMIA PRIORITY: SAFETY! (CBQ)
 Hypertension that develops AFTER the 20th week of FOLLOW: 3Cs, stay Calm, Cushion the head with a pillow to
pregnancy. prevent injury, and Call ambulance if the seizure lasts longer than
5 minutes.
CAUSE: Idiopathic (Unknown) BEFORE SEIZURE:
Linked cause: Arterial vasospasm P ad side rails with blankets/ pillows and side rails up
L ower the bed
Predisposing Factors: A void any stimulating environment (loud noise, area of
P rimipara below 17 and above 35 years old(CBQ) activities and bright lights)
I ntake of protein (LOW) in low socioeconomic C alm quite and dim lit non stimulating room (NO
status(CBQ) FLASH LIGHTS) (CBQ)
H istory of chronic hypertension, diabetes, renal and E nsure to give anticonvulsant drug as ordered
heart disease D o not disturb, provide rest, LIMIT VISITORS. (CBQ)
DURING SEIZURE
TRIAD Signs and symptoms: (CBQ)
S afety first! – clear surrounding, to prevent injury place
P roteinuria pillow under head (CBQ)
E dema (increase in weight) A irway patency – position to side (to prevent tongue for
H ypertension getting backward/drain secretions)
F ree of restraints (NO TO RESTRAINTS, NO
TAKE NOTE: A late sign of preeclampsia is epigastric pain as a TRANSFERRING/MOVING)
result of severe liver edema E nsure to remove and loosen any constrictive clothing
like collar and belt
TWO TYPES OF PIH T ongue blades/padded tongue depressor, spoon, cloth
 Preeclampsia – proteinuria, edema and in mouth should be AVOIDED
hypertension(headache & visual disturbances) (CBQ) Y ou must STAY with the patient, time the onset and the
 Eclampsia – proteinuria , edema, hypertension with duration of seizure.
CONVULSION/SEIZ  Permanent brain damage (irreversible) if brain
URE. (CBQ) is without oxygen for 4 – 6 minutes.

PRIORITY: TO PROMOTE SAFETY!! (CBQ) AFTER SEIZURE

Mild preeclampsia
Proteinuria: +1 to +2
(300mg/24 hour urine)
Edema: lower extremities
Hypertension: 140/90 mmHg
blood pressure
Severe preeclampsia
Proteinuria: +3 to +4 (5g/24
hour urine)
Edema: Fingers and face
Hypertension: 160/110 mmHg
blood
CUE: “I can’t put my wedding
ring on.” (CBQ)
O rient the patient
R emain with the patient
I nspect, / watch for any signs of ABRUPTIO
PLACENTA (CBQ)
E nsure fetal wellbeing ( FHT) and maternal well being
( VITAL SIGNS)
N O FOODS/DRINKS until patient is fully awake.
T he sense of hearing is the FIRST to return – Speak
quietly and calmly to the patient. (CBQ)
Pharmacological Management:

Additional symptoms: Hydralazine (apresoline)

Hyperreflexia, cerebral and
vision disturbances, and
epigastric pain
Diagnosis: ROLL OVER TEST or Supine pressor test(CBQ)
 Roll-over test is a simple, easily available clinical test
 Antihypertensive drug
Magnesium sulfate (MgSO4)
 DRUG OF CHOICE to treat and prevent
convulsions(CBQ)
 Prevent convulsion/seizure (anticonvulsant) (CBQ)
  Treatment is effective: IF SEIZURES DO NOT OCCUR.
(CBQ)
REMEMBER TO BURP!!!!
B EFORE giving MgSO4 check the
following FIRST:
U rine output – must be in normal
range: 30 – 60 ml/hour(CBQ)
R espiratory rate – must be in
normal rate: 12 – 20 (CBQ)
P atellar reflex/Deep tendon reflex
(DTR) – must be at least +2
TAKE NOTE: DEFER / DO NOT give MgSO4 if one of these
parameters is in abnormal range. (CBQ)
Administration:
 Piggyback to the main IV line by volumetric infusion
pump.
 Initial loading dose: 4 to 6 g(CBQ)
 Maintenance dose: diluted in an IV solution (1g) (CBQ)
 Therapeutic serum magnesium level of 4 to 7 mEq/L.
 Side effect of Magnesium Sulfate: Feeling of warmth,
diaphoresis, burning at IV site
 According to research: MgSO4 administered by Z-track
technique reduces drug leakage and significantly
reducing the injection-related pain. (CBQ)
 AFTER DELIVERY OF BABY: monitor for UTERINE
ATONY (because MgSO4 causes uterine relaxation)
(CBQ)
WOF! (Watch Out For): Signs of MgSO4 toxicity:
Diminished/Loss of DTR (CBQ)
Decreased Respiratory rate (less than 12) (CBQ)
Decreased urine output (less than 30ml/hour) (CBQ)
ACTION!!! – Give the antidote: CALCIUM GLUCONATE(CBQ)
 Calcium Gluconate: 10 ml of a 10% solution, or 1 g
(CBQ)
 given by SLOW IV push over at least a 3 minute period
to avoid arrhythmias, bradycardia, and ventricular
fibrillation (Cunningham, 2010)
MANAGEMENT:
B ed rest – rest in LEFT LATERAL/LEFT SIDE LYING position
(CBQ)
E pigastric pain – aura of convulsion (ALERT!) (CBQ)
D eliver baby vaginally (The ONLY CURE OF PIH is the delivery
of the baby)
R ecommend diet rich in PROTEIN and carbohydrates with
moderate sodium restriction.
E dema management: elevate with pillows in LATERAL /SIDE
LYING POSITION. (CBQ)
S AFETY is priority (goal of treatment is to protect the life and
health of the mother)
T he DANGER OF CONVULSION EXIST UNTIL 24 HOURS
AFTER DELIVERY. (CBQ)
 MgSO4 therapy is continued until the immediate 24
hours postpartum.
POSTPARTUM CARE:
 Ergometrine/Methergine or any ergot products are
CONTRAINDICATED because they are hypertensive.
(CBQ)
 Elapse 2 years before another pregnancy is attempted
to decrease likelihood of PIH to recur.
 Epigastric pain, severe headache and blurring vision
after delivery suggest POSTPARTUM PREECLAMPSIA
– REFER! (CBQ)
PIH SERIOUS COMPLICATION: HELLP syndrome
Hemolysis – red blood cells break down (causing anemia)
Elevated Liver enzymes – damage to liver cells (elevated bilirubin)
Low Platelets – thrombocytopenia caused by platelet aggregation
in fibrin deposits (bleeding)
HELLP SYNDROME may cause:
Placenta abruptio
Anemia
DIC
Signs and symptoms:
T enderness of liver
U pper right abdominal pain
L ack of appetite (anorexia)
O n examination patient looks unwell.
N ausea and vomiting
G um bleeding, ecchymosis, epistaxis (nose bleeding)
(CBQ)
Metabolic Disorders in Pregnancy
Gestational Diabetes Mellitus
 HEREDITARY endocrine disorder due to inadequate or
lack of insulin production that results in impaired
glucose absorption and metabolism.
CAUSE: Human Placental Lactogen (HPL) – insulin antagonist.
(CBQ)
Hallmark sign: HYPERGLYCEMIA (CBQ)
Cardinal signs:
Polyuria – increase in urination
Polydipsia – excessive thirst (important sign of
dehydration)
Polyphagia – excessive hunger
Oher Signs:
G lycosuria – glucose spills in urine
D iabetic ketoacidosis. – protein and fats breakdown
results to excessive KETONES.
M aternal weight loss – since glucose cannot be utilized
as a source of energy, the body uses its protein and fats
stores in the muscles and adipose tissue resulting in
weight loss. (CBQ)
*FRUITY BREATH ODOR(Kussmauls respiration) – due
to presence of ketoacids. (CBQ)
DKA – ADMINISTER normal saline solution. (CBQ)
Suspect Diagnosis of GDM in a woman with:
Glycosuria and OBESITY
Delivery of macrosomic or large infants in previous pregnancies.
(CBQ)
Maternal family history of DIABETES
 History of stillbirth delivery(CBQ)
 History of repeated abortions(CBQ)
 History of delivery of baby with anomaly.
DIAGNOSIS: performed between 24 – 28 weeks gestation. (CBQ)
1. Glucose challenge test(GCT) – no fasting required.
2. Oral Glucose Tolerance test (GTT/OGTT)
 Gold standard diagnosis for GDM(CBQ)
 Universal screening uses 50 gram oral glucose
 Use to determine how quickly glucose is cleared
from blood
 OGTT is performed in the morning
 Required fasting (water is allowed) 8–12 hours
prior tests.
 Avoid taking salicylates, diuretics, anticonvulsants,
and oral contraceptives before test.
 NOT performed if the mother is sick or ill.
CUT OFF VALUE: 140mg/dl(CBQ)
  If the plasma value is more than 140 mg/dl after 1 hour Amniotic fluid volume: less Amniotic fluid more than 2000 ml
of 50g oral glucose, then 100 gram 3 hour oral glucose than 500ml (CBQ)
tolerance test is performed to confirm if the woman is Causes Causes:
having HYPERGLYCEMIA Renal agenesis problem. M ultiple pregnancy
(CBQ) E sophageal atresia /
GDM Treatment: DIET CONTROL AND EXERCISE (WALKING) PROM TEF
(CBQ) M acrosomic infant
Caloric intake: 1,800 to 2,400 cal/day ( 20% of from protein foods, A nencephaly
50% from carbohydrates, 30% from fats.) S pina bifida
E ryhtroblastosis fetalis
DIET AND EXERCISE
Complication: Complication:
D ietary control and exercise. CLUBFOOT / AMPUTATION Postpartum hemorrhage
I ncrease dietary fiber ABORTION Prolapse cord.
A void fasting and feasting STILLBIRTH
B e familiar with food exchange list and caloric values Placenta abruptio Treatment: indomethacin
E stimate caloric intake accurately Episodes of prolonged labor Side effect: premature closure of
T he goal is to maintain blood sugar level of 80 mg/dl – Retarded fetal growth. ductus arteriosus.
110mg/dl(CBQ)
E at complex carbohydrate before exercising to prevent
hypoglycemia. (CBQ) PRETERM LABOR
S tuctured exercise 3x a week for at least 30 minutes Premature Labor:
like walking, swimming, dancing.  Labor that occurs between 20 weeks to 37 weeks
gestation(CBQ)
CONTACEPTION:
 IUD and combined oral contraceptives are RISK FACTORS
CONTRAINDICATED PROM – most often associated with infection
 Norplant (progestin implant system) and progestin only (Trichomoniasis and chlamydia)
pill (minipills) may be used SAFELY by diabetic women. Previous preterm labor or premature birth
Pregnancy with twins, triplets or other multiples.
Problems with the uterus or placenta.
Premature cervical dilation/incompetent cervix

EFFECTS OF DIABETES Signs and symptoms:

MOTHER NEWBORN Hallmark: Cervical effacement of 80% and dilatation of 2cm or
Maternal 4x fold risk for Macrosomia ( Large for more.
preeclampsia (CBQ) gestational age) (CBQ) Regular uterine contractions occurring 5-8 minutes apart
Maternal infection ( UTI and Hypoglycemia (CBQ) lasting 30 seconds
CANDIDIASIS) Preterm birth Rupture of membranes with increasing pelvic pressure.
Maternal Postpartum hemorrhage Respiratory distress Increasing vaginal discharge.
Maternal Preterm delivery (HYALINE MEMBRANE)
Maternal Mortality Intrauterine growth Fetal fibronectin (FFN) used to PREDICT he occurrence of
retardation preterm labor and who are most at risk for preterm birth.
TAKE NOTE: Birth injury (due to
Proper hygiene can prevent obstructed labor) (CBQ) CONSERVATIVE MANAGEMENT:
CANDIDIASIS(CBQ) Management: BED REST TO ARREST LABOR. (CBQ)
Trim fingernails straight across and Position: LEFT LATERAL /LEFT SIDE LYING (CBQ)
square file edges smooth. (CBQ) IVF FOR HYDRATION: RINGER’S LACTATE
BEST time to cut nails is after SOLUTION OR NORMAL SALINE (CBQ)
bathing (CBQ)
PHARMACOLOGICAL MANAGEMENT
HYPERMESIS GRAVIDARUM
Hyperemesis Gravidarum Tocolytics – medications to halt or stop uterine contractions (CBQ)
 Excessive nausea and vomiting that persists beyond 12 Magnesium sulfate
weeks gestation Ritodrine Hcl
 Resolves at 18 weeks Terbutaline –( check pulse rate, it can cause
 MOST SEVERE DEGREE OF VOMITING tachycardia)
 Characterized by persistent vomiting, weight loss,
ketonuria, electrolyte abnormalities, STARVATION and TAKE NOTE: If MORPHINE was given to the mother, check any
DEHYDRATION. (CBQ) respiratory depression
Give antidote, NARCAN or naloxone drug. (CBQ)
ACID BASED IMBALANCE: Metabolic acidosis. (Initially,
metabolic alkalosis) (CBQ) Drugs to hasten fetal lung maturity:
PRIORITY MANAGEMENT: IV FLUID – Lactated ringer, Normal  GLUCOCORTICOID therapy if labor can be delayed for
saline or Hartmann solution are suitable solutions; potassium 48 hours
chloride can be added as needed.  BETAMETHASONE accelerate fetal lung maturity &
ANTI-EMETIC – metoclopramide (plasil) (CBQ) prevents respiratory distress & hyaline membrane
disease ( most common problem of the premature
TAKE NOTE: PATIENT CAN EAT NORMALLY AT 20 WEEKS neonate). (CBQ)
(CBQ)

COMPLICATIONS OF LABOR
OLIGOHYDRAMNIOS VERSUS POLYHYDRAMNIOS
Oligohydramnios Polyhydramnios DYSTOCIA
  Labor lasting MORE THAN 24 hours(CBQ)
 Difficulty or prolonged labor. Prolonged rupture of membranes(PROM) refers to a rupture of
membranes lasting longer than 18- 24 hours (RISK FOR
CAUSES: MECHANICAL FACTORS INFECTION) – (CBQ)

UTERINE DYSFUNCTIONS: ABNORMAL LABOR PATTERNS

Uterine Rupture
1. HYPOTONIC UTERINE CONTRACTION  Tearing of the muscles of the uterus.
 WEAK AND INFREQUENT CONTRACTIONS  occurs when the uterus can no longer withstand the
 Insufficient to dilate the cervix. strain placed upon it.
 Common during ACTIVE PHASE  It is a serious complication of labor that can lead to
maternal & fetal death.
CAUSES: Causes:
Uterus is over distended. Rupture of scar from previous CS
Unripe cervix Use of OXYTOCIN – causing tetanic uterine contraction.
Uterine anomaly (CBQ)
Precipitate labor and delivery
MANAGEMENT: Trauma (sharp or blunt)
Confirm pelvic size to rule out fetopelvic disproportion. Use of forceps for delivery
Check bag of water – perform Amniotomy if still intact. Risk is increase in Hmole and multiple pregnancy.
Check order for oxytocin augmentation of labor. Extraction delivery (vacuum).
CS IS PERFORMED if contracted pelvis.
Signs and symptoms:
2. HYPERTONIC UTERINE CONTRACTIONS  Impending uterine rupture: presence of pathologic
 TOO FREQUENT BUT UNCOORDINATED retraction ring(CBQ)
uterine contractions(CBQ)  During the peak of a contraction, the woman suddenly
 THE uterus DOES NOT relax completely complain of a sharp tearing pain after which, relief will
(PAINFUL CONTRACTIONS) be felt as the uterus will no longer contract.
 Therapeutic rest and ANALGESICS
(MORPHINE) AND SEDATIVES like Types of uterine rupture:
phenobarbital to promote rest. (REST IN  Complete rupture – SUDDEN EXCRUCIATING PAIN at
LEFT SIDE LYING) the peak of a contraction
 REFER!  Incomplete rupture – localized tenderness & persistent
pain over the abdomen
PRECIPITATE LABOR / PRECIPITATE BIRTH:
 Labor less than 3 hours from the onset of contractions MANAGEMENT:
to the birth of infant(CBQ) Blood transfusion + Normal saline IVF (to correct shock)
Administer oxygen by mask
MATERNAL COMPLICATIONS: (CBQ) “E” laparotomy to deliver the baby
 increase risk of uterine rupture
 laceration of cervix, vagina and perineum Bandl’s ring or Pathologic retraction ring (CBQ)
 postpartum hemorrhage
 Maternal infection Presence of Bandl's ring suggest OBSTRUCTED LABOR – (CBQ)
 Presence of horizontal INDENTATION across the
FETAL COMPLICATION: (CBQ) abdomen. (CBQ)
 hypoxia/fetal asphyxia
 Intracranial hemorrhage Management:
 Fetal infection  Morphine SO4 to relax the uterus(CBQ)
 CS section for immediate delivery of the fetus.
Premature Rupture of Membrane  Give oxytocin only after the uterus is properly replaced
Initial sign: leaking watery discharge in vagina  If the placenta is still attached to the uterus, DO NOT
remove it(CBQ)
PREDISPOSING FACTORS:  Remove it when the uterus is replaced and contracted
 INFECTION
 INCOMPETENT CERVIX Inversion of the Uterus
 Uterus is completely turned inside out
DANGERS ASSOCIATED:
 CORD PROLAPSE Causes:
 INFECTION (Chorioamnionitis) Placenta accreta – deeply attached placenta ( MOST common) –
(CBQ)
PRIORITY: FHT assessment (CBQ)  Pulling of the umbilical cord in placental delivery
CONFIRM ROM: FERN TEST(CBQ)  Pressure on uncontracted uterus
Nitrazine paper: blue (ruptured BOW) and yellow(intact BOW)
(CBQ) Signs and symptoms:
 Fundus is no longer palpable(CBQ)
CORD PROLAPSE MANAGEMENT:  Sudden gush of blood from the vagina(CBQ)
1st action: Place the woman on KNEE CHEST OR  Uterus appear in the vulva
TRENDELENBURG POSITION– (CBQ)
2nd action: If cord is exposed to air, COVER it with a sterile gauze If patient is bleeding profusely and you cannot feel the fundus you
wet with normal saline. (CBQ) should : REFER TO THE HOSPITAL!!!!! – (CBQ)
TAKE NOTE: NEVER REPLACE CORD BACK INTO THE
VAGINA Prevention:
3rd action : administer oxygen by mask  NEVER apply pressure on an uncontracted uterus
4th action: DELIVER THE BABY AS SOON AS POSSIBLE.  NEVER pull the cord to hasten placental delivery(CBQ)
  Lower uterine segment is inserted first manually & Early skin to skin contact  Prevents
fundus last. (CBQ)  Uninterrupted hypothermia,
 DO NOT attempt to remove the placenta if it still  Place baby in chest hypoglycemia and
attached to the uterus. or abdomen of sepsis
mother  Increases
 Baby PRONE colonization of
PEDIATRIC NURSING position protective bacterial
Essential Newborn Care (ENC)  Doable even in CS flora
 “simple cost-effective newborn care intervention” DELIVERY  Improved
 Program of WHO to address the increasing mortality  Cover newborn’s breastfeeding
rate of neonates. back with a blanket initiation and
 Majority DIE within the first week of life. (CBQ) and head with a exclusivity
bonnet.  Establishes mother
Unang Yakap (First Embrace)  Place identification and child bonding
 Administrative Order 2009-0025 band on ankle.
 Adaptation of the Essential Intrapartum Newborn Care
(EINC) in the Philippines.
 The UNANG YAKAP protocol provides specific details
on newborn care during birth until FIRST 6 hours of life. Properly timed cord clamping  Decreases anemia
(CBQ) and cutting. in 1 out of every 7
 Remove first set of term babies.
At perineal bulging, with presenting part visible (2nd stage of gloves  Prevents brain
labor)  Delay cord (intraventricular)
INTERVENTION: Prepare for the delivery clamping hemorrhage in one
ACTION:  Wait until cord of two preterm
 Ensure that delivery area is draft-free & between 25 – pulsation stops babies.
28 °C using room thermometer. (CBQ) (usually 1 – 3
 Wash hands with clean water and soap. mins.)
 Double glove just before delivery.  Put ties tightly
around the cord at
WITHIN 30 seconds AFTER BIRTH the most important to check is 2 cm and 5 cm from
the BREATHING of newborn (CBQ) the newborn’s
abdomen.
 Cut between ties
Four Core Steps of Essential Newborn Care with sterile
instrument.
(Prevents tetanus)
STEPS Four (4) interventions Time-bound
(CBQ)
 Observe for oozing
1st Step Immediate and thorough drying First 30
blood.
seconds
2nd Step Early skin-to-skin After 30
Note:
seconds
 Do not milk the
3rd Step Properly-timed clamping and Within 1 – 3 cord towards the
cutting of the cord minutes newborn.
4th Step Non-separation of the newborn Within 90  After cord
from the mother for early minutes clamping, ensure
breastfeeding initiation and 10 IU IM is given to
rooming-in. the mother.

Breastfeeding initiation within  Prevents an

The following practices should NEVER BE DONE anymore to the the FIRST hour of life (CBQ) estimated 19.1% of
newborn: (CBQ) all neonatal deaths.
N – NO routine suctioning of secretions (it may cause trauma or
infection) (CBQ)
E – Early bathing earlier than 6 hrs. (MUST be done AFTER 24
hrs. or at least AFTER 6 hrs.) (CBQ)
W – Wiping out or removal of vernix caseosa if present(CBQ)
Non-separation of the newborn from the mother for early
B – Buttocks slapping, foot slapping and foot printing
breastfeeding initiation and rooming-in.
O – Offering baby prelacteal feedings or sugar water before
 Initiate breastfeeding within FIRST hour of life:
breastfeeding
INTERVENTION: Provide support for initiation of breastfeeding
R – Rubbing baby oil to baby's skin or oil bath. (CBQ)
Leave the newborn on mother’s chest in skin-to-skin contact.
N – NO squeezing of the chest and hanging the baby upside
Observe the newborn.
down just to drain secretions.
Only when the newborn shows FEEDING CUES: (CBQ)
 Licking(CBQ)
Interventions Benefits
 Opening of mouth(CBQ)
 Tonguing(CBQ)
Immediate thorough Drying  Provides WARMTH
 Rooting
 Immediate action to the baby
 Clenching of fist
 First 30 seconds  Prevents
 Flexing arms
 Wipe the fluids HYPOTHERMIA to
 Crying – late sign of hunger. (CBQ)
NOT the vernix set in(CBQ)
caseosa(CBQ)  Stimulates newborn
TAKE NOTE: BITING FINGERS IS NOT A FEEDING CUE (CBQ)
respiration.
Counsel on proper positioning and attachment. When the baby is
 ready, advise the mother to: Breathing irregular (Lusty cry)
 Make sure the newborn’s neck is NOT flexed nor (Feeble cry)
twisted. (CBQ) Nurse Juvy's assessment reveals the following: Heart Rate is 110
 Make sure the newborn is facing the breast, with the beats per minute, has a vigorous cry, moves actively and with good
newborn’s nose opposite her nipple and chin touching flexion, normal skin color and bluish extremities. What would be the
the breast. (CBQ)
APGAR score of Baby Sharon? (CBQ)
 Hold the newborn’s body close to her body.
A. 7 Points C. 5 Points
 Support the newborn’s WHOLE BODY, not just the neck
and shoulders. (CBQ) B. 10 Points D. 9 Points
 Wait until her newborn’s mouth is opened wide.
 Move her newborn onto her breast, aiming the infant’s RATIONALE:
lower lip well BELOW the nipple (NOT aiming directly to HR of 110 – score of 2
the nipple) (CBQ) Vigorous cry – score of 2
Moves actively – score of 2
Look for signs of good attachment and suckling: (CBQ) Good flexion – score of 2
C – chin touching the breast Normal skin color with bluish extremities: score of 1
A – areola is more visible above
L – lower lip turned outwards SCORING SYSTEM:
M – mouth wide open 0 – 3 points
S – suckling is slow, deep with  Severely depressed/distress
some pauses.  the baby is serious danger and need immediate
Notes: resuscitation. (SEVERELY DEPRESS)
 Health workers should NOT touch the newborn unless
there is a medical indication. (CBQ) 4 – 6 points(CBQ)
 Do NOT give sugar water, formula or other prelacteals.  Moderately distress (FAIR/GUARDED)
 Do NOT give bottles or pacifiers.  Airway clearance (suction) and supplementary
 Do NOT throw away colostrum. oxygenation.
NOTE: Administering high levels of oxygen to a premature neonate
can cause blindness as a result of retrolental fibroplasia or
retinopathy of prematurity.
APGAR SCORING SYSTEM
Suction the newborn properly:
Apgar score —standardized evaluation of the newborn’s condition.
1. Positions the infant with his neck slightly
hyperextended in a “sniffing” position.
Purpose: To determine how well the newborn is ADJUSTING TO
2. Suction gently and quickly (5 – 10 seconds)
EXTRA-UTERINE LIFE. (CBQ)
(CBQ)
 To assess newborns cardiac and respiratory adaptations
3. Suction the mouth first before the nose. (CBQ)
to extrauterine life (CBQ)
4. Apply suction upon withdrawing catheter
5. Gentle rotating suctioning (NO TO VIGOROUS
NOT ASSESSED by APGAR: Blood pressure, temperature and
SUCTION)
weight of newborn (CBQ)
EVALUATED BY APGAR: Color, respiratory rate, heart rate, muscle
TAKE NOTE: Place the newborn in slight Trendelenburg position to
tone & reflex irritability (CBQ)
facilitate further drainage of secretions.(CBQ)
Sign 0 1 2 7 – 10 points
Appearance: Color Pale, Blue Pinky body, Pink all over  WELL and GOOD condition(CBQ)
 Least all over blue (Ruddy complexion)  good and in the best possible health.
importan (Cyanosis) extremities  Document and proceed to newborn care procedures.
t (Acrocyanosis)
 Assess Keep Newborn Warm
skin Wipe fluids and dry newborn immediately, NEVER remove vernix
caseosa (CBQ)
color
Adjust/set the room temperature between 25 – 28 °Celsius (close
doors, windows/turn off electric fan)
Pulse: Pulse Rate Absent Less than 100 More than 100 Radiant warmer “25 watts” or wrap newborn with warm dry
blanket
 Most MOST important: maintain skin to skin contact. (CBQ)
importan
t TAKE NOTE: Newborn suffers large losses of heat because he is
 Most wet at birth, the delivery room is cold he does not have enough
Sensitiv adipose tissues and does not know how to shiver.
e Effects of Cold Stress:
 Metabolic acidosis
indicator
 Hypothermia
 Hypoglycemia
Grimace: Reflex No Grimace/feeble Sneeze/Coughs/
Irritability response cry when Pulls away when Proper Identification
to stimulated stimulated; good Attach ID bracelet in the ankle
stimulation strong cry with a number that corresponds to the mother’s hospital number,
mother’s full name, sex, date and time of birth. (CBQ)
Activity: Muscle Limp, Some flexion Well-flexed DO EYE CARE: Crede’s Prophylaxis
Tone flaccid of extremities extremities Administer erythromycin, tetracycline ointment or 2.5% povidone-
(No (Some muscle Good flexion iodine drops to both eyes after B.F.
muscle tone) Prophylactic eye treatment against gonorrheal and chlamydial
tone) conjunctivitis. (CBQ)
Respiration: Absent Weak or Good, strong cry Press lower & upper lid & apply at lower conjunctival sac from
inner canthus to outer canthus-CBQ
Let the drug be absorbed, Do not wash away the eye
antimicrobial.
Yes! Eye care may be delayed up to 1 hour to allow Newborn to
view his/her parents well for the first time. (CBQ)
TIME BAND: AFTER 90 Min (90 mins to 6 hours) - Give vitamin
K, Hepa B, BCG (CBQ)
INTERVENTION: Give Vitamin K prophylaxis
Administration of Vitamin K
 Vitamin K facilitates production of the clotting factor,
thus preventing bleeding. (CBQ)
 Vitamin K is NOT a vaccine, and it is NOT an
anticoagulant
 Vitamin K is ANTIHEMORRHAGE (CBQ)
 Method: Aquamephyton 1mg (Phytonadione),
 injected IM into the lateral aspect of the anterior thigh
(vastus lateralis). (CBQ)
 Give .1 ml ; intramuscular (CBQ)
ACTION:
 Wash hands.
 Inject a single dose of Vitamin K 1 mg IM.
(NOTE: If parents decline intramuscular injections, offer oral
vitamin K as a 2nd line).
AFTER 90 minutes (90 mins – 6 hours)
INTERVENTION: Inject hepatitis B and BCG vaccinations at birth
 Hepa B and BCG are the 2 vaccine antigen given at
birth. (CBQ)
ACTION:
 Inject .5 ml hepatitis B vaccine intramuscularly (vastus
lateralis) (CBQ)
 .05 ml BCG intradermally (right deltoid) (CBQ)
RECORD
INTERVENTION: Examine the baby
ACTION: Thoroughly examine the baby and Weigh the baby and
record.
TAKE NOTE: WEIGHING the newborn is done AFTER 90 mins.
to 6 hours. (CBQ)
INTERVENTION: Check for birth injuries, malformations or
defects.
ACTION:
Look for possible birth injury:
– Bumps on one or both sides of the head, bruises, swelling on
buttocks, abnormal position of legs (after breech presentation) or
asymmetrical arm movement, or arm that does not move.
If present:
 Explain to parents that this does not hurt the
newborn, is likely to disappear in a week or
two and does not need special treatment.
 Gently handle the limb that is not moving.
 Do not force legs into a different position.
Look for malformations:
 Cleft palate or lip
 Club foot
 Odd looking, unusual appearance
 Open tissue on head, abdomen or back –
meningocele (CBQ)
If present:
 Cover any open tissue with sterile gauze before referral
and keep warm. (CBQ)
 Refer for special treatment and/or evaluation if
available.
 Help mother to breastfeed. If not successful teach her
alternative feeding methods
CARE OF THE CORD (90 mins. – 60 hours. )
INTERVENTION: Cord care
ACTION:
Wash hands.
 Put nothing on the stump NOT even alcohol (unless
infected) . (CBQ)
 LET IT FALL ON ITS OWN.(7 – 10 days) (CBQ)
 DO NOT APPLY ALCOHOL just to hasten falling off!
(CBQ)
 Fold diaper below stump. Keep cord stump loosely
covered with clean clothes. (CBQ)
 If soiled with dirt, wash it with clean water & soap. Dry it
thoroughly with clean cloth. (CBQ)
 Explain to the mother that she should seek care if the
umbilicus is red or draining pus. (CBQ)
 Teach the mother to treat local umbilical infection three
times a day.
 Wash hands with clean water and soap.
 Gently wash off pus and crusts with boiled and cooled
water and soap. (CBQ)
 Dry the area with clean cloth.
 Paint with gentian violet.
 If pus or redness worsens or does not improve in 2
days, refer urgently to the hospital
Notes:
 DO NOT bandage or cover the stump or abdomen.
(CBQ)
 DO NOT apply any substances or medicine on the
stump. (CBQ)
 Avoid touching the stump unnecessarily.
REFER the newborn for the presence of SINGLE UMBILICAL
ARTERY. (Indicates congenital malformations of the heart,
neurological and RENAL ANOMALY and trisomy 21 /Down
syndrome of newborn) (CBQ)
Additional Care of a Small Baby (or Twin):
 If the newborn is delivered 2 months earlier or weighs <
1500 grams, REFER to specialized hospital.
 If newborn is preterm, 1-2 months early or weighing
1500 - 2499 g (or visibly small where scale not
available)
ACTION:
P – provide WARMTH
R – room temperature is maintained 25-28
°Celsius(CBQ)
E – ensure additional warmth for the small baby.
T – teach mother how to keep baby warm in skin-to-skin
contact via Kangaroo Mother Care
E – ensure warmth by wrapping the baby in a clean,
dry, warm cloth and place in a cot.
R – radiant warmer if the room is not warm or the baby
small.
M – mother and baby: provide extra blankets for mother
and baby, plus bonnet, mittens and socks for baby.
Note: DO NOT bathe the small baby. Keep the baby clean by
wiping with a damp cloth but ONLY after 6 hours. (CBQ)
Kangaroo Mother Care (KMC)
ACTION: Kangaroo mother care to STABLE Low birth weight and
preterm birth newborns
Notes: KMC can BEGIN AFTER BIRTH, after initial assessment
and basic resuscitation, provided the baby and mother is stable.
(CBQ)
If kangaroo mother care is not doable, wrap the baby in a clean,
dry, warm cloth and place in a crib. Cover with a blanket. Use a
radiant warmer if room is not warm or baby small.
Explain KMC to the mother:
 continuous skin-to-skin contact and
breastfeeding.
Position the baby for KMC:
-Place baby in upright PRONE
position between the mother’s
breasts.
-KMC should be done at least
up to 2 hours(CBQ)
-Position the baby’s hips in a
‘frog-leg’ position with the arms
also flexed.
-Secure the baby in this
position with the support binder
-Turn the baby’s head to one side, slightly extended
-Tie the cloth firmly
TAKE NOTE: KMC should last for as long as possible each day. If
the mother needs to interrupt KMC for a short period, the father, a
relative or friend should take over.
III. Care Prior to Discharge (but after the first 90 minutes)
TIME BAND: After the 90 minutes of age, but prior to discharge
INTERVENTION: Support unrestricted, per demand
breastfeeding, day and night
ACTION:
 Keep the newborn in the room with his/her mother, in
her bed or within easy reach.
 DO NOT separate them (rooming-in) for up to 24 hours .
(CBQ)
 Support exclusive breastfeeding on demand day and
night. (CBQ)
 Assess breastfeeding in every baby before planning for
discharge.
 Ask the mother to alert you if with difficulty
breastfeeding.
 Praise any mother who is breastfeeding and encourage
her to continue exclusively breastfeeding. (CBQ)
 Explain that exclusive breastfeeding is the only feeding
that protects her baby against serious illness.
 Define that exclusive breastfeeding means NO other
food or water except for breast milk.
Notes:
 DO NOT discharge if baby is not feeding well.
 DO NOT give sugar water, formula or other prelacteals.
(CBQ)
 DO NOT give bottles or pacifiers. (CBQ)
BATHING THE NEWBORN
INTERVENTION: Washing and bathing (Hygiene)
ACTION:
 Wash your hands.
 To avoid contact with blood and other body fluids, the
midwife should wear gloves when handling the neonate
until after the first bath is given
 Best to bathe baby in mid-morning (CBQ)
 Best to bathe baby BEFORE feeding (to prevent
aspiration) (CBQ)
 Take temperature before bathing (CBQ)
 Test water temperature using wrist of elbow
 Start washing the FACE FIRST (CBQ)
 Wipe the eyes, face, neck and underarms with a damp
cloth daily.
 Clean the diaper area last
 During bath, assess the skin condition of the baby and
note for birthmarks. (CBQ)
 prevent heat loss in the neonate, bathe one part of his
body at a time and keep the rest of the body covered.
 Wash the buttocks when soiled. Dry thoroughly
 Bathe when necessary, ensuring that the room is warm
and draft-free, using warm water for bathing and
thoroughly drying the baby, then dressing and covering
after the bath.
 If the baby is small, ensure that the room is warmer
when changing, wiping or bathing
 Expose baby to sun for not more than 30 minutes (10 –
15 mins), avoid exposure between 10 am to 4pm
 Sponge baths are done until cord falls off (7-10 days).
(CBQ)
INTERVENTION: Sleeping
ACTION:
 Let the baby sleep on his/her BACK or side. (Supine
lying) - NEVER place in prone. (CBQ)
 Keep the baby away from smoke or from people
smoking.
 Ensure mother and baby are sleeping under
impregnated bed net if there is malaria in the area.
INTERVENTION: Look for danger signs
ACTION: REFER!
Look for signs of serious illness :
– Fast breathing ( more than 60 breaths per min) – REFER!
(CBQ)
– Slow breathing (less than 30 breaths per min)
– Severe chest in-drawing
– Convulsions/seizure
– Floppy or stiff
– Grunting
– Fever (temperature more than 38° C)
– Temperature <35 °C or not rising after re-warming
– Umbilicus draining pus
– More than 10 skin pustules or bullae, or swelling, or redness, or
hardness of skin (sclerema)
– Bleeding from stump or umbilical cord. (CBQ) – stop bleeding by
applying firm pressure.
– Pallor
–Cyanosis – sign of distress in infants (CBQ)
INTERVENTION: Look for signs of jaundice and local infection
ACTION: Look at the skin. Is it yellow?
Pathologic jaundice (yellowish skin, face, WITHIN 24 HOURS
after birth) – refer urgently. (CBQ)
Refer urgently, if jaundice present in 24 hours newborn.
Refer urgently, if JAUNDICE IN PALMS AND SOLES after 24
hours. (CBQ)
Example: REFER If the newborn has a yellowish color of palms
and soles appearing on the 3rd to 4th day after birth. (CBQ)
– Encourage breastfeeding.
– If feeding difficulty, give expressed breast milk by cup
TAKE NOTE: A normal jaundice (PHYSIOLOGIC jaundice) is a
jaundice or yellowish discoloration of the babies skin usually
occurs between 2nd day and the 3rd day after birth or AFTER 24
hours of birth (CBQ)
Dealing with Feeding Problems
AREA OF CONCERN: Mother-Infant Separation
ACTION:
When mother and newborn are separated, or if the baby is NOT
suckling effectively use alternative feeding methods:
Teach the mother hand expression of milk. DO NOT do it for her.
(CBQ)
Teach her how to wash her hands thoroughly
Slightly press inward towards the breast between her
finger and thumb.
Express one side until milk flow slows. Then express the
other side.
Keep expressing and continue alternating sides for at
least 20-30 minutes.

If milk DOES NOT flow well:
 Apply warm compresses.
 Have someone massage her back and neck before
expressing.
TAKE NOTE:
F – feed baby mother’s own milk whenever possible (CBQ)
E – expressing milk by hand directly into the baby’s mouth (CBQ)
E – express the breast until some drops of breast milk appear on
the nipple. (CBQ)
D – do hold the baby in skin-to-skin contact, the mouth close to
the nipple.
W – wait until baby is alert and opens mouth & eyes, or stimulate
the baby lightly to awaken her/him.
E – express more drops of breast milk but wait until the baby
swallowed the milk.
L – let the baby smell and lick the nipple.
L – let some breast milk fall into the baby’s mouth.
TAKE NOTE: Repeat this process every 1-2 hours if the baby is
very small or every 2-3 hours if the baby is not very small
Provide Discharge Instructions
 Breast-fed babies are fed immediately after birth and
can be fed on demand or at least every 2 hours for the
first few days of life.
2. Bottle-fed babies routinely received an initial feeding of
about 1oz of sterile water at 4-6 hours of age to be certain
the infant can swallow without gagging and aspirating.
 The newborn is then fed every four hour(CBQ)
BREASTFEEDING
 The MOST adequate diet for an infant in the FIRST 6
months of life is breast milk.
3 E’s
• Early – within 30 mins or within an hour of birth
(MBFHI, 2011)
• Exclusive- first 6 months of life
• Extended – continuous feeding for 2 years and increase
frequency of feeding during illness.
Initiation of breastfeeding after birth is very important:
 Breastfeeding should be initiated at once – about 30
minutes after normal delivery
 And about 3 - 4 hours after delivery by caesarian
section(CBQ)
BENEFITS OF BREASTFEEDING TO NEWBORNS
A – Asthma and allergy risk reduction
N – Natural baby food – provides all the energy and
nutrient.
T – Taurine in breastmilk make the baby smarter
(higher IQ)
I – Immune booster, breastmilk contains
immunoglobulin (IgA antibodies) (CBQ)
B – Breast milk reduces the risk of type 1 diabetes,
pneumonia, otitis media, and measles
O – Obesity risk reduction
D – Diarrhea and necrotizing enterocolitis (in preterm)
prevention
Y – YES! Breast milk is the BEST food for babies(CBQ)
BENEFITS OF BREASTFEEDING TO MOTHERS
M – Maternal postpartum hemorrhage prevention
(Uterine contraction and involution) (CBQ)
O – Ovarian cancer, breast cancer, hip and bone
fractures prevention.
T – Type 2 diabetes risk reduction
H – Helps mother to burn more calories helping mother
to lose weight
E – Economical, saves time and money(CBQ)
R – Reduces the risk of postpartum depression.
S – Suppress ovulation due to elevated levels of
prolactin (CBQ)
MUST KNOWS!
 Oxytocin – “Milk ejection Reflex” or “let – down reflex”
(posterior pituitary gland) – (CBQ)
 Prolactin – Milk Producing or “milk secretion
reflex”(anterior pituitary gland) – (CBQ)
 Alveoli cell- milk secreting cells
 Lactiferous tubules – milk storage
 Stress, dehydration, and fatigue may reduce a breast-
feeding mother’s milk supply.
 Breast-feeding mothers should increase their fluid intake
to (2,500 to 3,000 ml) daily.
 To establish a milk supply pattern, the mother should
breast-feed her infant at least every 4 hours. (CBQ)
 During the first month, she should breast-feed 8 to 12
times daily (demand feeding).
 1 ounce of milk is equivalent to 28.35 grams (CBQ)
 1 ounce of BREAST MILK is equivalent to 20 calories
(CBQ)
 More prolactin is being produce at night
 Breastfeed as often as THE CHILD WANTS, day and
night. (CBQ)
 Feed newborn at least 8 times in 24 hours. (8 – 12 x a
day)
 DO NOT give other foods or fluids, NOT even water.
 Wake the baby for feeding after 3 hours, if the baby has
not woken by her/himself.
 Suckling of the baby stimulates prolactin production.
 Newborn baby needs 120kcal/kg/day.
 Both colostrum and mother's mature milk are rich in
antibodies (CBQ)
 VITAMIN A supplements within one month after
delivery to build stores and to improve the vitamin A
content of breastmilk.
 For inverted nipples, use the Hoffman's maneuver, and
syringe plunger technique
 For those with no nipple problems, the expectant mother
can prepare her breasts during the last six weeks of
pregnancy
BREASTFEEDING CONTRAINDICATIONS:
C – chemotherapy
O – oral contraceptive pill (OCP): estrogen may affect
breast milk supply. (CBQ)
N – NO breastfeeding to babies with galactosemia
T – TB (active and untreated) , HIV/AIDS without ART,
herpes in breast region.
R – radioactive compounds
A – alcoholic and or drugs like chloramphenicol,
metronidazole and tetracycline
BREAST FEEDING JAUNDICE V.S BREASTMILK JAUNDICE
1. Breast feeding jaundice: due to lack of milk production
and subsequent dehydration
2. Breast milk jaundice: due to substances in breast milk
that inhibit conjugation of bilirubin (persists up to 4-6
months) (CBQ)
ORAL THRUSH : white, cottage-cheese-like patches or a milk
curd like on the tongue and sides of the mouth of the newborn.
Cause: Candidiasis or moniliasis (yeast infection)
Two specific causes of oral thrush are
 Reaction to antibiotics
 Transmission from a mother with a yeast infection
acquired by baby through the birth canal DURING
DELIVERY(CBQ)
MANAGEMENT: Remove patches using a clean cloth wet with
salt water or normal saline, then apply antifungal cream or paint
gentian violet.
THRUSH in breast:
 Y – yeast organisms hate sunlight, expose nipples to  lacks the enzyme called G6PD.
sunlight for several minutes in day.  risk for KERNICTERUS or deposition of
E – eat lots of yogurt and take oral acidophilus. bilirubin in the brain
A – air-dry your nipples after each feeding  AVOID THE FOLLOWING FOODS
S – suggest use of cotton underwear : avoid plastic- A – Antimalarial drugs like
lined breast pads that irritate skin. primaquine
T – treat with antifungal cream (mycostatin, M – Menthol-containing foods such
clotrimazole, myconazole) as breath mints or candy and mouth
wash
EXPANDED NEWBORN SCREENING (ENBS) ( RA 9288 - P – Peanuts and soya products
Newborn Screening Act of 2004) (tofu)
A – Ampalaya or bitter melon /bitter
- NBS is a simple procedure to find out if your baby has a gourd
congenital metabolic disorder L – Legumes (FAVA beans, lima
- Newborn Screening (NBS) is a simple procedure to find beans, monggo, kidney beans,
out if your baby has a congenital disorder that may garbanzos)
lead to mental retardation or even death if left untreated. A – Aspirin and ibuprofen (NSAIDS)
tylenol, sulfa drugs, quinolone
METHOD: Heel prick (CBQ) Y – Yes! Avoid artificial blue food
coloring (Methylene and Toluidine
DONE: ideal time is AFTER 24 hours from birth blue)
COLLECTION: collected by any of the following: physician, nurse, A – Anything containing
medical technologist or trained midwife. naphthalene (moth balls)
AVAILABILITY: ENBS is available in hospitals, lying-ins, rural
health units, health centers & some private clinics. 6. Maple Syrup Urine Disease (MSUD)
COST: ₱1750 and is included in the Newborn Care Package  Branched-chain alpha-keto acid
(NCP) for PhilHealth members. dehydrogenase deficiency
RESULTS:  LOW PROTEIN DIET : DO NOT feed with
 Normal NBS Results are available by 7 - 14 meat, eggs, milk, and other dairy foods nuts
working days  presence of sweet-smelling urine, with an odor
 NEGATIVE SCREEN means that the ENBS result similar to that of maple syrup
is NORMAL.
 A positive screen means that the newborn must be
brought back to his/her health practitioner for
further testing. PHYSICAL ASSESSMENT OF THE NEWBORN

The disorders tested for newborn screening are: Anthropometric Measurements

1. Congenital Hypothyroidism (CH)- lack or absence of Weight: 2.5 – 4kg  Physiologic weight loss : Newborn
thyroid hormone (5.5 to 8.8lbs) loses 5-10% body weight within
 not detected and hormone replacement is not the first 5 days (3 – 4 days ) and
initiated within two (2) weeks the baby may should regain birth weight by 2
have growth and mental retardation. Average Filipino weeks or 10 days
 Treated and manage alive and normal infant weight is - Physiologic weight loss
3000 grams (3kg) is may be due to
2. Congenital Adrenal Hyperplasia (CAH)- endocrine excretion of fluids from
disorder that causes severe salt loss, dehydration and the lungs, urinary
abnormally high levels of male sex hormones in both bladder and bowels.
boys and girls. - Passage of meconium
 If not detected and treated early, babies with
CAH may die within 7-14 days.  75 – 90% of NB weight is Fluid –
THEY GET EASILY
3. Galactosemia (GAL)- unable to process galactose, the DEHYDRATED
sugar present in milk.
 Accumulation of excessive galactose in MUST KNOWS;
the body can cause many problems,  Weight doubles (B.W x 2 at 6
including liver damage, brain damage months ) (CBQ)
and cataracts.  Weight triples (B.W x 3 at 12
 NEUTRAMIGEN – MILK FORMULA months ) (CBQ)
 Weight quadruples (B.W x 4 at 2
4. Phenylketonuria (PKU) – detected first using Guthrie – 2 ½ months )
Test
 cannot properly use one of the building Length Length increases:
blocks of protein called phenylalanine. 45 – 55cm (18″ to  1 inch /month from 1 – 6 months
 Excessive accumulation of phenylalanine 22″) (CBQ)  1.5 inches /month from 7 – 12
in the blood causes brain damage. months
 LOFENALAC formula– (CBQ) Average length of
 AVOID foods that are high Filipino newborn
in protein like meat, fish, poultry, is 50 cm
eggs, dairy, soy, legumes (dried beans) Head  Head circumference is larger than
or nuts and foods rich in aspartame (diet circumference chest until 2 years of life
soda) (H.C)  Point of reference : Occiput,
33 to 35cm Biparietal and Eyebrows
5. Glucose-6Phosphate Dehydrogenase Deficiency (G6PD Chest  Chest Circumference is 1″ (2.5
def.)
Circumference cm) less than the head MUST KNOWS:
31-33cm  Point of reference : Nipple line and  A low-birth-weight neonate weighs less than 2,500 g (5
shoulder blades lb 8 oz) or less at birth.
Abdominal  Not routinely measure  A very-low-birth-weight neonate weighs less than 1,500
Circumference  Point of reference: Above g (3 lb 5 oz)
31-33cm umbilicus  A extremely-low-birth-weight neonate weighs less than
1,000 g
VITAL SIGNS OF NEWBORN  Teenage mothers are more likely to have low-birth-
weight neonates
Temperature: 97.6 to 98.6°F (36.5 to 37 °C) axillary
 The goal of a neutral thermal environment is to General Appearance:
assist the newborns to stabilize its temperature that - due to increased RBC
does NOT drop below 97.7°F (CBQ) Normal Color — concentration and decreased
 Covering newborn with dry warm blanket prevents ruddy subcutaneous fat which makes
CONVECTION heat loss (CBQ) complexion blood vessels more visible.

Heart rate: 120 to 160 immediately after birth (CBQ)  Acrocyanosis

Respiratory rate: 30 to 60 breaths per minute, irregular rapid and - blueness and coolness of the
shallow with short period of apnea of 5 – 15 seconds. (CBQ) arms and legs(CBQ)
Blood pressure: 80/46 mmHg - Normal in neonates because of
Blood pressure screening should begin at 3 years of age and their immature peripheral circulatory
should be measured annually. (CBQ) system or Sluggish circulation

REMEMBER: Jaundice Jaundice is normal and common

 Respiratory rate in the newborn range is between 30 -
60 breaths/minute
 Transient tachypnea of the newborn (TTN) is a mild
breathing problem that affects babies soon after birth
and lasts about three days, it is self limited condition.
 Respiration might be periodic with short periods of
apnea (5 – 15 seconds)
 There should be no nasal flaring or intercostal of
subcostal retractions.
 The normal pulse rate of a newborn is 100 to 180
beats/minute
 Use the FEMORAL PULSE in taking PR in NB
 Use APICAL heart beat in taking Heart Rate in NB’s
(CBQ)
 Absence of peripheral pulses, especially the femoral
pulse, suggests coarctation of the aorta. (CBQ)
 Blood pressure in the arms and legs is essentially the
same in infants.
 Higher BP of the upper extremity than the lower
extremity may suggest COARCTATION of aorta (refer)
(CBQ)
 Temperature is between 36.5 – 37.3 stabilizes within 8
hours to 12 hours
 Premature Newborn have a thermo regulating problem
due to lack of subcutaneous and brown fats(CBQ)
 Temperature stabilize within 12 hours after birth (CBQ),
if NOT INVESTIGATE POSSIBLE BACTERIAL
INFECTION
 Hypothermia in newborn can be a sign of sepsis or
infection. (CBQ)
Definitions of Gestational Age (GA)
Pre-term: Delivered between 20 weeks to before 37 weeks
Term Delivered between 38-42 weeks
Post-term Delivered more than or after 42 weeks
 Small For Gestational Age (SGA) - MICROSOMIC
INFANT
- Weight below the 10th percentile for the gestational
age.
- Maternal smoking can cause SGA(CBQ)
 Large For Gestational Age (LGA) - MACROSOMIC
INFANT
- defined as a weight, length, or head circumference
that lies above the 90th percentile for
that gestational age
- A NB weight > 10 lbs is associated with DIABETIC
mother (CBQ)
after the second day of life. (after
24 hours) (CBQ)
- The presence of jaundice within the
first 24 hours of life suggests a
hemolytic process and it is a
pathologic jaundice. (CBQ)
- If jaundice is suspected in a
neonate, examine the infant under
natural window light or under a
white light.
- Best technique for assessing
jaundice in a neonate is to blanch
the TIP OF THE NOSE or the area
just above the umbilicus. (CBQ)
- Physiologic jaundice – continue
breastfeeding, to expel meconium
(purgative property of colostrum)
- Pathologic jaundice – Bililight or
phototherapy.
PHOTOTHERAPY:
1. Cover the eyes, place eye shield, patch
breast, cover the genitals of the newborn
to prevent priapism (CBQ)
2. Feeding is okay, remove from light for
feeding
3. Breastfeed every 2 – 4 hours(CBQ)
4. Turning every 2 hours(CBQ)
5. Hydrate the baby, assess skin turgor
and temperature
6. A yellowish green or bright stool is a
normal response to phototherapy(CBQ)
7. 25 watts of a droplight is used within 18
inches away from the baby(CBQ)
8. Transient discoloration of skin is known
as “BRONZE BABY SYNDROME”
(CBQ)
9. Physiologic Jaundice - appears at about
2 days of age, peaks at 3-4 days &
disappears by 4-7 days(CBQ)
10. Kernicterus is fatal, deposition of
bilirubin in the brain
Cyanosis - suggests an obstructed airway,
respiratory disease, cardiac
anomalies, neurologic depression
  Most common danger sign in the Stork bite nevi  Capillary dilatation in upper eyelids,
newborn (Telangietic forehead and nape. (CBQ)
 Sign of DISTRESS in the newborn. nevi)  tend to fade with time. Fade by age 2.
(CBQ)
SKIN ASSESSMENT Salmon patch  Pink or red, flat, irregularly shaped
patches that appear on the baby's face
A. Harlequins Sign – E. Milia - pinpoint white or the back of the neck.
dependent side of papules caused by  Capillary dilatation.
the body appear red blocked sebaceous  Salmon patch on the face, it is often
& pale on upper glands on the nose called an angel kiss
side and cheeks.  Stork bite if it occurs on the back of the
 disappears by 2-4 neck
B. Cutis Mamorata - weeks  Tend to fade by age 1–2 salmon patch
Mottling of and a port-wine stain.
newborns skin upon F. Miliaria – clear
exposure to cold vesicles on face , Café au lait  Color of "coffee with milk," which may
environment scalp, and perineum macules be light to dark brown
 A skin spots or due to retention of (CALM)
blotches of sweat in unopened Infant’s Anatomy and Physiology
different color sweat glands. (prickly
upon exposure heat) Head – newborn’s head is disproportionately large about ¼ of its
to cold air  Remove excess body size
(CBQ) clothing &broom in a
cooler environment  Craniotabes —localized softening of the cranial
C. Lanugo—fine downy  Proper washing and bones. (Sign of rickets)
hair that covers a airing  Craniosynostosis - premature fusion or complete
newborn’s closure (ABNORMAL)
shoulders, back and G. Erythema toxicum -  Molding — over-riding of the skull bones may
upper arms. Urticaria Neonatorum / temporarily reduce the size of the anterior fontanel
Flea Bite Rash to permit fetal head delivery (central cone shape or
elongated head is normal) (CBQ)
D. Vernix Caseosa - a  Yellow papules on a Newborn with birth injury
cheesy white red base.  Caput succedaneum  Cephalhematoma –
covering, is normally  Appear between 2nd - a round boggy accumulation of blood
present at birth. and 4th days of life. swelling of the soft in the periosteum;
- do not remove but  Resolves in 2-3 days tissues of the scalp (CBQ)
spread(CBQ) after appearance from accumulation - DOES NOT cross
 It is NORMAL of fluid within the suture line.
2 functions: area - Common in
1. Bacteriostatic -  Intertrigo - skin - Edema of parietal area
Inhibits Bacterial redness and irritation scalps - Appears within
Growth on the skin creases. - Present at birth hours after birth
2. Thermoregulatory –  prevented - Can cross - Disappears a
prevents by good skin suture lines week or it may
hypothermia hygiene - Disappears 1 – take up to 3
2 days (CBQ) months to
 Skin turgor – for  Eczema - Skin disappear.
- Do nothing its
hydrated NB, it disease causing skin
normal - It may cause
should be resilient red, rough, and itchy.
jaundice. (CBQ)
and elastic  Allergic condition in
- do nothing its
 Desquamation – the baby leads to this
normal
peeling of the skin type of disease
(normal within 1st
week) TWO OTHER BIRTH INJURIES ARE THE FACIAL AND
BRACHIAL PALSY
BIRTHMARKS
FACIAL PALSY BRACHIAL PALSY
Mongolian  Large blue or gray patches of pigment
spots over the buttocks. (CBQ)  Weakness of the  Erb's palsy or Erb–
 These tend to fade over time. affected side of face Duchenne paralysis
 Injury to the FACIAL  Weakness or paralysis
NERVE (CN 7) of the muscles of the
Port-wine  Red like stains(CBQ)
 Due to too much arm on the affected
stain  Most commonly found on the face,
pressure exerted on side.
Nevus neck, scalp, arms, or legs
face during vaginal  Caused by forceful
Flammeus  Persist throughout life
birth grip on head and neck
Firemark
 He cannot wrinkle during delivery
Strawberry  Nevous vasculosis or Infantile
his eyebrow and  Injury to the
mark hemangioma
CANNOT close the sternocleidomastoid
 Capillary hemangioma. , Can enlarge
eye completely. muscle.
and even ulcerate.
 One side of the  Damage to the set of
 resolve by age 6, but can persist until
mouth moves more nerves which go to the
age 10.
than the other side arm and spine.
 May require surgical intervention
 The baby CANNOT  Can be due to delivery
depending on location.
also move the angle of shoulder dystocia
 of his mouth when baby. retina checked with a  White reflex
crying on that side.  Asymmetrical Moro flashlight or - Suggest
reflex ophthalmoscope retinoblastoma
FONTANELS
Fontanels (soft spot) is an anatomical feature of the infant human  Black-and-white pictures  Colobomas
skull comprising any of the soft membranous gaps (sutures) or toys will attract and - are missing
keep baby's interest far pieces of tissue in
NORMAL FONTANEL is SOFT(CBQ) longer than objects or structures that
Bulging or intense – MOST significant sign of increasing pictures with lots of form the eye
intracranial pressure(CBQ) similar colors.
Depressed or sunken – indicates dehydration.  Brushfield spots
 Subconjunctival - suggests Down
Anterior fontanel Posterior fontanel hemorrhage is NORMAL syndrome
(common in vertex baby)
B – Bregma L – Lambda (CBQ)
A – Anterior fontanel P – Posterior fontanel
D – Diamond shape T – Triangular in Ears - Nose – Mouth- Neck
(CBQ) shape(CBQ) Ears  pinna of the ear usually joins
the head above a horizontal
SIZE: 3 x 4 cm. in SIZE: 1x1 cm in size line from the external canthus
size CLOSURE: closes at of the eye.
CLOSURE: 12-18 2-3 months(CBQ)  malformed ears are
months. (CBQ) associated with
Cradle cap renal abnormalities
 Neonatal ”seborrhea”  low-set ears are associated
 Milk crust, honeycomb disease with chromosomal
Characteristic: yellowish flaky, patchy, greasy, scaly and crusty abnormalities such as Down
skin rash on the scalp, ears or eyebrows of newborn. syndrome.
Cradle cap most commonly begins sometime in the first 3 months  Hearing is present as soon as
amniotic fluid is drained at
Cause: Excess oil production from the scalp. birth(CBQ)
Management: Rub baby oil on the infant's head at night and  Test hearing - by ringing a
shampoo the hair the next morning. (CBQ) bell held 6” from crib,

EYES OF THE NEWBORN Nose N – Nose appear large for the

face.
Normal Findings Abnormal Findings O – Obligatory breathers
(REFER) (newborns are born nasal
 No tears until age 3 mos. breathers)
(CBQ)  Purulent S – Snoring is normal within 2
 Irises – gray or blue, discharges (CBQ) weeks after birth
sclera – blue - suggest E – examine the nares for
 Dark pupils - Normal in opthalmia patency
3rd – 12 moths neonatorum
 Should be clear without Abnormal:
purulent discharges or  Nasal flaring – suggest
conjunctivitis  Retrolental respiratory distress
fibroplasias (CBQ)  Choanal atresia – Abnormal;
 Edema on eyelids- - Suggest oxygen blockage of the nasal canal.
disappears in 2-3 days toxicity  Down Syndrome nose may
until kidneys are capable - Common among be small, with a flattened
of draining body premature babies nasal bridge.
fluids(CBQ)
 Retinal
 Strabismus/ cross eye hemorrhage.
and nystagmus - is a - suggest Shaken
normal finding in a baby syndrome
neonate. Due to Mouth
IMMATURE EYE  Large eyes Normal :
MUSCLES coordination suggest 1. Neonatal tooth is occasionally
(CBQ) congenital visible but requires extraction
glaucoma due to excessive maternal
CALCIUM deposition
VISION:  Eyes that are too intrauterine life (CBQ)
close together 2. Epstein pearls – white
 Studies have shown that - Suggest fetal glistening, well circumscribed
CLOSE UP VISION alcohol syndrome. cyst commonly seen in the
(myopia) is present in buccal cavity due to
newborns, focus on  Opaque pupils CALCIUM deposits
items that are held 8″ to (CBQ) intrauterine life.
12″ away. (CBQ) - indicates - DO NOT try to remove; it is
congenital NORMAL – (CBQ)
 Pupillary light reflex and cataracts
ed reflex - light from the Abnormal:
  Excessive Mucus in the
mouth –may indicate trachea-
esophageal fistula /T.E.F or
esophageal atresia (CBQ)
 THRUSH – a grayish white
adherent milk- curd plaques
like found in the tongue and
buccal cavity, signs of
moniliasis (CBQ)
 Splits in lips and roof of the
mouth – Cleft Lip Or Palate
 Thin upper lip and small chin
– Fetal Alcohol Syndrome
Neck N – Neck muscles are fairly weak at
birth
E – Examine neck for full range of
motion
C – Congenital torticollis or wry neck is
relatively common
K – Keep support to newborns head
and neck during breastfeeding.
Chest Assessment
B – Breasts are palpable and enlarged in term infants
R – Rhonchi is normal (harsh innocent sound of air
passing over mucus)
E – bony bump at the tip of the breastbone (Prominent
Xiphoid process)
A – Assess for any signs of respiratory distress such as
retractions – refer!
S – Supernumery nipples is NORMAL
T – Thin watery discharge in newborns breast is
NORMAL and it is known as WITCH MILK, due to
maternal estrogen hormone withdrawal (CBQ)
 Witch Milk - DO NOT EXPRESS MILK!!
EXTREMITIES
H – Have three palmar creases
A – A single palmar crease crossing hand is associated
with Down syndrome (CBQ)
N – Number of digits : Five digits each extremity
Polydactyly – extra digit (finger or toe)
Syndactyly – fusion of digit
Adactyly – absence or missing digits
D – Duchenne paralysis – Injury to sternocleidomastoid
muscle
S – Some movements of newborn are uncoordinated
and purposeless
TAKE NOTE: Blood pressure in the arms and legs is
essentially the same in infants.
ABDOMINAL ASSESSMENT
A – Abdomen contour is slightly protuberant (sticking out
from the surroundings)
B – Bowel sound should be present within 1 hour after
birth (CBQ)
D – Diaphragmatic hernia – Refer!
O – Observe the rise and fall of abdomen when taking
newborns Respiratory rate
M – Missing abdominal content (depressed abdomen) –
refer!
E – Expect that liver normally extends 2 cm below the
costal margin
N – Number of blood vessels in umbilical cord : 3 blood
vessels , 2 arteries and 1 vein. (CBQ)
GASTROINTESTINAL TRACT
G – Gastrointestinal tract is sterile at birth. (CBQ)
A – Absent normal flora that synthesize Vitamin K.
S – Stool of newborn must pass within the FIRST 24
hours (Meconium) (CBQ)
T – The passage of meconium suggest patent anus
R – Regurgitation is normal due to immature cardiac
sphincter muscles (CBQ)
O – Obstruction of anus and imperforate anus – failure
to pass meconium in the FIRST 24 HOURS (CBQ)
RENAL
R – Red stains in urine or diapers is NORMAL due to
excretion of uric crystals (CBQ)
E – Expect newborn to void within 24 hours after birth.
N – Normally newborn voids daily up to 6 – 8 times per
day (CBQ)
A – Assess urine output by measuring diaper weight
L – Limited ability of kidneys to concentrate urine
GENITALIA
FEMALE NEWBORN
1. Pseudomenstruation
 mucoid discharge, which might be bloody
secondary to estrogen withdrawal, is
NORMAL. (CBQ)
2. Ambiguous Genitalia
 labia minora and clitoris are prominent,
but the clitoris should be contained within
the prepuce.
MALE NEWBORN
 Meatus should be located at the tip of the penis
 Epispadias – meatus located at
DORSAL aspect of penis (abnormal)
 Hypospadias – meatus located at
VENTRAL aspect of penis
(abnormal)
o Circumcision wouldn’t be
performed on hypospadias
because the foreskin may
be needed during surgical
reconstruction
 Cryptorchidism is the absence of one or both testes
from the scrotum , sign of prematurity.
 Phimosis – prepuce adheres to the glans penis and
should NOT be retracted.
DIAPER RASH – acute inflammatory reaction in area of skin
covered by a diaper.
Causes:
W – Wee & poo( irritated from urine and feces)
E – Emaciation( moisture from urine and feces)
T – Tension and friction ( skin rubbing diapers )
Management:
D – Do FREQUENT changing of diapers (when full and EVERY
POOP not every voiding) (CBQ)
I – Irritant must be avoided ( no to talcum powders and baby oil)
A – Avoid alcohol - based wipes and perfumed soap. (Use gentle
baby soap like dove soap)
P – Position he baby every 2 hours(CBQ)
E – Expose the skin to air ( air dry ) for several minutes each
day(CBQ)
R – Rest without diapers especially when asleep(CBQ)
TAKE NOTE: Apply barrier cream type ointment such as zinc
oxide / Vaseline ointment ( when skin is dry) (CBQ)
STOOLS OF THE NEWBORN
1. Meconium
 FIRST stool of newborn (CBQ)
 Passed within 24 hours (CBQ)
 sticky, tar-like, blackish-green,
odorless material formed from
mucus, vernix, lanugo, hormones,
and carbohydrates. (CBQ)
2. Transitional stool
  Passed on 2nd or 3rd day of life W – Wean the child gradually
 Green and loose/watery stool E – Earliest age of giving solid foods
resembling like diarrhea. (CBQ) is 4 months (CBQ)
A – Always serve a newly
3. Milk stools prepared/cooked food. (CBQ)
 Passed on day 5 or day 6 N – NO added salt or added sugar
(CBQ)
Breastfed Newborn stool I – Introduce one kind of food at a time, wait 5 – 7 days
 SEEDY, mustard yellow or golden / before giving new food (CBQ)
bright yellow stool (CBQ) N – NEVER MIX solid food with milk in a feeding bottle.
 Sweet smelling stool due to LACTIC (CBQ)
ACID (CBQ) G – Give the solid food before breastfeeding. (CBQ)
 3 – 4 stools per day. (CBQ)

Formula fed/Bottle-fed Newborn 6 months Begin with 2 – 3 tablespoons of soft food twice a
 Bulker and formed, pale yellow stool day
 Distinctive odor
 2 – 3 stools per day (average of 2) R – Rice cereals (CBQ)
 I – Iron-fortified cereals
TAKE NOTE: Newborns under phototherapy have a BRIGHT C – Carbohydrate is the first nutrient received by
GREEN stools (CBQ) newborns (CBQ)
E - Energy giving food like porridge or lugaw
Estimation of Age of Gestation by Dr. Ballard’s and Dubowitz 7 months Fruits and vegetables should be pureed or mashed
Same food at 6 months plus:
Physical characteristics
Pre-mature Term Full-term P – Papaya with milk (vitamin A rich food) (CBQ)
R – Rootcrops like mashed potato with butter and
Skin: very thin, smooth, thick, parchment, mashed yellow camote
gelatinous, & less visible blood leathery, U –Usually you can give Chicken liver, pork liver
visible blood vessels cracked, as early as 6 – 7 months
vessels wrinkled T – Thicker lugaw and soft rice.
Lanugo: Abundant thinning bald A – Apples, peaches, pears, mango, and ripe
Plantar anterior 2/3 with creases entire sole w/ banana (latundan FIRST) (CBQ)
creases: transverse creases S – Squash with milk (rich in Vitamin A) and
carrots (CBQ)
Breast: stippled areola raised areola full areola
Pureed green leafy vegetables like kamote tops,
Ear: flat & folded thin & soft thick & firm
kangkong, petsay, and malunggay
Genital undescended intermediate fully descended
(M): testes 8 months 2 – 3 tablespoons up to At least ½ cup at each
Genital prominent labia minora & completely meal; 2 – 3 times each day
(FM): labia & clitoris clitoris partly covers minora & Same food at 6 – 7 months plus:
covered by labia clitoris Minced or finely chopped meat, tofu & poultry
majora (minced CHICKEN BREAST) for protein (CBQ)

TAKE NOTE: 9 months Same food at 6 – 8 months plus:

 The MOST common symptoms of PREMATURITY in a Egg yolk, fish flakes
baby are: lack of subcutaneous fat, abundance of fine hair
(lanugo) covers the forehead, shoulders, and arms, 10 – 11 At least ½ cup at each meal; 3 – 4 times each day
overlaid or abundant cheese-like vernix caseosa. The mos. and 1 – 2 snacks
Same food at 6 – 9 months plus:
extremities appear short. The soles of the feet have FEW
Legumes like mashed munggo enriched with
creases. The abdomen protrudes. The nails are short. The
milk(CBQ)
genitalia are small. (CBQ)
12 months All table foods
 The MOST common symptoms of POSTMATURITY in a Finger foods like peeled fruits
baby are dry, peeling skin; overgrown or long nails; and Pasteurized full cream milk or whole cows milk
abundant thick scalp hair, long thin body, little lanugo, little may be introduced to the non-breastfed infant’s
vernix and matured appearance. (CBQ) diet from 12 months of age.

INFANT AND CHILD FEEDING Foods to Avoid During the First Year

WEANING – process of gradually introducing your baby to solid Risk for allergic reaction
foods alongside their usual breast milk or infant formula.  nuts and nut products, egg whites(give after 1 year),
Sign of readiness for weaning and shellfish. (EGG -most allergenic food) (CBQ)
Sitting erect and head control
Spitting/extrusion reflex disappears (CBQ) Choking Risk
Shows interest in table foods  grapes, candy, corn, raisins, cherry tomatoes, nuts,
olives, popcorn, peanut butter, sausage, hotdogs, and
Wean Baby: between 4 – 6 months(CBQ) gum. (CBQ)
BEST time to wean – 6 months. (CBQ)
EARLIEST age for solid foods – 4 months (CBQ) Poisoning Risk
 Honey (due to hazardous botulism spores) (CBQ)
REMEMBER:
BEST FOOD SOURCES FOR NEWBORNS mouth
(CBQ)
IRON RICH FOODS  Baby will
 BEST SOURCES: Meat (especially kidney, spleen, turn head
chicken livers), dark green leafy vegetables, legumes and opens
(dried beans, peas and lentils). (CBQ) mouth to
 Iron is absorbed BEST in the presence of vitamin C. follow and
(CBQ) "root" in the
 Tea, coffee and whole grain cereal interfere with iron direction of
absorption. the stroking.
 The root
VITAMIN A RICH FOODS reflex helps
 Vegetable oil, liver, mango, pawpaw or papaya, the baby
squash, yellow sweet potato, Milk (CBQ) find the
breast or
VITAMIN C RICH FOODS bottle.
Citrus fruits (oranges) melons, mango
Sucking reflex. When the roof of the 3 – 4 months
baby's mouth is
touched with the
TEETHING breast or bottle nipple,
Teething is the process by which an infants first teeth (the the baby will begin to
deciduous teeth, or "baby teeth" or "milk teeth") sequentially suck. (CBQ)
appear by emerging through the gums, typically arriving in pairs
Extrusion Newborn extrudes or 4 months
Teething starts at: 6 months reflex spits out any
substance that is
Signs of teething: Drooling, discomfort, irritable, slightly feverish, placed on the anterior
chewing on objects, pulling ears, sucking on hands, and not portion of the tongue;
eating well. (CBQ) this reflex prevents
Sign that is NOT associated to teething : Diarrhea or loose stools the swallowing of
inedible substances.
Management: cool teething ring or cool damp clean cloth to (CBQ)
relieve inflammation
DONT'S in teething : Avoid sugary candies, rubbing gums, and Solid foods are NOT
frozen teething aids. given until this reflex
disappear. (CBQ)
Normal Primary dentition: 20 teeth (deciduous teeth) Moro reflex. MOST important 3 – 6 months
(10 in the upper jaw and 10 in the lower jaw) reflex
Complete set (20) have come in by the time the child is 2 to 3
years old Hold the newborn in a
FIRST TEETH to erupt in infants: INCISORS (two bottom/lower semi-sitting position,
central incisors) (CBQ) then allow the
newborn's head and
Primary tooth eruption facts: trunk to fall backward.
T – Tooth brushing starts as soon as the first tooth
erupts(CBQ) In response to a
A – At 6 months 2 lower central incisors erupt(CBQ) sudden backward
L – Lower teeth usually erupt before upper teeth. head movement, the
A – As a general rule of thumb: for every 6 months of newborn abducts and
life, approximately 4 teeth will erupt. extends arms and
G – Girls generally precede boys in tooth eruption. legs, then swings the
A – All primary teeth should have erupted by the time a arms into an embrace
child is 2 to 3 years of age position and pulls up
the legs against the
B – Both jaws teeth usually erupt in pairs abdomen.
A – a primary teeth are smaller in size , whiter in color
than the permanent teeth. Absent and
exaggerated or
TAKE NOTE: First visit to the dentist is as soon as the first tooth persistent Moro reflex
erupt(CBQ) is Abnormal. – refer
Normal Secondary dentition: 32 teeth (permanent) the newborn (CBQ)
FIRST “PERMANENT TEETH” TO APPEAR: MOLARS (FIRST
MOLARS at 6 – 7 years old) (CBQ) Startle reflex Jarring bassinet, 3 – 6 months
Last permanent teeth to appear: third molar (wisdom teeth) – age clapping hands,
17 – 21 years old banging doors and
other loud noises may
REFLEXES OF THE NEWBORN startle the newborn
(CBQ)
REFLEXES TRIGGER/ DISAPPEARANCE
RESPONSE Baby throws back his
Rooting reflex.  Touching 3 – 4 months or her head, throws
CORNER of out his or her arms
the baby's and legs, cries, then
 pulls his or her arms position
and legs back in.
Sometimes, a baby's
own cries can startle Growth and Development
him or her, initiating  Growth – increase in physical size of the body
this reflex. (CBQ) (quantitative change)
 Development – progression in skill and or ability to
Tonic neck baby's head is turned 3 – 4 months function/maturation (qualitative change)
reflex. to one side, the arm
on that side stretches Principles:
out and the opposite C – Continuous process
arm bends up at the H – Head to toe development (cephalocaudal)
elbow, known as I – Important indicator of development is maturation
FENCING REFLEX /behavior.
L – Language of children is PLAY
Palmar Grasp stroking the palm of a The VOLUNTARY D – Development proceeds in
reflex. baby's hand causes ACTIVE GRASP  Proximo-distal
the baby to close his ACTIVITY is FIRST  Gross motor to fine motor (mass to specific)
or her fingers in a EVIDENT at the age  Sequential predictable pattern
grasp. of 4 – 5 months
(CBQ) DEVELOPMENTAL MILESTONES
Involuntary grasp Age in months
reflex disappears 1 month C – lose up vision “myopia” (CBQ)
between 3 – 4 months A – Able to follow object to midline – “midline
and replaced by vision” (CBQ)
voluntary grasp as R – Regards face
early as 4 – 5 months E – Enjoys sweet scents and the scent of
(CBQ) breastmilk

Babinski reflex. Stroking the sole of 1 year 2 months S – Social smile (2 – 3 months) (CBQ)
the baby's foot in an M – May lift head momentarily “head lags”
inverted "J" curve (CBQ)
from the heel upward I – Involuntary grasp is present – hold rattle
and the newborn fans briefly (CBQ)
the toes in response L – Loves and enjoys bright colored mobile
(positive Babinski toys
sign) (CBQ) E – Eyes begin to follow and responds to
familiar voices
Positive Babinski S – Sounds – “COOING” as language of 2
reflex or Fanning of months old (CBQ)
toes suggest
immaturity of Central 3 months L – Laugh aloud – giggling sounds(CBQ)
Nervous system O – Object / hands to mouth
(CBQ) L – Lift head erect and steady when in prone
position (CBQ)
Plantar reflex plantar grasp reflex is 8 – 10 months S – Smile in mothers presence
elicited by pressing a
thumb against the Ave: 9 months (CBQ) 4 months S – S.T.E.P. reflexes disappears (Stepping,
sole of a foot just Tonic neck, Extrusion, Palmar Grasp)
behind the toes H – Head control (head lags disappears) lift
head and shoulder (CBQ)
The toes curl around A – Active VOLUNTARY grasp is first evident
the finger (involuntary grasp fades) (CBQ)
R – Reach toys with one hand near to
Stepping reflex walking or dance 6 – 8 weeks or 2 him(CBQ)
Placing reflex reflex because a baby months E – Eyes from side to side – follows moving
appears to take steps object
or dance when held
upright with his or her 5 months Mirror image - Likes to look at self in a mirror
feet touching a solid (5 – 6 months) (CBQ)
surface. ROLL OVER - prone to supine(CBQ)
Takes object presented to him and can
Truncal Stroking the side of 2 – 4 months handle rattle well
incurvation the baby's trunk,
/Galant reflex running parallel to the 6 months S – Sit with support (CBQ)
spine. I – Introduce solid foods – rice cereals
first(CBQ)
A positive response is R – Rocks back and forth
flexion of the pelvis
toward the side of the C – Can pull to sitting to standing
stimulus E – Eruption of first tooth (lower central
incisors) (CBQ)
Landau reflex The infant is placed in 12 months – 2 years D – Doubles birth weight(CBQ)
a horizontal, prone R – Rolls from back to abdomen prone-
 supine to prone(CBQ)
I – Imitates sound/copies sounds
C – Can DRINK from a CUP (5 – 6 months)
(CBQ)
7 months T – Transfer object from one hand to
another(CBQ)
R – Responding to own name begins (7 -10
months)
A – Anticipates to being picked up
S – Stranger anxiety begins – fear of
stranger(CBQ)
H – Hand to hand coordination(CBQ)
M – May start Toilet training
Y – Yes, promote sense of autonomy(CBQ)
2 years T – Tower of 6 cubes and copies straight line
old W – Words per talk: 2 and 50 vocabulary
words
O – Open door knobs
Gross motor: Runs. Kick ball. Climb 2 steps
Fine motor: Undresses self CBQ
Speech: 2 word sentences, with pronouns.
Favorite word is 'No'.
Social: Parallel play

8 months Sits securely WITHOUT support (sit alone) TAKE NOTE: BLADDER TRAIN THE CHILD
(CBQ)
Begins to clap hands 3 years old Tiptoe
Stranger anxiety at peaks (CBQ) Tricycle riding (3 – wheel bike) (CBQ)
T shirt removal (undress alone) except
9 months C – Can hold bottle with good hand to mouth buttons(CBQ)
coordination(CBQ) Tries to copy and draw circle
A – Able to understand the word “NO!” Talks well enough for strangers to
N – New words “Dada” (first word) , understand most of the time
baba(CBQ) Turns book pages one at a time
Takes turns in games
C – CRAWL(CBQ) The child can say I,” “me,” “we,” and “you”
R – Responds to parent anger and some plurals (cars, dogs, cats)
E – Elevate himself to sitting position
E – Enjoys back and forth play 4 years old F – First name and last name (can say)
P – Pincer grasp begins O – Often can’t tell what’s real and what’s
S – Stranger anxiety disappears (CBQ) make-believe
10 months Pincer grasp U – Uses scissors(CBQ)
Patty-cake R – Remembers parts of a story and tell
Peek-a-boo(CBQ) stories
Pull self to standing S – Square drawing and Draws a person with
Place hands together “CLAPPING” 2 to 4 body parts
Waves “bye – bye ” (10 – 12 months) (CBQ)
5 years old C – Count using fingers
11 months Standing by holding on to furniture O – Oedipal complex
(“cruising”) – gross motor U – Untie and tie shoe laces
Stands with support N – Now can ride to bicycle
Stirs spoon T – Triangle drawing and prints own name
12 months Stands well alone
Scribbles after demonstration AGE TOYS APPROPRIATE
Small object picking like pellet – FINE pincer 0 – 3 months Brightly colored crib mobile toys
grasp 6 months RATTLES(CBQ)
 FINE motor skill – picking an object 8 months LARGE BLOCKS, Large cubes(CBQ)
with thumb and finger. (CBQ) 18 months – 2 Push and Pull toys – Wagon cart, walker
years old wagon, walker cart (CBQ)
Triples birth weight (CBQ)
Walks with support
Age Groups Stage Task Play
Eats well with fingers can eat all types of
Infancy (0 – 1 Oral Trust v.s. Solitary (CBQ)
table foods serve(CBQ)
year) Mistrust(CBQ)
Easily find hidden objects – “Object
Toddler ( 1 – 3 Anal Autonomy v.s. Parallel
permanence”
yrs.) Shame / Doubt
Two words – Dada and mama
Enjoys to Bang two things together “banging Preschooler (3 – Phallic Initiative v.s. Guilt Associative
two cubes” (CBQ) 6 yrs.)
Responds to simple spoken requests and cry School age (6 – Latent Industry v.s Cooperative
when mother leaves the room 12 yrs.) Inferiority
15 months W – Walks well alone or independently(CBQ) Adolescence (12 Genital Identity v.s. Role Competitive
A – Able to walk backward – 18 yrs.) confusion
T – Throws toys
C – Creep up stairs
H – Hand to eye coordination VIRTUE, FEAR AND ACCIDENTS

18 months A – Able to jump and climb up and down Age Groups Virtue Fear Accident
stairs Infancy (0 – 1 Hope Fear of Choking
U – Uses spoon and fork(CBQ) year) Stanger (suffocation)
T – Temper tantrums is common (CBQ)
O – Often shakes head Toddler ( 1 – 3 Will Separation Burn,
N – “NO!” is the favorite word to say yrs.) anxiety poisoning,
O – Often point to an object in a book when drowning
asked. Preschooler (3 Purpose Castration / Playground
– 6 yrs.) mutilation accidents
School age (6 Competence Displacement Vehicular
– 12 yrs.) & Death accidents
Adolescence Fidelity Death Vehicular
(12 – 18 yrs.) accidents,
firearm
accidents,
drowning and
fire accidents

Age Groups Management on Behaviors

Infancy (0 – 1 Promote Trust – breastfeed, attend needs,

year) provide consistent caregiver(CBQ)

Toddler ( 1 – Promote autonomy

3 yrs.)  Let child to eat on his/her own
pace(CBQ)
 Set limits to unacceptable behaviors

Child always says NO! (Negativism) – Questing

autonomy, independence
 OFFER choices (not to many) (CBQ)

Bed rituals – allow to finish rituals, reinforce

expected behaviors.
Temper Tantrums
 ignore the behaviors, provided that the
actions are NOT dangerous to the
child. (Appear to ignore) (CBQ)
Separation anxiety
 When leaving a child who has
separation anxiety, parents should say
goodbye firmly, explain that they will
return, and then leave promptly. (CBQ)
Preschooler Castration anxiety and mutilation
(3 – 6 yrs.)  Fear of loss, removal of or damage to
the genital organ
 Fear of injections and taking blood
specimens
Imaginary friends /imaginative minds
 Imaginary friends help the preschooler
cope with stress in his or her life
Electra complex /penis envy
 girl, aged between 3 - 6, becoming
unconsciously sexually attached to her
father & increasingly hostile toward her
mother
Oedipal complex
 boy, aged between 3 and 6, becoming
unconsciously sexually attached to his
mother, and hostile towards his father
(who he views as a rival)
Sibling rivalry- jealousy between brothers and
sisters
 Having the sibling make or choose a
gift for the new baby helps to make the
child feel a part of the process.
 Children should be actively involved in
the care of the baby according to their
ability without overwhelming them
OBSTETRICS and GYNECOLOGY
 DEPO PROVERA – 3 months injectables, assess weight gain
 feso4- 1 gram per singleton pregnancy- start at 5 months to 2
months postpartum
 MDG target- reduction of maternal mortality by 80/100,000 live
births (mdg5)
 In the Philippines, 11 mothers die everyday from childbirth
 The majority of maternal deaths are due to HEMORRHAGE,
 Around 11 Filipino mothers die everyday or an estimated 4,500
every year due to severe hemorrhage, hypertensive disorders,
sepsis and problems related to obstructed labor and abortion.
 The Philippines contributes to 97% of maternal, neonatal and
child health deaths worldwide.
 2/3- reduction of child mortality rate (mdg4)
 MDG 5- reduction by three quarters TARGET by 2015
 SDG- 17 GOALS – target by 2030
 FETAL HEAD in the FLANK – TRANSVERSE LIE
presentation
 Goodell sign= softening of the cervical tip; observed
a~6thweek in normal/unscarred cervix
 Cardinal ligaments (aka Mackenrodt's) - attach upper
vagina, cervix and uterus to the side walls of the pelvis
 Acetic acid in pap smear- vinegar
 SubMENTO bregmatic- widest or largest APD of fetal head-
presenting part- CHIN
 Left and right occipito-anterior are the only normal presentations
and positions.
 Malposition: occipito-posterior.
 Malpresentations: anything as face, brow, breech, shoulder,
cord and complex presentations. except VERTEX because it’s
the only normal presentation
 Dextro-rotation of the UTERUS: rotation of the uterus in anti-
clock wise favours occipito-posterior in right occipito-anterior
position.
 pendulous abdomen – sign of malpresentation fetus
 anthropoid and android pelvises are the most common cause of
occipito-posterior due to narrow fore-pelvis.
 0 Station, the biparietal diameter is at the pelvic inlet and the
head is fully engaged
 Suboccipitobregmatic- shortest APD – presenting part –
Vertex or OCCIPOT
 FSH MATURES FOLLICLES
 GRAAFIAN follicles to RELEASE ESTROGEN
 MELANOCYTE STIMULATING HORMONE – DARK
PIGMENTATIONS OF SKIN LIKE MELASMA AND LINEA
NIGRA
  EDC computation
 If the LMP falls between Jan- March ( add 9 in month and
add 7 in days)
 If the LMP falls between April to December ( subtract 3 to
months add 7 in days and add 1 at year)
August 12,2016 (May 19, 2017)
LEOPOLD’S MANEUVER
o Purpose: is done to determine the attitude, fetal
presentation lie, presenting part, degree of
descent, an estimate of the size, and number of
fetuses, position, fetal back & fetal heart tone
o Performed AFTER 24 WEEKS AOG
 Ist and initial action : Empty bladder- instruct to void – to
promote comfort
 Position of mom-supine with knee flex (dorsal recumbent
or genupectural– to relax abdominal muscles)
 Drape properly – to provide privacy
 Instruct procedure – to gain cooperation
 Warm hands by rubbing together- cold can stimulate
contractionr
- use palm! Warm palm.
-
 First 3 maneuvers face the mother, last maneuver face the
feet of the mother
 1st maneuver: place patient in supine position with knees
slightly flexed; put towel under head and right hip; with both
hands PALPATE UPPER ABDOMEN AND FUNDUS.
Assess size, shape, movement and firmness of the part to
DETERMINE PRESENTATION
 2nd Maneuver: with both hands moving down, identify
the back of the fetus ( to hear fetal heart sound) where the
ball of the stethoscope is placed to determine FHT. Get
V/S(before 2ndmaneuver) PR to diff fundic soufflé (FHR) &
uterine soufflé.
 Uterine souffle= sound made by blood in the uterine
arteries, synchronous w/ maternal pulse
 Funic souffle (also known as funicular or fetal souffle)-
sound made by blood rushing thru the umbilical vessels
and synchronous w/ fetal pulse
 3rd Maneuver: using the right hand, grasp the symphis
pubis part using thumb and fingers.
 To determine degree of engagement.
 Assess whether the presenting part is engaged in the
pelvis )
 Alert : if the head is engaged it will not be movable).
 4th Maneuver: the Examiner changes the position by facing
the patient’s feet. With two hands, assess the descent of
the presenting part by locating the cephalic prominence or
brow. To determine attitude – relationship of fetus to 1
another.
 When the brow is on the same side as the back, the head
is extended. When the brow is on the same side as the
small parts, the head will be flexed and vertex presenting.
 Attitude – relationship of fetus to a part – or degree of
flexion
 Full flexion – when the chin touches the chest
Assessments:
 leopolds manever 1-fundic height assessment and AOG
assessment
 LM1- breech palpation is CEPHALIC
 LM2- palpation of the head or round hard mass in the flank
or sides is a Transverse lie
 LM2- Fetal heart tone assessment
 LM3- non movable hard mass- engaged baby
 LM4- facing the mother
 Leopolds maneuver – mother must be in Dorsal
Recumbent position
 LM1- (fundal grip) – IST phase of assessment ; fetal
presentation , Aog, fundic height
 *If nodular it angular parts is palpated in LM1 - baby is in
shoulder presentation and transverse lie
 Lm2 / umbilical grip - fetal back,lie,position
*grasp the side of abdomen.
 LM3- (PAWLIKS GRIP) fetal engagement/balottement,
*grasp lower abdomen
 Lm4(pelvic grip)- fetal descent , fetal attitude, fetal cephalic
prominence and presenting part.
* grasp inguinal region facing the feet of mother
BARTHOLOMEWS RULE
 12 weeks – fundus over the symphysis pubis
 12 weeks - the fundus is slightly palpated above the above
the symphysis pubis.
 Level of Symphisis pubis- 12 weeks _between pelvis and
symphisis also)
 Midway between symphysis pubis and umbilicus- 16 weeks
 Level of navel or Umbilicus- 20 weeks
 Just above the navel – 24 weeks
 Just below navel – 16 weeks
 Midway of navel and xyphoid – 28 weeks
 Level of Xiphoid process 36 weeks
OB –CBQ bullets
 Heart burn- pyrosis – avoid acidic beverages or drinks like
citrus juices, calamansi, lemon and alikes… avoid also
milk, tea and coffee, avoid odorous , fatty , greasy foods
 Ectopic – presence OF ADNEXAL MASS
 Ectopic – SUDDEN SHARP STABBING LOWER
QUADRANT ABDOMINAL PAIN radiating to shoulder or
neck
 Ectopic- spotting bleeding, mass in abdomen usually lower
quadrant and nausea and vomiting with diziness
 Lochia rubra – 1st 3 days only --- red more on erythrocyte or
RBC
 Lochial serosa – 4-9 days present – pink to brown with
leukocytes or plasma
 Lochia alba – CREAMY WHITE, from 10 days up to 6
WEEKS postpartum
 Lochia must be FREE or absent of FOUL odor, blood Clots
and fever and chills – Puerperal SEPSIS
 RECTO VAGINAL FISTULA – abnormal opening or
communication between rectum and vagina
 Kegels exercise – for strengthening of perineal muscles –
3x a day at least 10-15 times in sitting, standing position
 Secretory phase - progesterone
 Proliferative phase - estrogen
 Iron source – LIVER products, kidney beans, lima or lentil
beans
 Liver must be avoided by pregnanat mother for the first
trimester of pregnancy
  Meconium – tarlike, odorless blackish first stool of the baby
within 24 hours after delivery
 Breast feeding , colostrums, antibodies - IgA, storage of
breastmilk – 6-8 hours room temperature
 How to relieve backpain of the mother– PELVIC
ROCKING AND SQUATTING EXERCISE
 MagS04 antidote – Calcium Gluconate
 Braxton hicks contraction. – intermittent, painless irregular
or false or practice labor contraction.....
 IUD – long term reversible method
 IUD – inserted during menstruation, or 1-4 days after
delivery , inserted in the uterus\
 Presumptive sign of pregnancy -
AMENORRHEA...morning sickness or nausea and
vomiting less than 12 weeks
 Uterine contraction - must be rhythmic and regular
 Oxytocin stimulates contraction
 Vit. A IU POSTPARTUM MOTHER – 200,000 IU..
 Vit. A for pregnant mother – not more than 10,000 IU at 4
months pregnancy 2x a week only
 tetracycline – causes discoloration of the baby teeth and
bones – permanent GREEN Teeth
 HCG – for POSITIVE PREGNANCY TEST ,
 Diagnosed HMOLE – by ultrasound – round masses
 PROGESTERONE – PYROSIS, PREGNANCY,
OVULATION
 Lordosis, back ache and waddling gait – Relaxin hormone
influence
 PRETERM LABOR – labor before 37 weeks and after
20weeks
 Dexamethasone, betamethasone, celestone – drugs given
in preterm labor TO MATURE FETAL SURFACTANTS
 POSTPARTUM.HEMORRHAGE within 6 days bleeding or
more suggest RETAINED FRAGMENTS OF
CONCEPTION like placenta
 PSEUDOCYESIS – false pregnancy
 CERVIX - squamo columnar cells
 QUICKENING – first fetal movement at 20 weeks
GERM LAYERS...
 ECTO - sense organs and brain
 ENDODERM- lining of G. I and also liver
 Mesoderm – uterus, ovaries and blood cells, and the heart
PARTOGRAPH – NOT ASSESSED in partograph are, input and
output, RR, Weight and Height
 Assesed in partograph – FETAL WELLBEING, MATERNAL
WELLBEING, PROGRESS OF LABOR
 Central feature of partograph– cervical dilation
 IE is done every – 4 hours
 Active phase begins at 4 cm
 Distance between alert line and action line – 4 hours
 POSTPARTUM HEMORRHAGE 500- 100ml of blood loss
 POSTPARTUM BLUES- common normal 2-3 days
postpartum,
 Oxytocin- rhythmic uterine contraction, given after 3rd stage
of labor
Oxytocin the so-called "love hormone"
 Onset:
o (IV) Immediate
o (IM) Within 3-5 min
 Duration:
o (IV) 20 minutes after the infusion is stopped
o (IM) 30-60 min
 Reduction of postpartum bleeding.
Dilute 10-40 units (1-4 mL) to 1,000 mL with isotonic saline
or 5% dextrose for IV infusion.
 Methergine- check vital sign esp. Bp - hypertension
 THREATENED ABORTION- closed cervix, mild bleeding or
spotting, mild cramping
 SEPTIC ABORTION – fever and chills abdominal
cramping, foul discharges and abortion
 HBMR – is a tool used to render prenatal care consisting
the risk factors and danger signs of pregnancy
 PANEL 2 of HBMR – contains the risk factor and danger
signs of pregnancy
 CATEGORY1 - NO RESTRICTION....NO CONDITION
WHICH CONTRADICTS THE USE OF THE METHOD...
 CATEGORY 3 –Use of method not usually recommended
unless other more appropriate methods are not available or
not acceptable No (Do not use the method)
A condition where the theoretical or proven risks usually
outweigh the advantages of using the method
 CATEGORY 4--- Method not to be used- A condition which
represents an unacceptable health risk if the contraceptive
method is used
 Pneumococcal conjugate vaccine (PCV) – safe for mother
and baby
 Tetracycline: permanent GREEN TEETH STAINING or
discoloration of baby if used by pregnancy
 heat lamp – perineal heat therapy - 18-24 INCHES ( 25
watts – 12 -18 inches; 40 watts bulb – 18-24 inches)
 Cramps in pregnancy – CALCIUM DEFICIENCY,
DORSIFLEX FOOT EXTEND KNEE
 Leg cramps – vit. B, D, Calcium supplementation
 Vit B rich sorces are Fruits and GREEN LEAFY
VEGETABLES
 VIT. B can be used to treat NAUSEA AND VOMITING OF
PREGNANCY esp. vit. B-6
 H-mole - sago like discharges and a liver fossicles
discharges or grapelike
 In Hmole – No FHT or Fetal movement
 Auscultation fhb @20wks.
 QUICKENING at 20 weeks
 site of BBT assessment – AXILLARY TEMPERATURE
 Iodine- cretinism...iron
 TETANUS toxoid- with chorionic gonadotrophin content
2 primary doses tt1&2
3 booster doses Tt3-4-5
IM -0.5ml right deltoid.... 90 degree angle injection....
Protects the mother against tetanus... and the baby against tetanus
neonatarum
***TT CAN PREVENT CLOSTRIDIUM INFECTION
 1st pregnancy give TT1&2
2nd pregnancy give Tt3
3rd- Tt4
Succeeding pregnancies- TT5
 TT1- ASAP/20wks-**no protection (0% and 0 year)
 TTT2- 4 Wks or 1 month after TT1- 80%-**3years
protection
 TT3- **6 mos. After TT2- 95% - 5 yrs protection
 TT4- 1 Year after TT3-99%- **10years protection
 TT5- 1 Year after TT4-99%- **lifetime protection
 BTL – permanent IRREVERSIBLE – laparoscopic (incision
near the navel of abdomen)
 Vasectomy - permanent IRREVERSIBLE (incisions in the
scrotum. One incision in the middle of the scrotum or two
incisions (one on each side) )
 Endometrial cancer s/s – abnormal vaginal bleeding or
menorrhagia
 Crown heel length/CRL – 25 cm below is an abortus
 Cardinal movements – EXTENSION - crowning occurs
( cardinal movement that precedes restitution or external
rotation)
 RESTITUTION – external rotation to follow extension
 Unang yakap ist action- dry the baby
 ISchial spine / levels (-1 is 1 cm above ischial spine)
 Sation 0 - Engaged
 +3 station is Crowning or 3 cm below ischial spine
 Molding – OVERLAPPING OR OVERRIDING of skull
bones
 Ruptured BOW- check FHT
 Cheesy discharges and pruritus vulva – candidiasis,
MONILIASIS
 Itchy genitalia or vagina is Vulvovaginitis
 CAULIFLOWER CELLS – CONDYLOMATA
ACCUMINATA – HPV
 CLUE CELLS by pap smear – BACTERIAL VAGINOSIS
 Foul fishy thin gray discharges by Whiffs test–
BACTERIAL VAGINOSIS
 STRAWBERRY CERVIX by pap smear –
TRICHOMONIASIS
 FROTHY DISCHARGES – TRICHOMONIASIS
 PID – CAUSED BY CHLAMYDIA AND secondary is
GONORRHEA
 Most common STI – CHLAMYDIA
 Most common affected in PID – oviducts or fallopian tubes
 Most common affected in gonorrhea- bartholins glands
 HIV – attacks CD4 cells
 HIV/AIDS .– attacks immune sytem
- 52yrs old menopaused for 2yrs then nag pnta s clinic with
signs of bleeding?- REFER for further examination or to
a gynecologist or doctor for endometrial biopsy maybe a
sign of endometrial cancer or myoma and polyps
 VIT.D- RICKETS – risk for CPD
 Rigid like abdomen painful – abruption
 T cu 380 – 10 YEARS PROTECTION
 SPOTTING in the use of iud must be reported
 COC – COMBINED ORAL CONTRACEPTIVES – NO to
obesity, heavy smokers and DM patient and pt. with heart
condition
 COC – REPORT IF HEADACHE AND MIGRANE IS
EXPERIENCED
 CRETINISM –IODINE deficiency
 BREASTFEEDING – the 3 E (Early, Exclusive, Extended)
 Oxytocin is given after placental delivery for rhythmic or
regular uterine contaction
 Breech palpation in LM1- cephalic presentation (lm1)
 Shoulder dystocia- MC ROBERTS MANEUVER
 Not to suture- anal and rectal sphinter muscles (3&4) –
pubococcygeous
 Occipito mental presenting diameter- CHIN
 Tt that protects.pregnant mother -TT2
 Tt to.2nd pregnancy mother (Gravida 2) – TT3
 Transverse diameter - not less than 8 cm - Narrowest outlet
 OB conjugate – narrowest and smallest APD or
anteroposterior of pelvis
 6 days postpartum bleeding – retention of fragments
 Ritgens maneuver used to control fetal head delivery..
 Involution- return of uterus to prepregnant state
 Too thin, too young, too sick woman must avoid getting
pregnant
 33 weeks onward pregnancy check up is every week....
 Mother with risk factors check up just be As frequent as
necessary
 Abruptio placenta- boardlike rigid abdomen (painful,
extreme or severe and tender)
 Placenta previa- abnormal implantation to lower uterus
( painless bright red ) – bleeding without uterine contraction
 Spacing of pregnancy - 3-5 years
 High risk pregnancy- below 18 years old and above 35 y.o
PRIMIGRAVIDAS
 Anterior Pituitary gland - produces FSH,LH,
 Rectovaginafistula - opening or communication of vagina
and rectum
 LOA - occiput facing left side of maternal pelvis towards the
front or symphisis pubis
 Menstrual cycle -32days cycle ovulation day is 18
 28 days ovulation day is 14)
 Moniliasis - white, cheesy,patches with itchiness or pruritus
vulva
 Clitoris - landmark of catheterization, erectile tissue with
genital corpuscles
 Magnesium sulfate - anti seizure, anti convulsant
 Ferrous sulfate- take with vitamin c.... avoid coffee, milk,
cheese and calcium
 feso4- 1 gram per singleton pregnancy- start at 5 months to
2 months postpartum
 Eclampsia - SEIZURE UP TO 72 HOURS – danger of
seizure end at 48 hours
 CORPUS LUTEUM - SECRETORY PHASE -
PROGESTERONE PRODUCE
 Appearance of pubic hair- androgen like testosterone in
men
 HIP AND BREAST DEVELOPMENT* ESTROGENefffect
 PROLIFERATIVE AND FOLLICULAR PHASE-
ESTROGEN rich phase
 SECRETORY.& LUTEAL PHASE * PROGESTERONE rich
phase
 Voiding of a laboring women is every 2 hours
 Pulse and FHT every 30 mins
 Top left corner of partograph ----maternal info...
 Central feature - cervical dilatation
 Plot at left side of alert line marking X at the Active phase
(4cm)
 PARTOGRAPH- not assessed is fluid intake and output...
 I.E every 4 hours
 Alert line is 4 hours from action line
 Postpartum hemorrhage- criterion is blood loss more than
500 ml (500-1000ml)
 Postpartum hemorrhage- massage fundus and 10 iu
oxytocin
 Effleurage- backrubbing during labor
 thickening of uterus- estrogen
 good for implantation- secretory
 secretion of endometrial lining - progesterone.
 Thickening of cervical mucus- estrogen
 Hcg- positive pregnancy test
 Hcg- morning sickness
 FSH - matures egg cell or primordial to graafian follicle
 Melanocyte stimulating hormone- dark pigmentation of skin
(linea nigra,chloasma)
 Pelvis- android (heart male)
 gynecoid-(for female,permit vaginal delivery,wide deep,
apple shape)
 identifiable sex of fetus(4months or 16 weeks)
 FHT- (120 - 160) for breech take it Above umbilicus
 ECTOPIC PREGNANCY - lower abdominal sudden
knifelike pain that radiates to shoulder
 PSEUDOCYESIS- false pregnancy - amenorrhea
CERVIX - SQUAMO COLUMNAR CELLS
 QUICKENING— 16(multi).& 20wks ( primi)
 Ritgens maneuver used to control fetal head delivery..
 Kegels strengthens the levator anii muscles.... pelvic floor
muscles or perineal muscles.... and MOSTLY BENEFITED
IS THE " " "Pubococcygeus Muscle"
 PROM- PREMATURE rupture of membrane for more than
20 hours mothers temperature must be checked - RISK
FOR INFECTION....
- I.E is every 4 hours
 Amenorrhea - presumptive sign..
 vit A/RETINOL food sources  Stored milk in room –6-8hours
-SQUASH,PAPAYA,YELLOW CAMOTE, EGG YOLK,  Stored milk in freezer – 6 months
RIPE GUAVA, RIPE MANGO, FORTIFIED CEREALS,  Mastitis – cold compress before feeding
legumes and beans  Engorgement – warm compress before feeding
 Iodine- prevents CRETINISM or MENTAL RETARDATION  Avoid soap in breast
- SOURCES- iodized salt, talaba oyster, anchovies or dilis,  Breastfeeding is immediately or within 30 minutes after
shells , clams, seaweeds birth and after 3-4 hours in CS
 Hot Sitz bath – 15-20 minutes  EO – 51 is milk code – no pacifiers and prelacteal feeding
– is a procedure whereby patient’s perineal area is like sugar waters and formula
submerged to water with solutions depending on the needs  RA 7600 – Rooming in and breastfeeding act –
of the client. June 2, 1992.
- a bath in which only the pelvic area is immersed in warm  Normal Spontaneous Deliveries. The following newborn inf
fluid.(38-42 celcius) idications : Hemorrhoids, Anal ants be put to the breast of the
Fissures/Surgery, Episiotomy or laceration, Uterine Cramps mother immediately after birth and forthwith
 Contraindication : Pregnancy , Menstruation  roomed in within thirty (30) minutes:
 iron- PREVENT ANEMIA OF PREGNANCY- LIVER  Republic Act 10028 or the “Expanded Breastfeeding
PRODUCTS, RED MEAT AND INTERNAL ORGANS, Promotion Act of 2009”
MONGGO, GREEN LEAFY VEGETABLES
 KIDNEY BEAN PELVIS – plattypeloid
 Vit.D for calcium absorption prevents RICKETS in children
 OVAL PELVIS- anthropoid
and osteomalasia in adult- sources dairy products , fish,
 FLAT PELVIS – PLATTYPELOID
milk, cheese , anchovies, salmon, sardines
 round , sphere, discoid- gynecoid
 Trichomonas vaginalis-trichomoniasis- trichomonas
vaginalis protozoan * frothy creamy, strawberry ( Drug :  heart shape- android
flagyl or metronidazole)  apple shape- gynecoid
 Moniliasis, candidacies, - albicans.yeast infection - itchy,  rarest pelvis- plattypeloid
white cheesy, pruritus vulva(vaginitis) ( High risk factor :  wide APD; narrow TD- anthropoid
Obesity and DM)  Wide TD ; narrow APD- plattypeloid
 KOH test or potassium hydroxide test for moiniliasis  Anterior portion of pelvis
 Hep b- acquired through blood, needle prick, sex - ( use  Posterior potion - sacrum
one needle per patient)  Inferior portion of pelvis - ischium
 Syphilis - painless sores, ulcers,  Lateral sides of pelvis ilium
 Hpv- condylomata- cauliflower CELLS  Globular abdomen or rising out of abdomen – 1st sign of
 POSTPARTUM BLUES- common normal placental separation
 Postpartum psychosis- with delusions, illusion and  2nd sign – sudden gush of blood
halucinations  Rubra- red
 Oxytocin- uterine contraction  Serosanguinous discharge is serosa- pinkish
 INEVITABLE ABORTION open cervix  Prolactin for milk production
 Menopause is climacteric or change of life  3rd trimester – preparation of the motherhood to parenthood
 Endometriosis- ectopic growth or growth of endometrial roles – acceptance of parenthood
tissue outside uterus  Taking in- egocentric or self centered mother
 – most common site - ovaries DIAMETERS OF THE FETAL HEAD
 Drug of choice : Danazol – methotrexate and hormonal
therapy – common to postmenopauseal… 1.Tranverse Diameters BBB
 Accutane or tretinoin – anti acne contraindicated in ● Biparietal – most important TD
pregnancy - greatest diameter presented to the pelvic inlet’s AP and at the
 PENICILLIN AND AMOXICILLIN safest antibiotics of outlet’s TD
pregnancy - average measurement is 9.5 cm
● Bitemporal – average measurement is 8 cm
 Rubella vaccine is contraindicated in pregnancy
● Bimastoid – average measurement is 7 cm
 Complication of streptomycin in pregnancy – deaf baby or
abortion
2. Anteroposterior Diameters (APD)
 Complication of chloramphenicol in pregnancy – gray baby ● Suboccipitobregmatic – smallest APD
syndrome - fully flexed (presenting part)
 Complication of smoking in pregnancy is SGa or Low birth - measured from the inferi or aspect of occiput to the anterior
weight baby fontanel
 Complication of DM of mother is macrosomia and preterm - average measurement is 9.5 cm
baby ● Occipitofrontal – head partially extended and presenting part is the
 Position of mother in IUD- lithotomy anterior fontanel
 Position of mother in labor – Left side lying - average size is 12. 5 cm
 Position in mother for Leopolds- dorsal recumbent ● Occipitomental – head is extended and the presenting part is the
 Position of m other with vaginal bleeding- trendelenburg face
 Position of mother with ruptured BOW – knee chest or - measured from the chin to the posterior fontanel
trendelenburg - average size is 13.5 cm
 Position of mother with shock – TRENDELENBURG
 Position of mother with cord prolapse - knee chest or ⦿ FETAL LIE – relationship of the long axis of the fetus to the long
trendelenburg axis of the mother
 Position for fetal distress – Left side lying ● Longitudinal Lie – “parallel”
 Position of mother in BED PAN – sitting position ● Transverse Lie – “right angle/lying crosswise”
 Position for BSE- Supine lying ● Oblique Lie – “slanting”
 Position for TSE of male- standing after warm bath
⦿ Attitude or Habitus – degree of flexion or relationship of the fetal
 Position of CS in Breast feeding- side lying
parts to each other.
 Position of chatting mother in Breast feeding – sitting
POSITION
 Position of mother in NSVD breastfeeding- Cradle hold
⦿ LOA (Left Occipitoanterior) – most favorable & common fetal
position DRYING – prevents EVAPORATION HEATLOSS
- fetus in vertex presentation (occiput)
- fetus usually accommodates itself on the left because the BIRTHPLAN
placement of the bladder is at the right
⦿ LOP/ROP – mother will suffer more back pains Preparing a birth plan is important and helpful in the course of
⦿ Submento bregmatic- widest or largest APD of fetal head- safe birthing. A birth plan is a short-page statement of your
presenting part- CHIN preference during and after the birth of your child.
 Left and right occipito-anterior are the only normal presentations Birth Plan may include the place (hospital or lying in) where delivery
and positions. should take place,
 Malposition: occipito-posterior. means of transportation
person/s in-charge of the house when you and your husband are

away,
EINC
needs of the mother, needs of the baby, and anticipated expenses.
How many percent of neonatal deaths occur in the first two days of
life?- 50%
Package of evidence-based practices, which is a series of time-
bound, chronologically ordered, standard procedures that a baby
receives at birth- EINC Protocol

Four Core Steps in EINC

 - first 30 seconds-= Immediate and thorough drying to
stimulate respiration
 – after 30 seconds-= Early skin-to-skin contact
 - within 1 – 3 mins-= Properly timed cord clamping
 – within 90 mins = Non-separation of newborn from mother
for early breastfeeding
 When does immediate newborn care take place?- 90
minutes
 When does essential newborn care take place?
- 90 minutes to 6 hours

Functions of immediate and thorough drying A basic Birth Plan template.

 Stimulates breathing This should be the first item on your birth plan as this can affect what
 Prevents hypothermia you need to put into the rest of your plan. For example, if you are
planning to give birth in a birth centre, which are usually staffed by
The general perception for skin-to-skin contact is that it is purely for women who cater and support natural births, you may only need a
 Mother-baby bonding very small plan.
Have a think about where you want to have your baby – at a hospital,
Other benefits of Skin-to-skin contact in a birth centre, at home?
 Breastfeeding success Who do you want to be with you? –Consider who you want to be with
Lymphoid tissue system stimulation you during your birth. Do you want to have a midwife with visiting
Exposure to maternal skin flora rights present, a doula, your partner, family? Will there be
Sugar (protect from hypoglycemia) children/siblings at the birth? If so, who will look after them?
Thermoregulation What positions would you like to use? – Do you want to be mobile
during labour?
When is cord clamping best done? Where can you rest if you wish to? What kind of movements do you
 When cord pulsations have stopped have in mind? Walking, standing, using a rope, a tub, a birth ball?
 Immediate cord clamping is only done when the baby is Will there be a mat, pillows, a ball, a bathtub? Will you be able to be
on all fours, kneeling, leaning, walking, standing, squatting?
 Antenatal steroids should be administered to all patients
What type of pain relief do you want? – Massage, hot packs, tens
who are at - In distress or is asphyxiated
machine, acupuncture, homeopathy, hypnosis, relaxation techniques,
bathing, breathing, moving, medication etc.
Active management of the 3rd stage of labor includes
What type of equipment do you want to use? – A Pinard horn,
 Oxytocin after delivery of the baby
handheld Doppler, CTG? Do you want an IV line or not?
Controlled cord traction
Uterine massage
 Oxytocin is given after excluding- 2nd baby 3 delays in maternal care
These are administered to the baby after the first breastfeed Delay 1: Delay in decision to seek care due to;
 Eye ointment  The low status of women
Vitamin K IM
Hepatitis B vaccine IM  Poor understanding of complications and risk factors in
BCG vaccine ID pregnancy and when to seek medical help

When is the first set of gloves removed?  Previous poor experience of health care
 After the umbilical pulsations have stopped
 Acceptance of maternal death
The dyad or mother and baby is monitored every __ for ___  Financial implications
- Every 15 minutes for first 1-2 hours

Bathing of the baby is postponed until at least ___

- 6 hours Delay 2: Delay in reaching care due to;
 Distance to health centres and hospitals
Covering and wrapping with warm blanket – prevents CONVECTION  Availability of and cost of transportation
heat loss
  Poor roads and infrastructure
 Geography e.g. mountainous terrain, rivers

Delay 3: Delay in receiving adequate health care due to;

 Poor facilities and lack of medical supplies
 Inadequately trained and poorly motivated medical staff
 Inadequate referral systems