MCN SAS#1
FRAMEWORK FOR MATERNAL AND CHILD
HEALTH NURSING
1. Primary Goal of Maternal and Child
Health Nursing
 the promotion and maintenance of
optimal family to ensure cycles of
optimal childbearing and
childrearing.
Maternal and Child Nursing Practice
Throughout the Childbearing-Childrearing
Continuum
 Provision of preconception health care
 Provision of nursing care of women
throughout pregnancy, birth, and
postpartum period
 Provision of nursing care of children
from birth through adolescence
 Provision of nursing care to families in
all settings
2. Philosophy of Maternal and Child
Health Nursing
o Family-centered
o Community-centered
o Evidence-based
3. Maternal and Child Health Goals and
Standards
GLOBAL HEALTH GOALS:
a. The United Nations (UN) and the World
Health Organization established
Millennium Health Goals in 2000 in an
effort to improve health worldwide.
b. These concentrate on improving the
health of women and children because
increasing the health in these two
populations can have such long-ranging
effects on general health.
c. These Global Health Goals are:
MILLENIUM DEVELOPMENT GOALS- These
eight goals, set by the United Nations back in
2000 to eradicate poverty, hunger, illiteracy and
disease, expire at 2015.
SUSTAINABLE DEVELOPMENT GOALS:
 are a collection of 17 global goals set by
the United Nations General Assembly in
2015 for the year 2030.
 part of a wider 2030 Agenda for
Sustainable Development
 built on the Millennium Development
Goals (MDGs) as framework
 In total, 5 million people from across 88
countries in all the world’s regions took
part in the consultation, and
shared their vision for the world in 2030.
 It aims to transform our world and to
improve people's lives and prosperity on
a healthy planet.
 It applies to all countries through
partnerships and peace. Countries,
regions, cities, the business sector and
civil society are actively engaged in
implementing the Agenda and the
SDGs.
 They are mobilizing efforts to end all
forms of poverty, fighting inequalities
and tackling climate change, while
ensuring that no one is left behind.
4. Theories Related to Maternal and
Child Health Nursing
Nursing theories that are related in
promoting healthy pregnancies and
keeping the children well are designed
to offer helpful ways to view patient so
nursing activities can be created to best
meet patients’ needs.
Examples:
a. Callista Roy’s Adaptation Theory-
nurse’s role is to help patients adapt to
change caused by illnesses or
other stressors
b. Dorothea Orem’s Self-Care Theory-
involves examining the patient’s ability
for self-care
c. Patricia Benner’s Novice-Expert
Model- describes nurse’s move from
novice to expert
5. Roles and responsibilities of a
Maternal-Child nurse.
Six (6) Competencies Necessary for
Quality Care:
 Patient-Centered Care
 Teamwork & Collaboration
 Evidence-Based Practice
 Quality Improvement
 Safety
 Informatics
6. Legal Considerations of Maternal-
Child Practice
 Nurses are legally responsible for
protecting the rights of their patients,
including confidentiality, and are
accountable for the quality of their
individual nursing care and that of other
healthcare team members
 Proper documentation is essential for
justifying actions.
A. Definitions of Family
1. “A group of people related by blood,
marriage, or adoption living together.” (US
Census Bureau, 2009)
2. “Two or more people who live in the same
household (usually), share a common
emotional bond, and perform certain
interrelated social tasks. (Allender &
Spradley, 2008)
B. Influence of Family on Its Members
1. Provides long-lasting emotional ties
2. Provides a depth of support
3. Determines how members relate to people
4. Influences what moral values members
follow
5. Molds the members’ basic perspectives on
the present and future
C. Family Nursing
 focus of modern nursing practice
 it is nursing care that considers the
family, not the individual
F. RECOGNIZED FAMILY STRUCTURES
1. Childfree or childless family
 2 people living together without
children
2. Cohabitation family
 Couples perhaps with children who
live together but remain unmarried
3. Nuclear family
 Composed of 2 parents and children.
4. Extended (multigenerational) family
 Nuclear family plus grandparents,
uncles, aunties, cousins and
grandchildren.
 Nurses need to be conscientious about
obtaining informed consent about
invasive procedures in children and
determining if pregnant women are
aware of any risk to the fetus associated
with a procedure or test.
 Nurses are legally responsible to report
inappropriate or insufficient care
provided by another practitioner.
7. Ethical Considerations of Practice
 Nurses should provide factual, complete
information, supportive listening and
helping them in clarifying their values
without imposing their own.
D. Family Theory
 a set of perspectives from the
family’s point of view
 helps address important issues of
childbearing and childrearing
families.
 Modern concept of MCN Nursing is
based on a family and community
standpoint
E. Basic Family Types
1. Family of orientation: the family one is
born into (e.g., oneself, mother, father,
and siblings, if any)
- refers to the family in which a person
is RAISED.
2. Family of procreation: the family one
establishes (e.g., oneself, a spouse or
significant other, and children, if any)
-the family that we CREATE by getting
married and having children
8. Binuclear family
 A family that is created by divorce or
separation when the child is raised in two
families
9. Communal Family
 group of people who choose to live
together as an extended family
 motivated by social or religious values
rather than kinship
 freedom & free choice rather than those of
a traditional family
 prefer complementary or alternative
therapies
  Contains more people to serve as
resources during crises and models
for behavior and values.
5. Single-parent family
 family can offer the child a special
parent-child relationship & increased
opportunities for self-reliance &
independence.
6. Blended
family/Remarriage/Reconstituted
Family
 a divorced or widowed person with
children marries someone who also
has children;
7. Dyad Family
 2 people living together, usually man
& woman (e.g., newly-married couple)
 single, young, same-sex adults who
live together as a dyad for
companionship & financial security
G. 5 Universal Characteristics of a Family
1. Small social system- interrelated;
actions of 1 affect the other.
2. Performs certain basic functions:
provides for the physical, spiritual,
mental health, socialization of
members, provision of economic
well-being
3. Has structure- who are the
members?
4. Has its own cultural values and roles
5. Moves through stages in the life
cycle
I. 8 Family Tasks:
a. PHYSICAL MAINTENANCE-
food, clothing & shelter
b. SOCIALIZATION OF FAMILY
MEMBERS
c. ALLOCATION OF RESOURCES
establishment of fam. values/roles d. MAINTENANCE OF ORDER
e. DIVISION OF LABOR
f. REPRODUCTION,
RECRUITMENT AND RELEASE
OF FAMILY MEMBERS
g. PLACEMENT OF MEMBERS
INTO THE LARGER SOCIETY
h.
maintain sense MAINTENANCE OF
MOTIVATION AND MORALE
of duty
10. Gay or Lesbian (LGBT) Families
 individuals of the same sex live together
as partners for companionship, financial
security and sexual fulfilment
 -ome include children from previous
heterosexual relationships, artificial
insemination, adoption or surrogate
Motherhood
11. Foster Family
 foster parents may or may not have
children of their own and receive
remuneration for their care of the foster
child; theoretically temporary until the kids
can be returned to
their own parents
12. Adoptive Family
 type of family structure in which a person
from the family assumes the parenting of
a child fromhis/her biological parents
through adoption agencies, international
adoption and private adoption
H. Characteristics of A Healthy Family
Members:
 interact with each other repeatedly in
many contexts.
 encouraged to grow and develop
as individuals and members of the
family
 enhanced and fulfilled by
maintaining contacts with a wide
range of community groups and
organizations
 make efforts to master their lives by
becoming members of groups, finding
information and options, and making
decisions
J. Family Life Cycles
Stage 1: Marriage
Stage 2: The Early Child-bearing Family
Stage 3: The Family with a Pre-school Child
Stage 4: The Family with a School-age Child
Stage 5: The Family with an Adolescent
Stage 6: The Launching Stage Family
Stage7: The Family of Middle Years
Stage 8: The Family in Retirement or Old Age
*BOOMERANG GENERATION- young adults return
home to live with their family after college or a failed
relationship until they can afford their own apartment
or form a new relationship
* SANDWICH FAMILY- a family that is squeezed into
taking care of both aging parents and returning young
adult.
*EMPTY NEST SYNDROME- is a feeling of boredom
or grief and loneliness parents may feel when their
 children leave home for the first time, such as to live
on their own or to form families of their own
K. ASSESSMENT OF FAMILY STRUCTURE AND FUNCTION
GENOGRAM- diagram that details family structure, provides info about the family’s history and the
roles of various family members over time, usually through several generations; provides a basis for
discussion and analysis of family interaction.
ECOMAP- to document the fit of a family in their community; a diagram of family and community
relationships
FAMILY APGAR - a screening tool of the family environment
 a Family APGAR form is administered to each family member and their scores are compared

MCN #2

I. Definitions of Terms: II. REPRODUCTIVE DEVELOPMENT (Intrauterine

A. Obsterics - a branch of medicine that
deals with the care of women during
pregnancy, labor, and the period of
recovery following childbirth.
B. Gynecology- is the study of female
reproductive organs and diseases
affecting it.
C. Andrology- is the study of the male
reproductive organs
D. Pediatrics- the branch of medical science
concerned in children and their illness.
E. Neonatology- the branch of medicine
concerned with the development and
disorders of newborn babies
F. Sexual Health- is not just an absence of
disease, dysfunction, or infirmity but a
condition of physical, emotional and
psychological well-being.
G. Gonad- is a body organ that produces the
cells necessary for reproduction (the
ovary in females, the testis in males)
Development)
 Sex is determined at the moment of
conception
 A GONAD produces sex cells (ovary &
testes); by week 5 in utero, primitive gonads
are formed
 In both sexes, there are 2 undifferentiated
ducts, the mesonephric (WOLFFIAN) &
paramesonephric (MULLERIAN) duct
 Week 7-8 (males)- gonadal tissue
differentiates into primitive testes & begins
formation of testosterone
 Testosterone influences the
mesonephric(W) duct to develop into male
reproductive organs as the
paramesonephric(M) duct regresses.
 If testosterone is absent by week 10, gonadal
tissue differentiates into ovaries &
paramesonephric duct(M) develops into
female reproductive organs. Oocytes are
formed
 Week 12, external genitals begin to be visible.
 In males, dt testosterone, penile tissue
elongates & the urogenital fold on the ventral
surface of the penis closes to form the
urethra.
 In females with no testosterone, urogenital
fold remains open to form the labia minora;
what would be formed as scrotal tissue in the
male becomes the labia majora in the female.
III. PUBERTAL DEVELOPMENT C. Secondary Sex Characteristics in Females:
 Growth spurt
PUBERTY is the stage of life at which secondary  Increase in the transverse diameter of the
sex change begins; begins at 9 to 12 years old in pelvis
girls.  Breast development
 Growth of pubic hair
A. Role of Testosterone:  Onset of menstruation
Responsible for:  Growth of axillary hair
muscular development physical  Vaginal secretions
growth increase in sebaceous gland D. Secondary Sex Characteristics in Males:
secretions that cause typical acne in
 Increase in weight
both boys and girls
 Growth of testes
duringadolescence.
 Growth of face, axillary, and pubic hair
 Initiates adrenarche (pubertal  Voice changes
changes in testes, scrotum, penis,  Penile growth
prostate, and seminal vesicles; the  Increase in height
appearance of male pubic, axillary,  Spermatogenesis - production of sperm
and facial hair; laryngeal enlargement
with its accompanying voice change;
and maturation of spermatozoa).
 Androgens are produced by the
adrenal gland and the testes in
males.
 Androgens are produced by the
adrenal gland and the ovaries in
females.

B. Role of Estrogen:
 Release is triggered by FSH, ovaries in
females excrete a high level of estrogen.
 Influences the development of uterus,
fallopian tubes, and vagina; typical fat
distribution; hair patterns; breast
development.
 Thelarche = the beginning of breast
development; which usually starts 1 to 2
years before menstruation.
 Menarche = the beginning of
menstruation
Onset: 9 – 17 years old in females
Average: 12.4 years old in females

EXTERNAL STRUCTURE
1. SCROTUM 2. TESTES
 rugated, skin-covered, muscular, deeply  2 ovoid glands, 2 to 3 cm wide, encased by
pigmented pouch suspended from the protective white fibrous capsule
perineum  male sex glands, correspond to the ovary in
 left scrotum is larger & lower due to female
longer spermatic cord
  Cremaster muscle- responsible for
contraction of the scrotum
 midline septum- separates each sac
 each compartment contains a testis, its
epididymis, & a part of the spermatic
cord
 Functions of the scrotum:
 supports the testes,
 helps regulate the temperature of
sperm
 protects the testes from trauma
1. EPIDIDYMIS
 a tightly coiled tube responsible for
conducting sperm from the tubule to the
vas deferens.
 It is the storage of immature sperm, and a
part of the alkaline fluid (semen, or seminal
fluid that contains a basic sugar and
protein) that will surround sperm at
maturity is produced by the cells lining the
epididymis.
 Sperm are immobile and incapable of
fertilization as they pass through or are
stored at the epididymis level.
 It takes at least 12 to 20 days for them to
travel the length of the tube, and a total of
65 to 75 days for them to reach full
maturity
 Sperm is capable of surviving for 72 hours
inside the woman’s body.
 Aspermia = absence of sperm
 composed of lobules, each lobule containing
interstitial cells (LEYDIG’S CELLS) &
seminiferous tubules
 900 coiled seminiferous tubules produce
spermatozoa
 Interstitial cells (Leydig’s cells) produce
testosterone
 Functions:
 manufacture male sex cells
(gametes) or spermatozoa
 produce several steroid hormones
primarily testosterone
 3cylindrical masses of erectile tissue in the
penis shaft:
2 CORPUS CAVERNOSA
1 CORPUS SPONGIOSUM
 corpus spongiosum contains the urethra
which serves as a passage for both
sperm and urine
 organ of copulation & urination
 Penile artery supplies blood to the penis
 Erection is innervated by the Peripheral
Nervous System
 GLANS- bulging, sensitive ridge of tissue at
the distal end of the penis; similar in function
to the clitoris
 PREPUCE/foreskin- retractable casing of
skin, protects the glans
 PHIMOSIS- condition in which the prepuce is
too tight that it interferes with the flow of
urine
2. VAS DEFERENS/DUCTUS DEFERENS
 is an additional hollow tube surrounded by
arteries and protected by a thick fibrous
coating, which altogether, are referred to as
the spermatic cord.
 It carries sperm from the epididymis through
the inguinal canal into the abdominal cavity,
where it ends at the seminal vesicles and the
ejaculatory ducts below the bladder.
 Sperm completely matures as they pass
through the vas deferens. They are still not
mobile at this point
 This is the site severed during vasectomy to
 prevent passage of sperm, a popular means
of male birth control.
  Oligospermia = fewer than 20 million
sperm per milliliter
3. PROSTATE GLAND 5. URETHRA
 is a chestnut-size gland that lies just below  is a hollow tube leading from the base of the
the bladder and allows the urethra to pass bladder, which, after passing through the
through the center of it, like the hole in a prostate gland, continues to the outside
doughnut. through the shaft and glans of the penis.
 Function: to secrete a thin, alkaline fluid,
which, when added to the secretion from
the seminal vesicles, further protects
sperm by increasing the naturally low pH
level of the urethra.
4. BULBOURETHRAL GLAND
 or Cowper’s glands lie beside the prostate
gland and empty by short ducts into the
urethra. They supply one more source of
alkaline fluid to help ensure the safe
passage of spermatozoa.
 SEMEN is derived from the prostate gland
(60%), the seminal vesicles (30%), the
epididymis (5%), and the bulbourethral
glands (5%).
EXTERNAL STRUCTURES
1. MONS PUBIS or MONS VENERIS 2. LABIA MAJORA (Large lips)
 It is a pad of adipose tissue located over  2 folds of adipose tissue covered by loose
the symphysis pubis, the pubic bone joint. connective tissue & epithelium
 It is covered by a triangle of coarse, curly  Function: protects the external genitalia and
hairs known as “escutcheon”. inner vulvar structures
 Function: to protect the junction of the
pubic bone from trauma.
3. LABIA MINORA (Small lips) 4. VESTIBULE
 2 flat hairless, reddish folds of connective  almond-shaped area that is found within the
tissue located between the labia majora labia
 anteriorly fuse to form the prepuce  contains openings to the urethra, vagina,
(hoodlike covering of the clitoris) and the skene’s glands and bartholin’s glands
frenulum (fold of tissue under the clitoris) 5. GLANS CLITORIS
 posteriorly join to form the FOURCHETTE  a small (1 to 2cm), rounded organ of erectile
(torn during childbirth & is the site of tissue at the forward junction of the labia
episiotomy) minora
 Protects and obscures the vestibule,  site or center of sexual arousal & orgasm in
urinary meatus and vaginal os females
 when the ischiocavernosus muscle
surrounding it contracts with sexual arousal,
the venous outflow for the clitoris is blocked,
leading to clitoral erection.
 Secretes smegma
6. SKENE’S GLANDS/ PARAURETHRAL 8. PERINEAL MUSCLE/ PERINEAL BODY
GLANDS  Located posterior to the fourchette
 Located on each side of the urinary  muscular area easily stretched during
meatus childbirth
 produce alkaline mucus for lubrication &  Exercises to strengthen the perineal body:
protection Kegel exercises, tailor-sitting, squatting
7. BARTHOLIN’S GLANDS / PARAVAGINAL
GLANDS
 Located on each side of the vaginal
opening
 secrete an alkaline substance to lubricate
the vaginal orifice & neutralize the acidity
of the vagina
 Site of Bartholin’s cyst & infection
(Bartholinitis)
INTERNAL STRUCTURES
1. OVARIES
 approximately 3 cm long by 2 cm in
diameter and 1.5 cm thick, or the size and
shape of almonds. They are
grayish-white and appear pitted, with
minute indentations on the surface.
 Function: to produce, mature, and
discharge ova (egg cells). In the process of
producing ova, the ovaries also produce
estrogen and progesterone and initiate and
regulate menstrual cycles.
 Organ of ovulation, oogenesis, and
hormone production.
 3 principal divisions/layers
 TUNICA ALBUGINEA-protective
layer of epithelium
 CORTEX- filled with ovarian &
graafian follicle
 MEDULLA- contains nerves, blood
vessels, lymphatics
 ***At birth, each ovary contains about 2
million immature ova; by age 7 years, only
500T are present per ovary; by 22 years,
300,000 ova; by menopause none are left
(atrophied or matured
2. FALLOPIAN TUBES/OVIDUCTS/UTERINE
DUCTS
 They arise from each upper corner of the
uterine body and extend outward and
backward until each open at its distal end,
next to an ovary.
 The fallopian tubes are approximately 8-10 site of sterilization or BTL (Bilateral Tubal Ligation)
cm long in a mature woman.
Functions: to convey the ovum from the ovaries to fertilization
the uterus and to provide a place for fertilization of INFUNDIBULLUM- most distal, funnel-shaped; rim
the ovum by the sperm
9. HYMEN
 tough but elastic tissue that covers the
vagina
 imperforate hymen- a hymen so complete it
does not allow passage of menstrual blood
from the vagina or for sexual relations until
it is surgically incised
Functions of ESTROGEN (Hormone of the
Woman)
 Development of secondary sexual
characteristics
 Inhibits production of FSH
 SPINNBARKEIT formation
 Development of ductile structure of the
breasts
 Increase in height in females
 Hypertrophy of the uterine lining
Functions of PROGESTERONE (Hormone of the
Mother)
 Inhibits LH production
 Inhibits motility if the GIT- decrease in
peristalsis, increase in H2O reabsorption
causing constipation
 Mammary gland maturation
 Mood swings
 Increase in BBT (Basal Body Temperature)
4 Segments of the FALLOPIAN TUBE:
INTERSTITIAL- most proximal, lies within uterine
wall (1 cm); most dangerous site for ectopic
pregnancy
ISTHMUS- next distal portion, extremely narrow;
AMPULLA- 3rd & longest portion (5 cm); site of
is covered by fimbriae (small hairs) that help guide
the ovum into the FT
3. UTERUS
 It is a hollow, muscular, pear-shaped organ
located in the lower pelvis, posterior to the
bladder and anterior to the rectum
 During childhood it is the size of an olive &
reaches its adult size by 17 years-old
 Dimensions: 5-7 cm long, 5 cm wide, 2.5
cm deep and weighs 60 g.
 Functions:
 receive the ovum from the oviduct,
 implantation & nourishment of the
fetus,
 protection of the fetus,
 expulsion during childbirth
Three divisions of the uterus:
Body of the uterus (corpus) = the uppermost part
and forms the bulk of the organ.
 The lining of the cavity is continuous with
the fallopian tube, which enter at its upper
aspects (the cornua).
 The fundus is the uppermost part of the
corpus
 During pregnancy, the body of the uterus is
the portion of the structure that expands to
contain the growing
 fetus.
 The fundus is the portion that can be
palpated abdominally to determine the
amount of uterine growth during
pregnancy, to measure the force of uterine
contractions during labor, and to assess
that the uterus is returning to its
nonpregnant state after childbirth.
Isthmus = is a short segment between the body
and the cervix. In the nonpregnant uterus, it is only
1 to 2 mm in length.
 It is the portion where the incision most
commonly is made when a fetus is born by
a cesarean birth.
 It is considered as “the lower uterine
segment” during pregnancy.
Cervix = is the lowest portion of the uterus.
 It represents about one third of the total
uterine size and is approximately 2 to 5 cm
long.
 Its central cavity is termed as cervical canal.
 The opening of the canal at the junction of
the cervix and isthmus is the internal
cervical os;
 the distal opening to the vagina is the
external cervical os.
 The level of the external os is at the level of
the ischial spines
Uterine and Cervical coats:
Endometrium = an inner layer of mucous
membrane innermost layer
highly vascular with 3 layers (compact, spongy &
basal layers); basal layer is unaffected by hormones
& the upper 2 are sloughed off during menses and
are greatly affected by hormones
Myometrium = a middle layer of muscle fibers
 3 interwoven layers of smooth muscle
arranged in longitudinal, transverse &
oblique directions
 provides strength to the organ during
contractions
Functions:
 constrict tubal junctions & prevent
regurgitation of menstrual blood into the
tubes
 holds internal os closed during pregnancy;
 limits blood loss during childbirth
Perimetrium = an outer layer of connective tissue
that provides support
 UTERINE LIGAMENTS
CARDINAL/ TRANSVERSE-CERVICAL/ UTEROSACRAL LIGAMENT
MACKENRODT LIGAMENTS  connects uterus to the sacrum
 lower portion of the broad ligaments ANTERIOR LIGAMENT
 main support of the uterus  provides support to the uterus in connection
 damage to this ligament results to with the bladder.
UTERINE PROLAPSE  Overstretching will lead to herniation of the
bladder to the vagina, a condition called
BROAD/PERITONEAL LIGAMENTS CYSTOCELE
 from the sides of the corpus & extends to POSTERIOR LIGAMENT
the lateral pelvic  It forms the cul-de-sac or pouch of Douglas.
 the sides of the uterus & assists in holding  Damage will led to herniation of the rectum
the uterus in tly tipped forward to the vagina, a condition called
ROUND LIGAMENT RECTOCELE
 connects the uterus to the labia majora
and gives stability to the uterus
UTERINE DEVIATIONS

 BICORNUATE UTERUS- horns at the junction of the fallopian tubes

 SEPTUM which divides the uterus
 DOUBLE UTERUS
 RETROVERSION- fundus is tipped backward
 ANTEVERSION- fundus is tipped forward
 ANTEFLEXION- body is bent sharply forward at the junction of the cervix
 RETROFLEXION- body is bent sharply back just before the cervix
4. VAGINA  FORNICES- recesses at the cervical end of
 it is a hollow, musculomembranous, the vagina: posterior, anterior & lateral
rugated canal located posterior to the o posterior fornix- site were semen
bladder & anterior to the rectum pools after intercourse
 rugae make the vagina elastic & expand  It is lined with stratified squamous
during childbirth epithelium similar to the cervix
 from the cervix of the uterus to the external  mucus secretions contain glycogen broken
vulva down by DODERLEIN’S BACILLUS
 FUNCTIONS: organ of intercourse forming lactic acid making the pH 4 to 5
and birth canal which is acidic; thus, preventing infections
 Low E (menopause, childbirth & lactation)
causes dryness & thinness of the vaginal
walls and smoothening of the rugae
 bulbocavernosus muscle acts as a
voluntary sphincter; kegel’s exercise
strengthens this muscle
ACCESSORY ORGANS
1. MAMMARY GLANDS AREOLA
Located anterior to the pectoralis major muscle,  Areola appears rough due to sebaceous
between the sternum & the midaxillary line (between glands called MONTGOMERY’S
2nd & 6th ribs), with an extension called the TAIL TUBERCLES
OF SPENCE and extends well into the axilla
Composition: divided into 15 to 20 LOBES divided
into LOBULES
LOBULES -clusters of ACINAR CELLS/ ACINI
which are saclike terminal parts of the gland
emptying through a narrow lumen of duct lined with
epithelial cells that secrete MILK & COLOSTRUM
 below the epithelium is the
MYOEPITHELIUM whichcontracts to expel
milk from the acini into the LACTIFEROUS
or MILK DUCTS towards the nipple
 As the ducts converge, they dilate to form
common LACTIFEROUS SINUSES or
AMPULLA which serve as milk reservoirs.
These are located just posterior to the
NIPPLE
2. PELVIS
A. Functions:
 Support & protect the reproductive &
other pelvic organs
 Accommodation of the growing fetus
 Anchorage of the pelvic support
structures
B. Composition:
 Anterior & lateral portion made up of 2
innominate hip bones divided into 3
parts (ilium, ischium and pubis)
 Posterior portion: sacrum, coccyx
 Stimulation leads the APG to secrete
OXYTOCIN which makes th myoepithelium
to contract, pushing the milk forward into
the nipples (LETDOWN REFLEX or MILK
EJECTION REFLEX)
 Increase in P & E 3-4 days before menses
increase vascularity of the breasts, induce
growth of ducts & acini, promotes H2O
retention, resulting in breast swelling,
tenderness & discomfort.
 After menses, regression occurs & H2O is
lost & reaches minimal alteration levels 5
to 7 days after menses. (BEST TIME FOR
Breast Self- Examination)
Hormones that Influence the Mammary Glands
 ESTROGEN- development of the ductile
structure of the breast
 PROGESTERONE- development of the
acinar structures of the breast
 HUMAN PLACENTAL LACTOGEN
(HPL)- breast development during
pregnancy
 OXYTOCIN- let-down reflex or milk
ejection reflex
 PROLACTIN- directly stimulates milk
production
2 Divisions of the Pelvis:
 FALSE PELVIS- upper half which
supports the uterus during the late months
of pregnancy & aids in directing the fetus
into the true pelvis for birth
 TRUE PELVIS- lower half of the pelvis;
long, bony, curved canal divided into 3
parts:
o inlet,
o pelvic cavity
o outlet
 LINEA TERMINALIS or BRIM- imaginary
line from the sacral promontory to the
superior border of the SP which divides the
pelvis into true & false pelves
MCN #3

I. Characteristics of A Normal Menstrual

Cycles:

CHARACTERISTICS
Beginning (menarche)
Interval between cycles
Duration of menstrual flow
Amount of menstrual flow
Color of menstrual flow
Odor
DESCRIPTION
Average age at onset: 12.4 years
Average range: 9 – 17 years
Average: 28 days
Cycles of 23 – 35 days not unusual
Average flow: 4 – 6 days
Ranges of 2 – 9 days not abnormal
Difficult to estimate; average: 30-80 mL per
menstrual period; saturating a pad or tampon in
less than 1 hour is heavy bleeding
Dark red; a combination of blood mucus, and
endometrial cells
Similar to marigolds

II. Physiology of Menstruation:

Defintion: Menstrual cycle or female

reproductive cycle is defined as episodic uterine
bleeding in response to the cyclic hormonal
changes
Purpose: To bring an ovum to maturity & renew
uterine tissue bed that is responsible for the
growth of the fertilized ovum Release is
triggered by FSH, ovaries in females excrete a
high level of estrogen.

A. 4 STRUCTURES INVOLVED IN
MENSTRUAL CYCLE

1. HYPOTHALAMUS

 The release of GnRH (also called

luteinizing hormone-releasing hormone
[LHRH]) from the hypothalamus initiates
the menstrual cycle.
 GnRH then stimulates the pituitary gland
to send gonadotropic hormone to the
ovaries to produce estrogen
 When the level of estrogen rises,
release of GnRH is repressed and no
further menstrual cycles will occur (the
principle that birth control pills use to
eliminate menstrual flows). Excessive
levels of pituitary hormones can also
inhibit release.
2.PITUITARY GLAND

 It is under the influence of GnRH; the

anterior lobe of pituitary gland
(adenohypophysis) produces two
hormones:
 Follicle-stimulating hormone (FSH) =
is a hormone active early in the cycle
that is responsible for maturation of the
ovum.
 Luteinizing hormone (LH) = is a
hormone that becomes most active at
the midpoint of the cycle and is
responsible for ovulation, or release of
mature egg cell from the ovary. It also
stimulates growth of the uterine lining
during the second half of the menstrual
cycle.
 FSH and LH are called gonadotropic
hormones because they cause growth
(trophy) in the gonads(ovaries).

3. OVARIES (OVARIAN CYCLE) B. LUTEAL PHASE – from Day 15 to Day 28 of a

28- day menstrual cycle
A. PROLIFERATIVE PHASE –from Day 1 to Day
14 of a 28-day menstrual cycle
 Every month, one of the ovary’s oocytes is
activated by FSH to begin to grow and
mature
 As the oocyte grows, its cell produces a
clear fluid (follicular fluid) that contains a
high degree of estrogen and progesterone.
As the follicle surrounding the oocyte
grows, it is propelled toward the surface of
the ovary as a clear blister (Graafian
follicle).
 After an upsurge of LH, prostaglandins are
released and the graafian follicle ruptures
(ovulation)
 This happens on the 14th day before the
onset of the next cycle (not the midpoint).
 After the ovum and the follicular fluid have
been discharged from the ovary, the cells
of the follicle remain in the form of a
hollow, empty pit. The FSH has done its
work at this point and now decrease in
amount
 The second pituitary hormone, LH,
continues to rise in amount and directs the
follicle cells left behind in the ovary to
produce lutein, a bright-yellow fluid high in
progesterone. With lutein production, the
follicle is renamed a corpus luteum (yellow
body).
 If conception (fertilization by a
spermatozoon) occurs as the ovum
proceeds down a fallopian tube and the
fertilized ovum implants on the
endometrium of the uterus, the corpus
luteum remains throughout the major
portion of the pregnancy (to about 16 to 20
weeks)

4. UTERUS (UTERINE CYCLE) = the uterus also changes monthly as a result of stimulation from the
estrogen and progesterone produced by the ovaries
A. First Phase of the Menstrual Cycle
(PROLIFERATIVE PHASE) = from day 4 or 5 to
day 14
 Immediately after menstrual flow
(MENSTRUAL PHASE from Days 1-4), the
endometrium, or the lining of the uterus, is
very thin, approximately one cell layer in
depth.
 As the ovary begins to produce estrogen
(in the follicular fluid), the endometrium
begins to proliferate.
 This growth is very rapid and increases the
thickness of the endometrium
approximately eightfold.
 This happens from day 5 – 14
 Also known as estrogenic, follicular, or
 postmenstrual phase
C. Third Phase of Menstrual Cycle (Ischemic
Phase) = Day 24 to 28 of menstrual cycle
 If fertilization does not occur, the corpus
luteum in the ovary begins to regress after
8 – 10 days.
 Production of progesterone and estrogen
decreases.
 The endometrium of the uterus begins to
degenerate.
 Capillaries rupture, with minute
hemorrhages, and the endometrium
sloughs off.
 Happens approximately on day 24 or 25 of
the cycle.
 If conception does not occur, the
unfertilized ovum atrophies after 4 to 5
days, and the corpus luteum remains for
only 8 to 10 days. As the corpus luteum
regresses, it is gradually replaced by
white fibrous tissue called corpus albicans
(white body).
 The basal body temperature of a woman
drops slightly (by 0.5O to 1O F) just
before the day of ovulation because of the
extremely low level of progesterone that is
present at that time. It rises by 1OF on the
day after ovulation because of the
concentration of progesterone, which is
thermogenic.
 The woman’s temperature remains at this
level until approximately day 24 of the
menstrual cycle, when the progesterone
level again decreases.
B. Second Phase of the Menstrual Cycle
(Secretory Phase) = Day 14 to 24 of menstrual
cycle
 After ovulation, the formation of
progesterone in the corpus luteum causes
the glands of the uterine endometrium to
become corkscrew or twisted in
appearance.
 The capillaries of the endometrium
increase in amount until the lining takes on
the appearance of rich, spongy velvet.
 Also known as pregestational, luteal,
premenstrual, or secretory phase
D. Fourth Phase of Menstrual Cycle (Menses or
Menstrual Phase) = first day of the menstrual flow
to 5 days
Menstrual flow is composed of:
 Blood from the ruptured capillaries
 Mucin from the glands – protein
 Fragments of endometrial tissue
 Microscopic, atrophied, and unfertilized
ovum
B. The Fern Test
 Just before ovulation when estrogen levels are high, the cervical mucus has the ability to form
fernlike patterns on a microscope slide when allowed to dry. This pattern is known as arborization
or ferning.
 When progesterone is the dormant hormone, as it is just after ovulation, this fern pattern is no
longer discernible.
C. Spinnbarkeit Test
 At the height of estrogen secretion, the cervical mucus has the ability to stretch into long strands.
 Stretching the mucus at the midpoint of a menstrual cycle is another way to demonstrate that
high levels of estrogen are being produced, and that ovulation is about to occur.
D. Education for Menstruation Signs and Symptoms of Menopause:

Myths during menses: Periods of amenorrhea

 Should not plant vegetables or the “Hot flashes”
vegetables will die. Vaginal dryness leading to dyspareunia
 Should not eat sour foods because this will
cause cramping Aid: use a lubricating jelly such as KY jelly
Menstrual disorders: prior to sexual intercourse.
 Dysmenorrhea = painful menstruation
 Menorrhagia = abnormally heavy menstrual Osteoporosis (lack of bone mineral density)
flows
 Metrorrhagia = bleeding between Urinary incontinence
menstrual periods
 Amenorrhea = absence of menstrual flow Aid: practice Kegel exercise to help strengthen
 Menopause = is the cessation of menstrual bladder supports
cycles
Perimenopausal = is a term used to denote the Hot flashes can be accompanied by heart
period during which menopausal changes occur. palpitations and can occur up to 20 – 30 episodes
Postmenopausal = describes the time of life a day
following the final menses
First Aid: sip a cold drink or use a hand fan
Age range: 40 – 55
Mean average: 51.3
Women who smoke tend to have earlier menopause
MCN #4

Gene Replacement Therapy and Gene Editing

Gene Replacement Therapy- is an experimental technique that uses genes to treat or prevent disease.
Gene Editing- DNA is inserted, deleted, modified or replaced in the genome of a living organism targets
the insertions to site specific locations.
Genetic Disorders Nature of Inheritance
- Inherited or genetic disorders are disorders Genes- are the basic units of heredity that
that can be passed from one generation to determine both physical and cognitive
the next because they result from some characteristics of people. Are composed of
disorder in the gene or chromosome segments of DNA, which are woven into strands in
structure. the nucleus of all body cells to form chromosome.
- may occur at the moment an ovum and a Alleles-are the two like genes on autosomes.
sperm fuse or even earlier, in the meiotic Phenotype-refers to a person’s outward
division phase of the gametes appearance or the expression of genes
- 50% of 1st trimester spontaneous Genotype-refers to a person’s actual gene
miscarriages composition.
Genetics -is the study of the way such disorders Genome-is the complete set of genes present
occur. (about 50,000 to 100,000).
Cytogenetics- is the study of chromosomes by - the collection of genetic information.
light microscopy and the method by which Gene-basic unit of genetic information. Genes
chromosomal aberrations are identified. determine the inherited characters.
Chromosomes-storage units of genes.
DNA-is a nucleic acid that contains the genetic
instructions specifying the biological development
of all cellular forms of life.
Mendelian Inheritance
Gregor Mendel-described the principle of generic inheritance.
When dominant gene is paired with nondominant (recessive) ones, the dominant genes are always
expressed in preference to the recessive genes.

Ex: a gene for brown eyes is dominant over one for blue eyes.
2 healthy genes-HOMOZYGOUS
2 unhealthy genes-HETEROZYGOUS
Medical Genetics Dominant vs. Recessive
When studying rare disorders, general patterns of
inheritance are observed: Dominant- allele is expressed even if it is paired
1. Autosomal recessive with a recessive allele.
2. Autosomal dominant Recessive- allele is only visible when paired with
3. X-linked recessive another recessive allele.
4. X-linked dominant
INHERITANCE OF DISEASE

 Autosomal Dominant vs. Autosomal

Recessive Inheritance

1. Autosomal Recessive- disease does not occur 2. Autosomal Dominant- either a person has 2
unless 2 genes for the disease are present unhealthy genes (HOMOZYGOUS DOMINANT
(homozygous recessive pattern) e.g.DD) or is heterozygous, with the gene causing
 CF, albinism, adrenogenital syndrome, the disease stronger than the corresponding
Tay-Sach’s, Galactosemia, PKU, Rh- healthy recessive gene for the same trait (e.g Dd)
incompatibility
3. X-linked Dominant Inheritance 4. X-linked Recessive Inheritance
 genes are located on and transmitted only  Usually, only males will have the disorder
by the female sex chromosome (X  history of girls dying at birth for unknown
chromosome) reasons (females with affected gene on
 if the affected gene is dominant, only 1 X both X chromosomes)
chromosome with the trait need be  hemophilia A, Christmas disease, color
present for symptoms of the disorder to blindness, Duchenne muscular dystrophy
be manifested and fragile X syndrome (cognitive
 Alport’s syndrome- progressive kidney challenge syndrome)
failure disorder
Multifactorial (Polygenic) Inheritance
 from multiple gene combinations plus environmental factors
 heart disease, Diabetes Mellitus, cleft palate, Neural Tube Defects, pyloric stenosis
CHROMOSOMAL ABNORMALITIES (CYTOGENIC DISORDERS)
 Abnormalities due to fault in the number/structure of chromosome which results in missing or
distorted genes
 When chromosomes are photographed and displayed, the resulting arrangement is termed a
KARYOTYPE
 fluorescent in situ hybridization (FISH)-the number of chromosomes and specific parts of
chromosomes can be identified by karyotyping or by this process
A. Nondisjunction Abnormalities
 the division is uneven (NONDISJUNCTION) resulting to 1 sperm/ovum having 24 & the
other 22
 if this fuses with a normal sperm/ovum, the zygote will have 47 or 45 chromosomes
 Down syndrome (Trisomy 21) increases with maternal & paternal age
 Turner & Klinefelter syndrome
B. Deletion Abnormalities
 chromosome disorder in which
part of the chromosome breaks
during cell division, causing the
affected person to have the
normal # of chromosomes +/-
an extra portion of a
chromosome, e.g 45.75 or 47.5
 Cri-Du-Chat
syndrome(46XY5q-), 1 portion
of chromosome 5 is missing

C. Translocation Abnormalities
 a child gains an additional chromosome through another route
 TRISOMY 21
D. Mosaicism

 when the nondisjunction disorder

occurs after fertilization of the ovum,
as the structure begins mitotic cell
division
 different cells in the body will have
different chromosome counts

E. Isochromosomes
 chromosome accidentally divides not by
a vertical separation but by a horizontal
one, a new chromosome with
mismatched long and short
arms can result.
 much the same effect as a translocation
 Turner’s syndrome

GENETIC COUNSELLING
Purposes: Couples who may benefit include those:
 Provide concrete, accurate information:  who have a child with congenital disorder or
process of inheritance & inherited an inborn error of metabolism
disorders  whose close relatives have a child with a
 Allow people to make informed choices genetic disorder such as translocation
about future reproduction disorder or inborn error of metabolism
 Offer support to people who are affected  Who are known balanced translocation
by genetic disorders carriers
 With inborn error of metabolism or
chromosomal disorder
 Who are a consanguineous couple (closely
related)
 With the woman older than 35 and the man
older than 55
 Are of ethnic backgrounds in which specific
illnesses are known to occur; Chinese (G6PD,
Mediterranean, thalassemia)
Nursing Responsibilities
 Explaining to a couple what procedures they can expect to undergo
 Explaining how different genetic screening tests are done and when they are usually offered
 Supporting a couple during their wait for test results
 Assisting couples in values clarification, planning, and decision-making based on the results
 *do not impose your own values or opinions
ASSESSMENT FOR GENETIC DISORDERS Maternal Serum Screening

A. HISTORY Alphafetoprotein (AFP) secreted by the fetal liver

 Document diseases in family members peaks in maternal serum between the 13 and 32
 Ethnic background weeks; level is elevated with fetal spinal cord disease
 Mother’s age, spontaneous miscarriage
B. PHYSICAL ASSESSMENT
 Physical Examination of family member
with a disorder, siblings and the couple.
 Check: space between the eyes,
height, contour, shape of ears, number
of fingers & toes, webbing,
dermatoglyphics (markings on skin),
abnormal fingerprints, palmar creases,
abnormal hair whorls or hair coloring
DIAGNOSTIC TESTING
 Karyotyping-sample of peripheral
venous blood or scraping of cells from
the buccal cavity; cells are grown to
metaphase, stained, placed under a
microscope & photographed
(chromosomes are identified according
to size, shape & stain)
COMMON CHROMOSOMAL ABNORMALITIES
Trisomy 13 Syndrome (47XY13+ or 47XX13+) Klinefelter Syndrome (47XXY)
or PATAU Syndrome
 extra chromosome 13, severely
cognitively challenged
 midline body disorders like cleft
lip/palate, heart defects, abnormal
genitalia, microcephaly, microphthalmia, Fragile X Syndrome (46XY23q-)
low-set ears;
 most do not survive beyond early
childhood
Trisomy 18 (47XX18+ or 47XY18+)
 they have 3 copies of chromosome 18
 severely cognitively challenged, SGA,
low-set ears, small jaw, congenital heart
defects, misshapen fingers & toes,
rocker-bottom feet
 do not survive beyond early infancy
Cri-du-chat syndrome (46XX5p- or 45XY5p-)
 result of missing portion of chromosome
5 Down Syndrome (Trisomy 21) (47XY21+ or
 abnormal cry, small head, wide-set
eyes, downward slant to the palpebral
fissure, severely cognitively challenged
Turner Syndrome (45XO) or Gonadal
Dysgenesis only 1 functional X chromosome
 short in stature
decreased with fetal chromosomal disorder like
Trisomy 21
Chorionic Villi Sampling- involves retrieval &
analysis of chorionic villi from the growing placenta for
chromosome or DNA analysis
Amniocentesis- withdrawal of AF through the
abdominal wall for analysis at the 14th to 16th week
Percutaneous Umbilical Blood Sampling- or
cordocentesis is the removal of fetal cord blood at
17weeks using amniocentesis methods
 males with extra X chromosome
 no development of secondary sex
characteristics during puberty; small testes
with ineffective sperm, gynecomastia,
increased risk for breast C
 most common cause of cognitive challenge in
malesX-linked -1 long arm of X chromosome
is defective
 before puberty, boys demonstrate
maladaptive behaviours like hyperactivity or
autism, reduced intellectual functioning with
marked deficits in speech & arithmetic
 large head, long face with high forehead,
prominent lower jaw, large, protruding ears,
hyperextensive joints, cardiac disorders
 after puberty, large testicles
 fertile
47XX21+) most frequently occurring chromosomal
abnormality (1 in 800 pregnancies)
 broad & flat nose
 eyelids have an extra fold of tissue at the
inner canthus (epicanthal fold)
 palpebral fissure tends to slant upward,
 iris may have white specks (Brushfield
spots)
  streak (small non-functional) ovaries,
sterile, & secondary sexcharacteristics
except for pubic hair, do not develop
during puberty
 hairline at the nape of the neck is low-
set
 neck is webbed & short,
 Newborn may have edema of the hands
& feet & anomalies lik Coarctation of the
Aorta & kidney disorders
 learning disabilities
 human growth hormone and estrogen
therapy may cause appearance of sex
characteristics
 tongue may protrude since the oral cavity is
small
 back of the head is flat
 poor muscle tone (rag-doll appearance) that
the toe can touch the nose
 fingers are short & thick and the little finger is
curved inward,
 wide space between the 1st & 2nd toes &
between the 1st & 2nd fingers, palm of hand
has a simian line
 cognitively-challenged to some degree (50-
70%)
 neck is short, extra pad of fat at the base of
the head causes the skin to be loose it can be
lifted easily (puppy’s neck)

MCN #5

Definitions Related to Providing Culturally Sensitive Nursing Care

A. Culture: a view of the world and a set of traditions a specific social group uses and transmits to
the next generation
B. Diversity in a population means there is a mixture or variety of sociodemographic groups,
experiences and beliefs in the population.
C. Transcultural nursing = is care guided by cultural aspects and respects individual differences
D. Culture-specific values = are norms and patterns of behavior unique to one particular culture.
E. Ethnicity =refers to the cultural group into which the person was born, although the term is
sometimes used in a narrower context to mean only race
F. Race = a social construct, refers to a category of people who share a socially recognized
physical characteristic, often skin color or facial features. It can also refer to a group of people
who share the same ancestry.
Nursing Process Overview for care That Respects Cultural Diversity
A. Assessment:
 Assessment of cultural diversity factors is important so care can be planned based on the
actual preferences of a family
 Assess patients as individuals, not as a group
CONTINUUM OF CULTURAL COMPETENCY

Stereotype-a widely held but fixed and oversimplified image or idea of a particular type of person or
thing.
Prejudice-preconceived opinion that is not based on reason or actual experience.
Discrimination-the unjust or prejudicial treatment of different categories of people or things, especially
on the grounds of race, age, or sex.
B. Nursing Diagnosis, Outcome Identification and Planning
Several nursing diagnoses speak to the consequences of ignoring cultural preferences in care, including:
 Powerlessness related to expectations of care not being respected
 Impaired verbal communication related to limited English proficiency
 Anxiety related to a cultural preference for not wanting to bathe while ill
  Imbalanced nutrition, less than daily requirements, related to unmet cultural food preferences.
 Fear related to possible ethnic discrimination

Examples of Nursing Diagnoses and

Outcomes Related to Cultural Diversity

Nursing Diagnosis Outcome

Impaired verbal communication related to limited
English proficiency
Anxiety related to a cultural preference for not
wanting to bathe while ill
Powerlessness related to expectations of care
not being respected
C. Outcome Identification and Planning
Family will be able to communicate their needs
accurately to their health care provider.
Anxiety related to woman’s cultural preference will be
decreased.
Feelings of powerlessness will be decreased.

 Planning needs to be very specific for

individual families because cultural
diversity preferences tend to be very
personal.
 Begin with in-service education for team
members who are unfamiliar with a
particular cultural practice and its
importance to a specific family involved.
 This type of planning can be beneficial
not only because it makes health care
more acceptable to families but also
because it can motivate providers to
examine policies and initiate more
diverse care.
D. Implementation

 Do NOT impose your cultural values on

others
E. Outcome Evaluation

 Evaluation should reveal that a family’s

diversity preferences have been
considered and respected during care

Understanding Sexual Orientation in Maternal and Child Health Nursing

Sexual Orientation and Gender Identity
Terminology for Nurses:
Sex- biological, based on reproductive organs;
may be male, female or intersex
Sex Role- biological, function or role which a
male or female assumes because of the basic
physiological or anatomical differences between items of clothing commonly associated with the
the sexes
Intersex- or hermaphrodite; a person who is born with
a reproductive or sexual anatomy that doesn’t fit the
typical female or male definitions.
Queer- An umbrella term for those who wish to not
categorize sex, sexuality or gender
Cross-dressing (Transvestism)- act of wearing
opposite sex within a particular society
.
Gender- MASCULINITY or FEMININITY; refers
to the social attributes and opportunities
associated with being male and female
Gender Identity- Gender identity refers to a
person’ s deeply felt internal and individual
experience of gender, which may or may not
correspond with the sex assigned at birth
Perception of self; lesbian, gay, bisexual,
transgender, queer, intersex, asexual
Heterosexual- a person who finds sexual
fulfillment with a member of the opposite sex.
Homosexual- someone who finds sexual
fulfillment with a member of his or her own sex
Gay- male-identified individuals who are
sexually attracted to male partners
Lesbian- female-identified individuals who are
sexually attracted to female partners.
Asexual- Someone who does not experience or
feel sexual attraction
SEX vs. GENDER
SEX
 Same in all societies
 Never change with history
 Can be performed by only one of the
sexes
 Biologically determined
SEX ROLE STEREOTYPES
MASCULINE
 Unemotional
 Very aggressive
 Very good at making decisions
 Independent
 Rough
 Blunt
MSM- men who have sex with men
WSW- women who have sex with women
Bisexual- an individual attracted to both men and
women.
Cisgender- when individuals feel that their gender
and their sex match
Transgender- when individuals feel that their gender
and their sex do not match
Gender expression- way in which a person acts to
communicate gender within a given culture; for
example, in terms of clothing, communication patterns
and interests
Stereotypes- a widely held but fixed and
oversimplified image or idea of a particular type of
person or thing
Sexuality- totality of being; the sum of a person's
sexual behaviors and tendencies, and the strength of
such tendencies; It begins at birth and last a life time
GENDER
 May differ from society to society
 Can change with history
 Can be performed by both sexes
 Socially, culturally determined
FEMININE
 Emotional
 Not aggressive
 Not good at making decisions
 Dependent
 Gentle
 Tactful
MCN #6
I. FERTILIZATION: THE BEGINNING OF
PREGNANCY
 It is the union of the ovum and a
spermatozoon, in the outer 3rd of the
fallopian tube, in the ampullar segment
 Ovum is capable of fertilization for 24h
(48h at the most)
 Sperm is functional for 48h up to 72h
 Critical time for sexual intercourse is
about 72h (48h before ovulation + 24h)
 Mature ovum is surrounded by the
ZONA PELLUCIDA (ring of
mucopolysaccharide fluid) and the
CORONA RADIATA (circle of cells);
both serve to increase the bulk of the
ovum and serve as buffers against
injury
 Mature ovum is extruded from the GF
during ovulation & propelled into the
fallopian tube by currents initiated by the
fimbriae
 Movements of the tube cilia and
peristaltic waves help propel the ovum
along the length of the tube.
 Ejaculation of 2.5 ml of semen contains
50 to 200M sperm
 During ovulation, cervical mucus is thin
making the sperm able to penetrate it
 Sperms reach the cervix within 80
seconds & the outer end of the fallopian
tube within 5 minutes after deposition.
(ORGASM)
 Sperm move by wavelike movement of
the flagella and uterine contractions
through the cervix, body of the uterus
into the fallopian tube toward the waiting
ovum (PHONONES/SONG OF THE
SPERM)
 CAPACITATION- changes in the
plasma membrane of the sperm head,
which reveal the sperm-binding receptor
sites
 All sperm that achieve capacitation
cluster around the ovum.
II. IMPLANTATION or NIDATION
 Implantation (NIDATION) or contact
between the blastocyst and the
endometrium occurs 8 to 10 days after
fertilization
 HYALURONIDASE (proteolytic enzyme) is
released by the sperm & dissolves the
protective CORONA RADIATA.
 The large number of sperms provide enough
enzymes to dissolve the corona cells
 Upon entry, cell membrane changes
composition to become impervious to other
sperm
 HYDATIDIFORM MOLE- multiple sperm enter
leading to abnormal growth
 After entry, chromosomal material fuse
forming a ZYGOTE
 X-sperm + X ovum = female (XX); Y-sperm +
X ovum = male (XY)
 Factors determining fertilization
o equal maturation of both sperm and
ovum
o ability of the sperm to reach the ovum
o ability of the sperm to penetrate the
zona pellucida and cell membrane
and achieve fertilization
 Mitosis, or CLEAVAGE or MITOSIS, begins
within 24 hours & continue at a rate of 1/22
hrs
 When the zygote reaches the body of the
uterus, it has 16 to 50 cells, is bumpy in
appearance (MORULA- Lat. Morus or
Mulberry)- DAY 3
 Morula multiplies and floats free in the uterine
cavity for 3 to 4 days
 Large cells tend to collect at the periphery of
the ball, leaving a fluid space surrounding an
inner cell mass and is termed a
BLASTOCYST which attaches to the
endometrium
 Parts of the Blastocyst: Trophoblast,
embryoblast (inner cell mass) and blastocyst
cavity
III. EMBRYONIC AND FETAL STRUCTURES
A. THE DECIDUA
 After fertilization, corpus luteum in the ovary
continue to function dt influence of HCG
secreted by the trophoblast cells
 ENDOCRINE Functions:
 PROLACTIN- promotes milk production
  After 3rd or 4th day of free-floating (8  PROSTAGLANDINS- potent, hormone-like
days since ovulation), the last residues fatty acid
of the corona radiata and zona pellucida  Endometrium continues to grow in thickness
are shed and vascularity & is termed DECIDUA (Lat.
3 Phases of Implantation: Falling off
 APPOSITION- blastocyst brushes
against the endometrium (secretory 3 PARTS OF THE DECIDUA
phase of MC) 1. DECIDUA BASALIS- lies directly under the embryo
 ADHESION- blastocyst attaches to the (or the portion where the trophoblast cells are
surface of the endometrium establishing communication with maternal blood
 INVASION- blastocyst settles down into vessels)
the soft folds of the endometrium 2. DECIDUA CAPSULARIS- portion that stretches or
receiving nourishment of glycogen, encapsulates the surface of the trophoblast
mucoprotein from the endometrial 3. DECIDUA VERA- the remaining portion of the
glands uterine lining
 As the embryo grows, it pushes the D.
 Invasion is possible since trophoblast Capsularis before it like a blanket & later, as it
cells produce proteolytic enzymes. enlarges, comes into contact and fuses with
 As invasion continues it establishes an the opposite uterine wall.
effective communication network with
the blood system of the endometrium
 Implantation is usually high in the
uterus, at the posterior portion
 Occasionally, vaginal spotting occurs
with implantation because capillaries
are ruptured by the implanting cells
 Once implanted, zygote is an EMBRYO
B. THE CHORIONIC VILLI
 Trophoblastic layer of blastocyst matures rapidly & on the 11th to 12th day, miniature villi or
probing fingers called CHORIONIC VILLI reach out into the endometrium
 At term, almost 200 villi have formed
 Chorionic villi have a center core of loose connective tissue surrounded by a double layer of
trophoblast cells
 Central core of chorionic villi contains fetal capillaries.
 Outer portion has 2 layers: syncytiotrophoblast & cytotrophoblast

 SYNCYTIOTROPHOBLAST- outer layer or syncytial layer

o produce HCG, somatomammotropin (human placental lactogen) hormone, estrogen &
progesterone
 CYTOTROPHOBLAST or LANGHANS LAYER- inner layer, present at 12 days gestation
o protection from infections of spirochetes of syphilis
o this layer disappears between the 20th & 24th week

C. THE PLACENTA- Lat. For pancake 2. FUNCTIONS OF THE PLACENTA

 Arises from the trophoblast tissue
 Serves as fetal lungs, kidneys, GIT, a
separate endocrine organ throughout
the pregnancy
 15 to 20 cm in diameter & 2 to 3 cm in
depth at term, covering about half the
surface area of theinternal uterus
a. Endocrine Function
HUMAN CHORIONIC GONADOTROPIN
 1ST hormone,
 food in blood & urine as early as 1st missed
MP (shortly after implantation) through 100th
day of pregnancy
1. Fetal Circulation
o 12th day of gestation- maternal blood
begins to collect at the intervillous
spaces of the uterine endometrium
surrounding the chorionic villi
o 3rd week- O2 and nutrients like
glucose, amino acids, fatty acids,
minerals, vitamins & water diffuse from
the maternal blood through the layers of
the chorionic villi to the capillaries and
are transported to the developing
embryo
 Mature placenta has 30 segments
called COTYLEDONS which makes the
maternal side appear rough & uneven
 BRAXTON HICKS contractions, barely
noticeable, aid in maintaining pressure
in the intervillous spaces by closing off
the veins during contraction
 UTERINE PERFUSION and placental
circulation are efficient when the woman
lies on her left side lifting the uterus
away from the inferior vena cava,
preventing blood from being trapped in
her lower extremities
D. THE UMBILICAL CORD
 Arising from the chorion & amnion, it provides a circulatory pathway that connects the embryo to
the CV of the placenta
 Function: transport O2 & nutrients to the fetus from the placenta & to return waste products to
the placenta
 55 cm (21 in) long at term & 2 cm (3/4 in) thick
 WHARTON’S JELLY- gelatinous mucopolysaccharide which gives the cord body & prevents
pressure on the blood volume
 (-) for HCG within 1 to 2 weeks after birth
Functions of HCG:
 ensure that corpus luteum continues to
produce E/P
 suppresses maternal immunologic response
to prevent rejection of placental tissue
 structure of HCG is similar to LH so if fetus is
male, it influences testes to produce
testosterone
 8th week- outer layer of placenta begins to
produce P so CL is no longer needed and
HCG levels decrease
ESTROGEN
 2nd product of syncytial cells of placenta
 contributes to mammary gland development
 stimulates uterine growth to accommodate
growing fetus
PROGESTERONE
 Maintains endometrial lining; present in serum
by 4th week due to corpus luteum
 after placental synthesis (12th week),
PROGESTERONE rises progressively
 reduce contractility of uterine muscles
preventing premature labor
HUMAN PLACENTAL LACTOGEN (HUMAN
CHORIONIC SOMATOMAMMOTROPIN)
 growth-promoting and lactogenic (milk-
producing)
 produced by the placenta at 6th week, peaking
at term
 present in maternal serum & urine
 promotes mammary gland growth
 regulates maternal glucose, protein & fat
levels so that adequate amounts re always
available to the fetus
E. THE PLACENTAL MEMBRANES
1. THE AMNIOTIC MEMBRANE
 Chorionic Villi on the medial surface of
the trophoblast (those not involved in
implantation since they don’t touch the
endometrium) gradually become thin,
making the surface smooth (chorion
leave or smooth chorion)
 Smooth chorion becomes the
CHORIONIC MEMBRANE (outermost
fetal membrane) which supports the sac
that contains amniotic fluid and the inner
layer becomes the AMNIOTIC
MEMBRANE or AMNION
 2nd membrane lining the chorionic
membrane forms beneath the chorion
 Covers the fetal surface making it
typically shiny
 Functions of Amniotic Membrane:
o supports and produces amniotic
fluid,
o produces phospholipids that
initiate formation of
prostaglandins that initiate labor
by producing contractions
IV. ORIGIN AND DEVELOPMENT OF ORGAN
SYSTEMS
 STEM CELLS
 1ST 4 days of life- TOTIPOTENT STEM
CELLS- so undifferentiated they have
the potential to form a complete human
being
 Next 4 days, cells begin to differentiate
& slated to become specific body cells-
PLURIPOTENT STEM CELLS
 Next few days, MULTIPOTENT CELLS-
highly specific
 PRIMARY GERM LAYERS
 At implantation, blastocyst has
differentiated with 2 separate cavities
appear in the inner structure:
o 1.) a large one, AMNIOTIC
CAVITY, which is lined with the
ECTODERM
o 2.) smaller cavity, the YOLK
SAC, lined with ENTODERM
CELLS
 YOLK SAC- supply nourishment only
until implantation after which
THE AMNIOTIC FLUID
 Fetus continually swallows AF, from the
intestine, enters the bloodstream then to the
umbilical arteries to the placenta
 Volume at term: 800 to 1200 ml
 Slightly alkaline: pH 7.2
 If unable to swallow (esophageal atresia or
 anencephaly), HYDRAMNIOS occurs (> 2000
ml or pockets of fluid >8 cm on UTZ
OLIGOHYDRAMNIOS- reduction in the amount of AF
(< 300 ml or no pocket o UTZ > 1 cm) may be due to
kidney disturbance
Functions of Amniotic Fluid:
 shields fetus from pressure or blow to the
abdomen
 Regulates temperature
 Aids in muscular development since it allows
fetus to move freely
 Protects umbilical cord from pressure thus
protecting the fetal O2 supply
ECTODERM
 CNS (brain & spinal cord)
 Peripheral Nervous System
 Skin, hair, nails
 Sebaceous glands
 Sense organs
 Mucous membranes of anus, mouth & nose
 Tooth enamel
 Mammary glands
MESODERM
 Supporting structures (connective tissue,
bones, cartilage, muscle, ligaments and
tendons)
 Dentin of the teeth
 Upper portion of the urinary system (kidneys
& ureters)
 Reproductive system
 Heart
 Circulatory System
 Blood cells
 Lymph vessels
  it serves as a source of RBCs until the ENTODERM
hematopoietic system is mature enough  Lining of pericardial, pleural & peritoneal
to take over; then it atrophies leaving cavities
only a thin white streak discernible in  Lining of the Gastrointestinal tract, respiratory
the cord at birth tract, tonsils, parathyroid,
 Between the amniotic cavity & the yolk  Thyroid, thymus glands
sac a 3rd layer of primary cells, the  Lower urinary system (bladder & urethra)
MESODERM, forms.
 Development continues until the 3 germ
layers meet at a point called
EMBRYONIC SHIELD
 Each germ layer develops into specific
body systems

MCN #7

I. PSYCHOLOGICAL CHANGES OF PREGNANCY

A. PSYCHOLOGICAL TASKS OF 3RD TRIMESTER: PREPARING FOR
PREGNANCY- REVA RUBIN PARENTHOOD- “I am going to be a mother.”
 Nest building- interested in attending
1ST TRIMESTER: ACCEPTING THE prenatal and childbirth classes
PREGNANCY- “I am pregnant.”
 Task: accept the reality of the EMOTIONAL RESPONSES TO PREGNANCY
pregnancy 1.AMBIVALENCE
 Maladaptation: DENIAL 2.GRIEF
 Initially, she feels ambivalence- a 3.NARCISSISM
combination of pleasure and anxiety 4.INTROVERSION VS. EXTROVERSION
 Sonogram- seeing the fetal outline on 5.BODY IMAGE & BOUNDARY
screen may promote acceptance 6.STRESS
7.COUVADE SYNDROME
2 TRIMESTER: ACCEPTING THE BABY- “I
nd 8.EMOTIONAL LABILITY
am going to have a baby!” 9.CHANGES IN SEXUAL DESIRE
 Task: accepting the reality of having 10. CHANGES IN THE EXPECTANT FAMILY
a baby, a separate task from accepting
the pregnancy
 Quickening- 1st moment the woman
feels fetal movement; proof of the child’s
existence
 Mother starts to imagine, role- play,
fantasize
 Mother starts to believe that not only is
she pregnant but there is a child inside
her
 A good way to measure acceptance is
how well she follows prenatal
instructions
 II. PHYSIOLOGIC CHANGES OF PREGNANCY
A. DIAGNOSIS OF PREGNANCY
1. PRESUMPTIVE Signs of Pregnancy 2. PROBABLE SIGNS
 Least indicative of pregnancy &  Can be documented by the examiner
individually may be symptoms of other  Objective
conditions  More reliable than presumptive signs but still
 Subjective are not positive or true diagnostic findings

 Amenorrhea  Uterine enlargement

 Nausea and vomiting  Goodell’s Sign: softening of cervix
 Breast changes: tingling, darkening,  Hegar’s Sign: softening of lower uterine
enlargement segment (isthmus)- compressibility of uterus
 Urinary frequency  Chadwick’s Sign: bluish discoloration of
 Fatigue- due to increase in Estrogen cervix, vagina and perineum
 Skin changes: chloasma  McDonald’s Sign: ease in flexing the body
linea nigra of the uterus against the cervix
striae gravidarum  Braxton-Hicks contractions- painless and
 Diaphoresis irregular, relieved by walking
 Leukorrhea- whitish, mucoid, due to  Ballottement: fetal rebound against
increase in Estrogen examination
 Weight gain  Positive pregnancy test: HCG
 Quickening-Fluttering sensation,
mother’s perception of fetal movement
18-20th week for primipara
14-16th week for the multipara
3. POSITIVE SIGNS
 Fetal parts on palpation by examiner
 Fetal skeleton on X-ray (safe from 16 weeks)
 Fetal outline on ultrasonography
 Fetal Heart Tone is audible
 Normal range: 120 – 160 per minute
 FUNIC souffle- sound of blood in the cord
 Uterine souffle- NOT a diagnostic sign
Presumptive Finding Probable Finding Description
Serum laboratory tests Tests of blood serum reveal HCG
Breast Changes Feeling of tenderness, fullness, or
tingling; enlargement and
darkening of areola
Nausea, vomiting Nausea or vomiting on arising
Amenorrhea Absence of menstruation
Frequent urination Sense of having to void frequently
Chadwick’s sign Color change of the vagina from
pink to violet
Goodell’s sign Softening of the cervix
Fatigue General feeling of tiredness
Uterine enlargement Uterus can be palpated over
symphysis pubis
Ballottement When lower uterine segment is
tapped on a bimanual examination,
the fetus can be felt to rise against
abdominal wall
Quickening Fetal movement felt by woman
Braxton Hicks contractions Periodic uterine tightening occurs
Fetal outline felt by examiner Fetal outline can be palpated
through abdomen
Linea nigra Line of dark pigment on abdomen
Melasma Dark pigment on face
Striae gravidarum Red streaks on abdomen

B. REPRODUCTIVE SYSTEM CHANGES

1. UTERINE CHANGES
 Pre-pregnancy (pear), 8 weeks
(spherical), 16 weeks to term(ovoid)
 Volume of the uterus increases from 2 ml
to > 1,000 ml. Uterus can hold a 7-lb
(3,175 g) fetus plus 1,000 ml of AF
totaling 4,000g
 12th week: palpated as a firm globe
under the abdominal wall, under the
symphysis pubis
 20th to 22nd week: palpated at the
level of the umbilicus
 36th week: it should touch the xiphoid
process making breathing difficult
 38th week (2 weeks before term) for a
primigravida, fetal head settles into the
pelvis, uterus returns to its height at 36  Vital capacity (max volume exhaled after
weeks (LIGHTENING)
 Uterus is pushed slightly to the right
because of the bulk of the sigmoid colon
on the left
 Toward the end of the pregnancy, 1/6th
of the total body blood supply is
circulating through the uterus
 Uterus is pushed slightly to the right
because of the bulk of the sigmoid colon
on the left
 Toward the end of the pregnancy, 1/6th
of the total body blood supply is
circulating through the uterus
 BRAXTON HICKS CONTRACTIONS-
“practice” contractions felt by the 12th week;
probable sign
 Amenorrhea
 Endocervical glands undergo hypertrophy &
hyperplasia & distend with mucus forming a
MUCUS PLUG (OPERCULUM) to seal out
bacteria
 GOODELL’S SIGN- softening of the cervix;
just before birth, as soft as butter (RIPE for
birth)
 Consistency of non-pregnant uterus: like the
tip of the nose; pregnant uterus: like the
earlobe
 STUFFINESS- nasal congestion due to
increased E levels
max inspiration) does not decrease since the
lungs can still expand horizontally
 Slight increase in pH of maternal serum
increases binding capacity of maternal Hb
increasing O2 content of maternal blood
 RR increases slightly- 18 to 20 breaths
per minute
 TEMPERATURE
 PROGESTERONE increases temperature
slightly early in the pregnancy due to corpus
luteum activity
 As placenta takes over at 16 weeks, the
temperature decreases to normal
2. CARDIOVASCULAR SYSTEM
Blood Volume
 Increases by 30 to 50% for adequate
exchange of nutrients in the placenta &
to compensate for blood loss at birth
 Blood loss at a normal vaginal birth =
300 to 400ml
 Blood loss from CS = 800 to 1000 ml
 Increase begins at the end of the 1st
trimester & peaks at 28th to 32nd week
until term
 PSEUDOANEMIA- plasma volume
increases faster than RBC volume;
woman’s body compensates by
producing more RBC’s making levels
near-normal by the 2nd semester
3. GASTROINTESTINAL SYSTEM
 Growing uterus pushes stomach &
intestine to the sides and back slowing
peristalsis & emptying time of stomach
(leading to heartburn, constipation &
flatulence)
 RELAXIN produced by the ovary
decrease gastric motility; helpful because
it slows down blood flow to the GIT &
increases flow to the uterus
 PROGESTERONE makes smooth
muscles less active
 50% suffer from nausea (1 of 1st
symptoms) apparent early in the
morning, more frequent in smokers
 Morning sickness is noticed as hCG & P
levels rise; systemic reaction to
increased E levels or decreased glucose
levels because glucose is used by the
growing fetus
 subsides after 3 months
 Hyperptyalism- increased saliva
formation
Peripheral Blood Flow
 3rd trimester- bloodflow to the lower
extremities is impaired by the pressure of the
expanding uterus on veins & arteries
 It leads to edema & varicosities of the vulva,
rectum & legs
Supine Hypotensive Syndrome
 In supine position, the weight of the growing
uterus presses the vena cava against the
vertebra
 It causes decrease return of bloodflow to the
heart, & decreased cardiac output &
hypotension (causes fetal hypoxia)
 Symptoms: lightheadedness, faintness,
palpitations
 Best position: Left side-lying
Blood constitution
 Fibrinogen levels= increase as much as
50% (due to E)
 Clotting factors VII, VIII, IX, X increase
 Platelet count also increases
 Safeguard against major bleeding should the
placenta be dislodged & uterine arteries
opened
 Total WBC count increased as protection &
reflection of TBV (up to 20,000/mm3)
4. URINARY SYSTEM
 Alterations in fluid retention & alterations in
the renal, ureter & bladder function
 Due to: effects of high P & E levels
 Compression of bladder & ureters by
the growing uterus
 Increased blood volume
 Postural influences
Fluid Retention
 Total body H2O increases to 7.5L
 Increased P leads to increased response of
the angiotensin-renin system in the kidney,
leading to increased aldosterone production
 H2O is retained during pregnancy to aid in
increase of blood volume & to serve as a
ready source of nutrition to the fetus & the
excess fluid can serve to replenish the
mother’s own blood volume in case of
hemorrhage
 Na-restricted diet is harmful

5. SKELETAL SYSTEM
 Ca & Phosphorus needs are increased
for fetal skeletal formation
 Leg cramps- milk up to 1 pint/day and
increase Ca intake
 Gradual softening & pliability of the
woman’s pelvic ligaments & joints to
facilitate passage through the pelvis
 Softening is caused by the ovarian
hormone, RELAXIN & placental P
 Excessive mobility of the joints causes
discomfort
 Wide separation of symphysis pubis (by
3 yo 4 mm at 32 wks) causing the “pride
of pregnancy” stance which creates
lordosis (waddling gait)- use low-heeled
shoes
 Increase in shoe size is permanent
 Placenta
 Produces large amounts of
Progesterone, Estrogen, hCG, Human
Placental Lactogen, Relaxin &
Prostaglandins
 Estrogen causes breast & uterine
enlargement, palmar erythema
 Progesterone maintains the
endometrium, inhibits uterine contractility
and aids in breast development for
lactation
 Relaxin is secreted primarily by the
corpus luteum inhibits uterine activity,
softens cervix and collagen in the joints
Renal Function
 Woman’s kidneys excrete own waste and the
waste of the fetus
 Kidneys must also be able to excrete
additional fluids & manage the demands of
increased renal blood flow
 Kidneys increase in size
 Urine output gradually increases (60% to
80%)
 Specific gravity decreases
Urine & Bladder Function
 1st 3 months of pregnancy- increase in
urinary frequency,
 Frequency of urination returns at the end
of pregnancy, as lightening occurs
6. ADRENAL GLANDS
 Increased adrenal activity increases levels of
CORTICOSTEROID & ALDOSTERONE
 Suppresses inflammatory reaction, prevents
rejection of the fetus, regulates glucose
metabolism in the woman
7. PANCREAS
 Increases insulin production but insulin is
less effective because Estrogen,
Progesterone, & Human Placental Lactogen
are all antagonists to
insulin; more insulin is required by the
diabetic woman during pregnancy
 Glucose level of fetus is 30 mg/100ml lower
than maternal glucose level so to prevent
fetal hypoglycemia, maternal glucose is
higher than normal
 diet must be high in calories & should not go
longer than 12 hours between meals
 FBS in early pregnancy is usually low (80 to
85 mg/100 ml) because the rapidly growing
fetus uses so much glucose
8. IMMUNE SYSTEM
 Immunologic competency during
pregnancy is low to prevent the woman’s
body from rejecting the fetus
 IgG is particularly decreased making the
woman prone to infection.
 WBC count increases to help counteract
the decrease in IgG response
VISITS
 Months 1-7 = monthly
 Months 8-9 = 2X/month
 10 months = weekly
 Postterm= 2X/week
Marital Relations/Coitus
 1st trimester: less interest due to fatigue, N/V
 2nd trimester: increase interest in sex
 3rd trimester: less interest due to discomfort
 Generally, no restrictions except in: PROM,
PTL, History of abortion/bleeding, deeply
engaged head, incompetent cervix

9. PITUITARY GLAND
 No production of FSH & LH due to high levels
of E & P from the placenta
 Increased production of GROWTH
HORMONE & MELANOCYTE-STIMULATING
HORMONE (causing skin pigment changes)
 Later, Posterior Pituitary Gland produces
OXYTOCIN needed for labor
 PROLACTIN is produced later to prepare for
lactation
I. COMMON DISCOMFORTS and RELIEF MEASURES
DISCOMFORT RELIEF MEASURES
Morning Sickness  Eat dry crackers/CHO 30 mins before getting up
 Drink adequate fluids between meals
 Avoid spicy, oily, high-seasoned foods
Heartburn  Bend at the knees NOT at the waist when picking things up from the
floor
 Remain upright 3-4 hrs after eating
 Avoid taking sodium bicarbonate
 Take Aluminum-bearing antacids (Amphojel) as ordered
Flatulence  Eat small, frequent meals
 Avoid gas-forming foods
Frequency of  Increase fluids except at bedtime to prevent nocturia
Urination  Practice regular voiding
 Practice frequent flushing: “front to back”
 Report any burning sensation, dysuria, cloudy urine, or tea-colored urine
Fatigue  Adequate rest & sleep (8 hrs ave. at night)
 Avoid prolonged standing
 Practice good body mechanics
 Report increasing fatigue w/ regular activities- a danger sign of heart
disease
Constipation  Increase fluid intake (6-8 glasses of H2O/day)
 Increase roughage in the diet (daily fruits & vegetables
 Regular exercise (best is walking)
 Observe daily/regular bowel movement
 Drink warm water in the morning
Hemorrhoids  Avoid constipation and other forms of straining
 Promote comfort: Sitz bath, warm compresses
 Reinsert hemorrhoids
Faintness/Supine  Avoid sudden changes in position
Hypotensive  Avoid supine position in 2nd to 3rd trimesters
Syndrome/Vena  Arise from a bed from a lateral position and gradually
Caval Syndrome  Avoid staying in one position for a long time
 Assume frequent left lateral positions in bed.
Leg cramps  Include adequate Ca in the diet; Calcium-phosphorus imbalance is the
usual cause of cramps in early pregnancy
 Avoid prolonged standing and sitting
 Dorsiflex the foot while extending the leg; this hyperextends the
involved muscle causing relief
Varicose veins  No round garters around the abdomen and legs; avoid knee-high
stockings.
 Wear supportive pantyhose
 Frequent elevation of legs and hips
Backache  Maintain good posture
 Weal flat shoes with non-slip soles
 Avoid prolonged standing
 Pelvic rock exercise & tailor sitting are advised
 Use supportive mattress
 Wear maternity girdle in selected situations as recommended
Pedal Edema  Assume left-lateral position/elevation of legs frequently to promote
venous return
 Avid prolonged standing
 No round/constricting garters
 Report swelling of hands and face
Shortness of breath  Maintain good posture
 Avoid fatigue
 Elevate head by several pillows in sleep, avoid supine position
 Avoid constricting bra and other tight clothes
 Report increasing dyspnea with minimal activity or dyspnea prior to 36
weeks (with normal pressure on diaphragm)
II. DANGER SIGNS OF PREGNANCY
Vaginal Bleeding Sudden Escape of Clear Fluid from the Vagina
 Report vaginal bleeding or spotting no  It may indicate rupture of membranes
matter how slight (PROM) and release of amniotic fluid
 Sudden gush of blood- possible PROM  Risk for infection since the uterine cavity
is no longer sealed
Persistent Vomiting/ HYPEREMESIS  If fetus is small & the head does not fit
GRAVIDARUM snugly into the cervix, the umbilical cord
 Once or twice a day of vomiting is common may prolapse. If the cord is compressed
& expected by the fetal head, O2 is compromised &
 Vomiting past the 12th week or vomiting fetus is in immediate danger
frequently is classified as extended or  It may be confused for stress
persistent vomiting incontinence; vaginal examination is done
 It depletes the nutritional supply available to to make sure the membranes are intact
the fetus & endangers the pregnancy
Chills and Fever
 May indicate intrauterine infection, which is
serious for both mother & fetus
 May also be symptoms of relatively benign
gastroenteritis
 Further evaluation is necessary
Pregnancy-Induced Hypertension (PIH)
Abdominal or Chest Pain
 Abdominal pain at any time is a signal
that something is wrong & must be
reported at once
 Possible problems of abdominal pain:
ectopic pregnancy, separation of the
placenta, preterm labor, appendicitis,
ulcer, pancreatitis
 Possible causes of Chest pain: pulmonary
embolism, following thrombophlebitis
 Boardlike, rigid abdomen- possible
Abruptio placentae

Symptoms of developing PIH:

 Rapid weight gain (over 2 lbs/wk in the 2nd trimester, 1 lb/wk in the 3rd trimester)
 Swelling of the face (difficulty opening the eyes in the morning due to swollen eyelids) or fingers
(rings are too tight)
 Flashes of light or dots before the eyes (blind spots or scotomas)- cerebral edema or acute HPN
 Dimness or blurring of vision- cerebral edema or acute HPN
 Severe, continuous headache- cerebral edema or acute HPN
 Decreased urine output

Increase or decrease in fetal Movement
 Sign that the fetus lacks O2
III. PREPARING FOR LABOR
LIGHTENING RUPTURE OF THE MEMBRANES
 It is the settling of the fetal head into the  Sudden gush of clear fluid (amniotic fluid)
inlet of the true pelvis from the vagina indicates rupture of the
 It occurs approximately 2 weeks before membranes
labor in primiparas but is unpredictable in  Notify primary care provider immediately
multiparas  Dangers: cord prolapse & uterine infection
 Woman is relieved of shortness of breath
 Increase in frequency of urination or sciatic EXCESS ENERGY
pain (pain across her buttock radiating down  The sudden burst of energy is a
her leg) from the lowered fetal position physiologic preparation for labor & the
SHOW woman must rest to conserve her energy
 It is the common term used to describe the in preparation for the actual labor
release of the cervical plug (OPERCULUM)
that formed during pregnancy UTERINE CONTRACTIONS
 It consists of a mucous, often blood-  True labor starts in the back & sweep
streaked vaginal discharge & indicates the forward across the abdomen like the
beginning of cervical dilatation tightening of a band
 They gradually increase in intensity and
frequency
MCN #8
Assessment of Fetal Growth and Development
NURSING RESPONSIBILITIES
 Signed consent form
 Scheduling of procedure
 Explaining the procedure
 Preparing the woman
 Providing support during the procedure
 Providing necessary follow-up care
 Managing equipment & specimens
FETAL HEART RATE
 FHR = 120 to 160 bpm
1. Rhythm Strip Testing- test for good baseline
rate & presence of long- and short-term
variability
- Semi-Fowler’s position to prevent supine
hypotension & for comfort
- external fetal heart rate & uterine contraction
monitors are attached abdominally
- Tocotransducer over fundus-measures
contractions & fetal movement
- Ultrasound transducer over abdominal site where
FHR is distinct
- Mother remains in a fairly fixed position for 20 min after movement within the chosen time period
- FHR is recorded for 20 minutes
- short-term variability (beat-to-beat variability)-
small changes in rate from second to second if fetal
Parasympathetic NS receives adequate O2 &
nutrients
- long-term variability- differences in heart rate
over the 20-minute period
ASSESSING FETAL WELL-BEING
Fetal Movement- Daily Fetal Movement
Counting
 Quickening (felt by the mother) at 18 to
20 weeks & peaks at 28 to 38 weeks
 Healthy fetus moves with consistency or
at least 10 x a day
 Mom lies on left recumbent position after
a meal & record the # of fetal movements
in 1 hour (SANDOVSKY METHOD);
minimum 2x/10 min or average of10 to 12
times/hour
 If < 10 movements per hour, repeat test
for next hour; If (10 for the 2 hours, notify
MD)
 COUNT-TO-TEN (CARDIFF
METHOD/FETAL KICK COUNT))- mom
records time interval it takes to feel 10
movements (usually within 60 seconds)
 Done at the same time daily, preferably
after breakfast (most active), lie on left
side after stimulating activity like walking
 Warning: > 1 hour for 10 FM or < 10 FM
in 12 hours
 Alarm: weaker movements, < 3 FM in 12
hours
2. NON-STRESS TESTING (NST)- measures the
response of the FHR to fetal movement
-woman is positioned and monitors are attached
just like the rhythm strip test
- she pushes a mark button attached to the
monitor (similar to the call bell) whenever she
feels the fetus move. A dark line marks the paper
tracings at this point
- with fetal movement, FHR increases 15 bpm &
remain elevated for 15 seconds
- NST done for 10 to 20 minutes
- REACTIVE (NORMAL)- 2 accelerations of FHR
(by 15 beats or more) lasting for 15 seconds occur
- NONREACTIVE- no accelerations with the fetal
movement, no movement, low short-term FHR
variability (< 6 bpm) throughout the testing period
3. VIBROACOUSTIC STIMULATION
 A specially-designed acoustic stimulator is
applied to the mother’s abdomen to produce
a sharp sound 80 decibels at a frequency of
80 Hz, startling & waking the fetus
 in a NST with no acceleration within 5 min, a
single 1- to 2-second sound stimulation is
applied to the lower abdomen (may be
repeated at the end of 10 min if no
movement so that 2 movements within the
20- minute period could be evaluated)
5. ULTRASONOGRAPHY PURPOSES
 diagnose a pregnancy
 Confirm presence, location, size of placenta
& Amniotic fluid
 Establish fetal growth & r/o abnormalities
 Establish sex
 Establish presentation & position of fetus
 Predict maturity via the measurement of
biparietal diameter of the head
 Discover complications of pregnancy
Ask mom to drink a full glass of H20 q 15 minutes
beginning 90 mins before the procedure & should
not void before the procedure
7. HAASE’S RULE
- determines length of fetus in cm
- 1st half (1-5 months) = month2
- 2nd half = month X 5
9. PLACENTAL GRADING
- based on the amount of Ca deposits in the
base of the placenta, via UTZ
-0 = placenta 12 to 24 weeks
-1 = 30 to 32 weeks
-2 = 36 weeks
-3 = 38 weeks and fetal lungs are
mature
4. CONTRACTION STRESS TESTING
 FHR is analyzed in conjunction with
contractions (achieved by nipple
stimulation to release oxytocin)
 baseline FHR is obtained then woman
rolls nipple until contraction begins,
recorded by a uterine monitor
 -3 contractions lasting for 40 sec or more
in a 10-minute window
3 TYPES OF DECELERATIONS
Early deceleration-begins on or after onset of
contraction & ends when contraction ends; due to
head compression during labor
Late deceleration- begin after onset & peak of
UC & ends after contraction; due to uteroplacental
insufficiency
Variable deceleration- u, w or v shape, unrelated
to contraction; due to cord compression
6. BIPARIETAL DIAMETER
- Side-to-side measurement of the fetal
head via ultrasound
- usually, if it is 8.5 cm or greater, infant will
weigh more than 2500 g (5.5 lbs)
- Biparietal Diameter of 8.5 cm indicates
fetal age of 40 weeks
- head circumference (34.5 cm indicates
40-week fetus)
- Femoral length
8. DOPPLER UMBILICAL VELOCIMETRY
- Measures velocity at which RBCs in the
Blood volume are flowing
- helps determine vascular resistance in
women with Diabetes Mellitus and
Hypertension of pregnancy and whether
placental insufficiency occurred
10. AMNIOTIC FLUID ASSESSMENT
- decrease in amniotic fluid, risk of cord
compression
- AMNIOTIC VOLUME INDEX = sum of 2
measurements
- Normal AFI- 12 to 15 cm between 28 to
40 weeks
11. ELECTROCARDIOGRAPHY
- May be recorded as early as 11th week of
pregnancy
12. MAGNETIC RESONANCE IMAGING
- NO harmful effects to the fetus
- To diagnose complications like ectopic
pregnancy
13. TRIPLE SCREENING (15-20 weeks)
- analysis of 3 indicators (MSAFP,
unconjugated estriol, and hCG)
- requires only venipuncture of the mother
- Quadruple screening- includes INHIBIN
determination
MCN #9
I. MILESTONES OF FETAL GROWTH AND DEVELOPMENT
 Ovulation age- measured from the time of
ovulation
 Length of pregnancy- from 1st day of the
last menstrual period (LMP) is the
gestational age
 Ovulation & fertilization takes place about 2
weeks after LMP so ovulation age of fetus is
always 2 weeks less than the length of
pregnancy or gestational age
 Ovulation age & gestational age are
measured in lunar months (4-week periods)
or trimesters (3-month periods)
 Pregnancy- 10 lunar months (40 weeks or
280 days)
 Fetus grows in utero for 9.5 lunar months or
3 full trimesters (38 weeks or 266 days)
END OF 16TH GESTATIONAL WEEK
 Length: 38 to 43 cm
 Weight: 1,600 g
 Subcutaneous fat begins to be deposited
(the former stringy, “little old man”
appearance is lost)
 Fetus responds by movement to sounds
outside mother’s body
 Active Moro Reflex
 Birth position (breech or vertex) is assumed
 Iron stores beginning to be developed
 Fingernails grow to reach end of fingertips
13. MATERNAL SERUM ALPHA FETOPROTEIN
(MSAFP)
- Alpha-Fetoprotein is produced by the liver
& present in amniotic fluid and maternal
serum
- high in open spinal or abdominal defect
because open defect allows more AFP to
appear
- low in Down’s syndrome
- levels begin to rise at 11 weeks and
steadily increase until term
- assessed in the 15th week
14. CHORIONIC VILLI SAMPLING
- biopsy & chromosomal analysis of CV
done at 10 to 12 weeks of pregnancy
- Coelocentesis (transvaginal aspiration of
fluid from the extraembryonic cavity) is an
alternative method to remove cells for
fetal analysis
END OF 4TH GESTATIONAL WEEK
 Length: 0.75 to 1 cm
 Weight: 400 mg
 Spinal cord formed & fused at midpoint
 Lateral wings forming body are folded
forward to fuse at midline
 Head folds forward, prominent, 1/3 of
entire structure
 Back is bent so head almost touches tip
of tail
 Rudimentary heart bulges on anterior
surface
 Arm and leg buds
 Rudimentary eyes, ears, nose are
discernible
END OF 36TH GESTATIONAL WEEK
 Length: 42 TO 48 CM
 Weight: 1,800 to 2,700 g (5 to 6 lbs)
 Body stores of glycogen, iron,
carbohydrates & calcium are deposited
 Additional amount of subcutaneous fat is
deposited
 Sole of foot has only 1 or 2 crisscross
creases (full crisscross pattern at term)
 Lanugo begins to diminish
 Most babies turn into a vertex or head-
down position during this month
END OF 40TH GESTATIONAL WEEK (3RD TRIMESTER)
 Length: 48 TO 52 CM (CROWN TO RUMP, 35 to 37 cm)
 Weight: 3,000 g (7 to 7.5 lbs)
 Fetus kicks actively, causing discomfort
 Fetal hemoglobin begins conversion to adult hemoglobin
 Vernix caseosa is fully formed
 Fingernails extend over fingertips
 Creases on foot soles cover at least 2/3 of surface

*In primiparas, fetus sinks into the birth canal during the last 2 weeks, giving the mother a feeling that the
load she is carrying is less (LIGHTENING), an announcement that the third trimester has ended and birth
is at hand
II. FETOPLACENTAL CIRCULATION
A. Shunts or Bypasses
 Foramen ovale- between R atrium & L atrium
 Ductus venosus- bypasses the liver
 Ductus arteriosus- bypasses the lungs
 Umbilical Vein- carries oxygenated blood & nutrients to fetus
 Umbilical arteries- carries Carbon dioxide and other wastes from fetus to maternal circulation
 *Pressure is higher on the R side of the heart before birth

MCN #10

TERATOGEN- any factor, chemical or physical TERATOGENIC MATERNAL INFECTIONS

that adversely affects the fertilized ovum,
embryo or fetus
Requirements for optimal health
 sound genes
 healthy intrauterine environment
 Strength of the teratogen
TORCH INFECTIONS
Timing of the insult:
- before implantation, zygote is destroyed or
unaffected
- during organogenesis very vulnerable
3rd trimester, the harm decreases
 Teratogen’s affinity for specific tissues
 2 exceptions to the rule: syphilis & TORCH SCREEN
 toxoplasmosis affect fetus throughout the
pregnancy
 lead has affinity for nervous tissues,
thalidomide causes limb defects,
tetracycline causes tooth enamel & bone
deformities
 Involves STI or systemic infections
 Viral, bacterial or protozoan
 Most cause relatively mild, flulike
symptoms in a woman but have much
more serious effects on a fetus or a
newborn
 Toxoplasmosis,
 Other infections like syphilis, hepatitis B
virus, & HIV
 Rubella,
 Cytomegalovirus,
 Herpes simplex virus
 immunologic tests on the pregnant
woman (to identify fetal risk factors) & on
the newborn (to detect if antibodies vs the
teratogens are present)
 Result: negative=normal
 If positive for IgM abs, recent or current
infection
 If positive for IgG, maternal abs crossed
placenta
 A. TOXOPLASMOSIS
Toxoplasmosis in Infants
 CNS damage,
 hydrocephalus,
 microcephaly,
 intracerebral calcification,
 retinal deformities

MEDICATIONS
 SULFONAMIDES are given (may increase bilirubin levels in the NB & may not prevent
deformities),
 PYRIMETHAMINE (antiprotozoal drug which is also anti-folic acid)
 Folic acid
 Spiramycin (experimental use during pregnancy if fetus is not affected)

PREVENTION
 Removing the cat from the home is unnecessary if the cat is healthy
 Do not take in a new cat
 Avoid undercooked meat
 Do not change a litter box or work in soil in an area where cats may defecate
 Use gloves
B. RUBELLA DIAGNOSTICS
 Rubella titer obtained on 1st prenatal
MATERNAL SYMPTOMS visit.
 mild rash  If titer is > 1:8, mother is immune to
 mild systemic illness rubella
 if < 1:8, susceptible to viral invasion
Congenital rubella: Fetal damage from maternal  if greatly increased over a previous
infection reading or initially extremely high,
 Deafness suggests recent infection
 mental & motor challenges  Immunization cannot be done during
 cataracts pregnancy After immunization, a woman
 cardiac defects (PDA, pulmonary stenosis) is advised not to get pregnant for 3
 restricted intrauterine growth (SGA) months until the rubella virus is no longer
 thrombocytopenic purpura, active
 dental & facial clefts  Immediately after a pregnancy, assess
the titer & immunize if the titer is low
 Some women get re-infected so all
pregnant women should avoid all contact
with children with rashes
 Infants born to mothers who had rubella
during pregnancy must be isolated from
other NB’s during the NB period
 Nurses who care for pregnant women or
NBs should be immunized against
rubella.
C. CYTOMEGALOVIRUS
 A member of the herpes virus family
 Transmitted by droplet infection from person
to person
FETAL SYMPTOMS:
 neurological damage (hydrocephalus,
microcephaly, spasticity), or
 eye damage (optic atrophy, chorioretinitis),
 deafness,
 chronic liver disease,
 skin covered with large Petechiae (blueberry-
muffin lesions)
D. HERPES SIMPLEX VIRUS (GENITAL HERPES
INFECTION)
 1ST episode genital herpes infection is
systemic (viremia) & crosses the placenta to
the fetus
 1st trimester infection: severe congenital
anomalies or spontaneous miscarriage
 2nd or 3rd trimester infection: high incidence
of premature birth, IUGR, continuing infection
of the NB at birth
 If the woman had herpes simplex virus type 1
before the genital herpes, or if the genital
herpes (type 2) is a recurrence, antibodies to
the virus in her system prevent the spread of
the virus to a fetus across the placenta
 If genital lesions are present at the time of
birth, a fetus may acquire the infection
through direct exposure during birth (CS is
recommended)
E. SYPHYLIS
 When the cytotrophoblastic layer of the
chorionic villi atrophies at the 16th to 18th
week, Treponema pallidum can cross the
placenta
 If detected in the 1st trimester & treated with
antibiotic (benzathine penicillin), fetus is
rarely affected
 If untreated beyond the 18th week, deafness,
cognitive challenge, osteochondritis & fetal
death are possible
DIAGNOSIS
 isolation of CMV antibodies from the
mother or the infant’s blood serum
TREATMENT
 No treatment or vaccine is available so
routine screening during pregnancy is not
recommended
PREVENTION
 thorough handwashing before eating
 avoiding crowds of young children at
daycare or nursery settings
Treatment
 IV ACYCLOVIR or
 oral ACYCLOVIR (ZOVIRAX) can be
given to the woman during the pregnancy
DIAGNOSIS
 Serologic screening (VDRL or rapid
plasma reagin) should be done on the 1st
prenatal visit & repeated close to term if
exposure is a problem
 In infants born to a woman with syphilis,
the serologic test may be positive for up
to 3 months even though the disease was
treated during pregnancy
NB with congenital syphilis:
 congenital anomalies, extreme rhinitis
(SNIFFLES),
 characteristic syphilitic rash,
 oddly shaped teeth (HUTCHINSON
TEETH)
F. ZIKA VIRUS
 Zika primarily spreads through infected
mosquito bites. Aedes aegypti
 can be passed from a pregnant woman to
her fetus.
 Zika primarily spreads through infected
mosquito bites and through sex without a
condom with someone infected by Zika, even
if that person does not have symptoms of
Zika.
 spreads through mosquito bites and through
body fluids, like blood and semen of an
infected person
 Infection during pregnancy can cause a birth
defect called microcephaly and other
severe fetal brain defects.
 First symptom can be developed in 3 to 12
days
PREVENTION
 no travel to areas with risk of Zika
 to use precautions or avoid sex with
someone who has recently traveled to a
risky area.
 CDC continues to encourage mothers to
breastfeed, even if they were infected or
lived in or traveled to an area with risk of
Zika.
 should be tested if you have symptoms of
Zika or if an ultrasound shows that your
fetus has abnormalities that might be
related to Zika infection.

MCN #11

I. THEORIES OF LABOR ONSET

 Uterine muscle stretching, which results in the release of prostaglandins
 Pressure on the cervix, which stimulates the release of oxytocin from the posterior pituitary gland
(PPG)
 Oxytocin stimulation, which works together with prostaglandins to initiate contractions
 Change in the ratio of Estrogen to Progesterone (increasing E in relation to P stimulates uterine
contractions)
 Placental age, which triggers contractions at a set point
 Rising fetal cortisol levels, which reduce progesterone formation & increase prostaglandin
formation
 Fetal membrane production of prostaglandin, which stimulates contractions
THEORIES DESCRIPTION
Prostaglandin Theory Initiation of labor is said to result from the release
of arachidonic acids produced by steroid action on
lipid precursors. Arachidonic acid is said to
increase prostaglandin synthesis which in turn
causes uterine contractions
Oxytocin Theory Pressure on the cervix stimulates the hypophysis
to release oxytocin from the maternal posterior
pituitary gland. As pregnancy advances, the uterus
becomes more sensitive to oxytocin. Presence of
this hormone causes the initiation of contraction of
the smooth muscles of the body (uterus is
composed of smooth muscles).
Uterine stretch theory The idea is based on the concept that any hollow
body organ when stretched to its capacity will
inevitably contract to expel its contents. Uterus is
compared to a balloon of which if the point of
elasticity is met, it will burst thus labor process of
occurs.
Placental Degeneration Theory
Progesterone deprivation theory
II. PREMONITORY SIGNS OF LABOR
 All pregnant women should be taught these
signsso they can recognize when labor is
beginning
1. LIGHTENING
 Descent of the fetal presenting part into the
pelvis, approximately 10 to 14 days before
labor begins.
 The uterus becomes lower & more anterior
 Provides relief from diaphragmatic pressure
& shortness of breath, “lightening” her load
 Early in primiparas because of tight
abdominal muscles
 In multiparas, it is not as dramatic, occurring
on the day of labor or even after labor has
begun.
 Mother may experience shooting leg pains
due to increased pressure on the sciatic
nerve, increased vaginal discharge, urinary
frequency
5. SLIGHT LOSS OF WEIGHT
 Drop in Progesterone levels causes increased excretion of body fluids
 Increase in urine production can lead to a weight loss between 1 to 3 lbs
DIFFERENTIATION BETWEEN TRUE & FALSE LABOR CONTRACTIONS
FALSE CONTRACTIONS
Begin & remain irregular
Felt 1st abdominally & remain confined to the
abdomen & groin
Often disappear with ambulation & sleep
Do not increase in duration, frequency, or intensity
Do not achieve cervical dilatation
III. SIGNS OF TRUE LABOR
1. Uterine Contractions
 The surest sign that labor has begun is
productive uterine contractions
 Help her predict the pattern & use breathing
exercises to give her a sense of control
Because of decreased blood supply and functional
capacity, the uterus starts to contract
Decreased amount of progesterone initiates uterine
motility
2. INCREASE IN LEVEL OF ACTIVITY
 May awaken on day of labor full of energy
 It is due to increase in epinephrine release
initiated by a decrease in progesterone
produced by the placenta
 It prepares the body for the work of labor
ahead
3. BRAXTON HICKS CONTRACTIONS
 Weeks or days before labor, extremely
strong BH contractions occur, mistaken as
true labor
4. RIPENING OF THE CERVIX
 It is an internal sign seen on pelvic
examination
 Throughout pregnancy, it has the
consistency of an earlobe (GOODELL’S
SIGN)
 At term, cervix becomes softer (“buttery-
soft”), & it tips forward
TRUE CONTRACTIONS
Begin irregularly but become regular & predictable
Felt 1st in the lower back & sweep around to the
abdomen in a wave
Continue no matter what the woman’s level of
activity
Increase in duration, frequency & intensity
Achieve cervical dilatation
2. Show
 As the cervix ripens & softens, the mucus
plug that filled the cervical canal during
pregnancy (OPERCULUM) is expelled
 The exposed cervical capillaries seep
blood due to pressure from the fetus.
 The blood mixes with mucus, having a pink
tinge & referred to as “SHOW” or
“BLOODY SHOW”
3. Rupture of the Membranes
 Occurs as a sudden gush or as scanty, slow seeping of clear fluid from the vagina
 AF continues to be produced until delivery of the membranes so no labor will be completely dry
 Early rupture is advantageous if it causes the fetal head to settle snugly into the pelvis, shortening
labor.
 2 risks of ruptured membranes: intrauterine infection & prolapse of the umbilical cord which can cut
off O2 supply to the fetus
 If labor has not started by 24h after membrane rupture & the pregnancy is at term, labor is induced.
SESSION #12 2 Divisions of the Pelvis:

I. COMPONENTS OF LABOR FALSE PELVIS- upper half which

supports the uterus during the late
5 P’s: months of pregnancy & aids in
1. PELVIS (the PASSAGE) directing the fetus into the true pelvis
2. FETUS (the PASSENGER) for birth
3. Uterine factors (POWERS of labor) TRUE PELVIS- lower half of the
4. a woman’s PSYCHE pelvis; long, bony, curved canal
5. POSITION divided into 3 parts:
o inlet,
If the 5 components: o pelvic cavity
o outlet
(1) the woman’s PELVIS (the passage)
is adequate size & contour
 LINEA TERMINALIS or BRIM
(2) the FETUS (the passenger) is of
imaginary line from the sacral
appropriate size & in an advantageous
promontory to the superior border of
position & presentation
the SP which divides the pelvis into
(3) the uterine factors (powers of
true & false pelves
labor) are adequate
(4) her (Position) is comfortable and 1. Types of Female Pelvic Shapes
facilitates the labor process
(5) the woman’s PSYCHE is preserved a. Gynecoid Pelvis “FEMALE”
so that afterward, labor can be viewed Has an inlet that is well-
as a positive experience rounded and has a wide pubic
A. PASSAGEWAY or PASSAGE (PELVIS) arch
Ideal for childbirth
Refers to the route a fetus must
travel from the uterus through the b. Android- “MALE”
cervix & vagina to the external
The pubic arch forms an
perineum
acute angle, making the lower
It is the mother’s bony pelvis and soft dimensions of the pelvis
tissues of the cervix, pelvic floor, vagina
extremely narrow
and introitus
A fetus may have difficulty
Functions exiting from this type of pelvis

Support & protect the reproductive & c. Anthropoid- “APE-LIKE”

other pelvic organs
Its transverse diameter is
Accommodation of the growing fetus narrow; the anteroposterior
Anchorage of the pelvic support diameter of the inlet is larger
structures than usual.
Composition Even though the inlet is large,
the shape of the pelvis does not
Anterior & lateral portion made up of 2 accommodate a fetal head as
innominate hip bones divided into 3 well as the gynecoid pelvis
parts (ilium, ischium and pubis)
d. Platypelloid – “Flattened” (oval)

It has a smoothly-curved oval

inlet, but the anteroposterior
diameter is shallow.

-Castillote BSN2 A10

 A fetal head might not be able to
rotate to match the curves of the
pelvic cavity
2. ESTIMATING PELVIC SIZE (PELVIMETRY)
Measurement of the Transverse Diameter of
the Outlet
a. TUBERO-ISCHIAL or BI-ISCHIAL
Diameter of the Outlet

2 important pelvic measurements to It is the distance between the

determine the adequacy of the pelvic ischial tuberosities, or the
size: transverse diameter of the
- the DIAGONAL CONJUGATE outlet (the narrowest diameter
(anterior-posterior diameter of at that level, ot the one most apt
the inlet) to cause a misfit)
- the TUBERO-ISCHIAL or BI- It is made at the medial and
ISCHIAL DIAMETER lowermost aspect of the
(transverse diameter of the ischial tuberosities, at the
outlet) level of the anus
DC (Diagonal conjugate) is the Diameter of 11 cm is considered
narrowest diameter of the inlet & the adequate because it will allow
(TD) Tubero-ischial Diameter is the the widest diameter of the fetal
narrowest diameter of the outlet (11.5 head, or 9 cm, to pass freely
cm) through the outlet
TD of pelvic cavity/inter-spinous
diameter= 10 cm
TD of outlet/bi-ischial diameter= 11.5

Anteroposterior Measurements of the Inlet

a. DIAGONAL CONJUGATE= 10.5 - 11 cm.

o It is the measurement between the

anterior surface of the sacral
prominence (sacral promontory) and
the posterior surface (inferior margin)
of the symphysis pubis
o measured by internal examination; AP
diameter

b. OBSTETRIC CONJUGATE= > 10 cm.

o It is the distance between the

midpoint of the sacral promontory &
the midline of the symphysis pubis
which is ascertained by subtracting 1
to 1.5 cm from the diagonal
conjugate
o OC= DC – 1 to 1.5

c. TRUE CONJUGATE/CONJUGATA VERA= >

11 cm.

o It is the distance between the midpoint

of the sacral promontory and the
upper or superior margin of the
symphysis pubis
-Castillote BSN2 A10
SESSION #13
PASSENGER (FETUS)
The head is the body part of the fetus
with the largest diameter
- Its ability to fit depends on its
structure (bones, fontanelles,
suture lines) & its alignment with
the pelvis
The Cranium is composed of 8 bones:
frontal, 2 parietal, occipital, sphenoid,
ethmoid & 2 temporal bones
Cranial sutures are fibrous joints
connecting the bones of the skull,
allowing the bones to move & overlap
(molding), diminishing the size of the
skull so that it can pass through the birth
canal
o Sagittal suture- joins the 2
parietal bones
o Coronal suture- line of
juncture of the frontal bones
& the 2 parietal bones
o Lambdoid suture- juncture of
the occipital bone & the 2
parietal bones
ANATOMY OF THE FETAL SKULL
FONTANELLES- membrane-covered
spaces found at the juncture of the
main suture lines
ANTERIOR FONTANELLE (BREGMA)- at the
junction of the coronal & sagittal sutures,
diamond-shaped; closes at 18 mos
POSTERIOR FONTANELLE(LAMBDA)- at the
junction of the lambdoidal & sagittal sutures,
triangular and smaller than the bregma;
closes at 2-3 mos
VERTEX- the space between the fontanelles
Diameters of the Fetal Skull
It is wider in the anteroposterior
diameter than the transverse
diameter.
To fit in the birth canal, the smallest
diameter of the skull (Transverse
Diameter (TD) must present to the
smallest diameter of the pelvis
A. SUBOCCIPITOBREGMATIC DIAMETER-
narrowest, about 9.5 cm, from the inferior
aspect of the occiput to the center of the
anterior fontanelle
B. OCCIPITOFRONTAL DIAMETER- about 12
cm, measured from the bridge of the nose to
the occipital prominence
C. OCCIPITOMENTAL DIAMETER- widest
(Anterior Posterior (AP) diameter, 13.5 cm;
measured from the chin to the posterior
fontanelle
The AP diameter presented depends on the
degree of flexion of the fetal head
Full flexion- head flexes sharply that the chin
rests on the thorax; suboccipitobregmatic
diameter will be presented
Moderate flexion- occipitofrontal diameter is
presented
Poor flexion- head is hyperextended; the
largest diameter, occipitomental diameter is
presented
Molding
 Refers to change in the shape of the
fetal skull produced by the force of
the uterine contractions pressing the
vertex of the head against the not-
yet-dilated cervix; the incompletely
ossified bones will overlap making
the head longer & narrower
 Molding lasts only a day or 2
1. FETAL ATTITUDE
It describes the degree of flexion a
fetus assumes during labor or the
relation of the fetal parts to each
other
A. NORMAL or GOOD ATTITUDE: the chin
touches the sternum, arms are flexed &
folded on the chest, thighs flexed onto the
abdomen, calves pressed against the
posterior aspect of the thighs; presents the
smallest AP diameter of the skull
-Castillote BSN2 A10

B. MODERATE FLEXION- chin is NOT
touching the chest but, in an alert, or
“MILITARY POSITION”; presents the next-
widest diameter, (OCCIPITO-FRONTALIS (OF)
C. PARTIAL EXTENSION- presents the
‘BROW’
D. COMPLETE EXTENSION- or poor flexion,
back arched, neck extended; OM DIAMETER
(FACE presentation); in oligohydramnios or
neurologic abnormality (spasticity)
 0 station- at the level of the ischial
spines; synonymous to ENGAGEMENT
 -1 to -4 (Minus stations)- presenting part
is above the ischial spines; -4 is
FLOATING
 +1 to +4 (plus stations)- presenting part
is below the ischial spines
 +3 or +4- presenting part is at the
perineum & can be seen if the vulva is
separated; CROWNING; +4, head is at
the outlet
3. FETAL LIE

FETAL ENGAGMENT

2. FETAL ENGAGEMENT

It is the settling of the presenting part

of the fetus far enough into the pelvis
to be at the level of the ISCHIAL
SPINES, a midpoint of the pelvis
widest part of the fetus (BIPARIETAL
DIAMETER in a cephalic presentation;
the INTERTROCHANTERIC
DIAMETER in a breech presentation)
has passed through the pelvic inlet;
thus, adequate for birth.
Engagement is assessed by vaginal &
cervical examination
FLOATING- if the presenting part is
not yet engaged
DIPPING- presenting part is
descending but has not yet reached
the ischial spines

STATION

 It refers to the relationship of the

presenting part of the fetus to the level
of the ischial spines
-Castillote BSN2 A10
4. FETAL PRESENTATION d. Compound Presentation

 More than 1 body part presents

5. FETAL POSITION

4 quadrants according to mother’s left &

right:

o RIGHT ANTERIOR
o LEFT ANTERIOR
o RIGHT POSTERIOR
o LEFT POSTERIOR

4parts of the fetus are chosen as landmarks to

describe the relationship of the presenting part
 It is the first body part of the fetus to
to 1 of the pelvic quadrants
enter the true pelvis and also the
first body part to come out during
delivery
TYPES OF FETAL PRESENTATION
a. Cephalic Presentation- most frequent
 The fetal head is the 1st body part
that will contact the cervix
 4 types: Vertex, brow, face, mentum
 Vertex presentation is the ideal because
skull bones are capable of molding for a
better fit, aids in cervical dilatation,
prevents cord prolapse
b. Breech Presentation
 Either the buttocks or the feet are the
1st body parts that will make contact
with the cervix
 Good attitude- fetal knees are up
against the umbilicus
 Poor attitude- knees are extended
3types of breech:
 In vertex presentation, it is the
OCCIPUT or CHIN (MENTUM); in
breech, SACRUM, in a shoulder
presentation, SCAPULA or ACROMION
PROCESS
 Composed of 3 letters: middle letter
denotes fetal landmark (O, M, Sa, A/Sc)
 1st letter defines whether the landmark
is pointing to the mother’s LEFT(L) or
RIGHT®
 Last letter defines whether the
presenting part points anteriorly (A),
posteriorly(P) or transversely(T)
 Fastest birth- ROA or LOA position
 Labor is extended & painful- ROP or
LOP
 POSTERIOR positions are more
painful because rotation of the fetal
head puts pressure on the sacral
nerves, causing back pain

 Complete (good flexion), Types of Positions

 Frank (moderate flexion)
 Footling breech (very poor flexion)
c. Shoulder Presentation
 In a transverse lie, presenting part is
1 of the shoulders (ACROMION
PROCESS), iliac crest, or an elbow;
caused by relaxed abdominal walls (in
multiparity), pelvic contraction, placenta
previa
 Breech presentation (sacrum)
- LSaA, LSaP, LSaT- same with
Right
 Face Presentation- (Mentum)
- LMA- left mentoanterior, LMP,
LMT- same w/ right
 Shoulder presentation (acromion
process)
- LAA- left scapuloanterior, LAP,
RAA, RAP

-Castillote BSN2 A10

SESSION #14
POWERS
 This is the force supplied by the
fundus of the uterus and
implemented by uterine contractions
which causes cervical dilatation and
then expulsion of the fetus from the
uterus.
 After full dilatation of the cervix, the
primary power is supplemented by use
of a secondary power source, the
abdominal muscles
 It is important for women to understand
that they should not bear down with their
abdominal muscles to push until the
cervix is fully dilated. Doing so could
impede the primary force and cause
fetal and cervical damage.
1. PRIMARY POWER: Uterine Contractions
a. Characteristics:
 Involuntary, rhythmical, regular
activity of uterine musculature
 Occurs intermittently by allowing for
a period of uterine relaxation
between contractions followed by
uterine and maternal rest and
restoration of uteroplacental
circulation effecting sustained fetal
oxygenation
b. Purposes:
 Propel presenting part
downward/forward
 Effacement of the cervix- thinning
out, pulling up, shortening of the
cervical canal
 Dilatation of the cervix- opening,
widening, enlarging, increasing in
diameter of the cervical os from 0
to 10 cm
c. Effects of Contractions:
 Increased maternal BP due to
increased peripheral arteriole
pressure (Check BP between
contractions for accurate results).
 Myometrial contractions constrict
blood vessels decreasing
uteroplacental circulation
 Prolonged uterine contractions
can cause fetal hypoxia
 Cervical dilation during the first
stage.
EFFACEMENT- shortening & thinning of the
cervical canal; normally, it is 1 to 2 cm long
but with effacement, the canal virtually
disappears
Primiparas- effacement occurs before
dilatation
Multiparas- dilatation may proceed before
effacement is complete but must occur
before the fetus can be safely pushed
 Contractions with pushing/bearing
down, expel the fetus and the placenta
during the second and third stages of
labor, respectively.
 Contour Changes. The uterus gradually
differentiates into 2 distinct functioning
areas. The upper portion becomes
thicker & active, preparing it to be able
to exert strength necessary to expel the
fetus. The lower segment becomes thin-
walled, supple & passive, so that the
fetus can be pushed out easily
 Boundary between the 2 portions
becomes marked by a ridge on the inner
uterine surface, called the
PHYSIOLOGIC RETRACTION RING
 The uterus changes from an ovoid
structure to an elongated one with a
longer vertical diameter.
d. 3 Phases of Uterine Contractions
1. INCREMENT (CRESCENDO)- the phase of
increasing or ‘building up’ of a contraction;
the first phase; the longest phase
2. ACME (APEX)- the height or peak of a
uterine contraction
3. DECREMENT (DECRESCENDO)- the phase
of decreasing contraction, “letting up”; the
last or end phase
-Castillote BSN2 A10
Measuring contractions
DURATION – the period from the beginning
of increment to the completion of decrement
of the same contraction; expressed in
seconds; the maximum normal duration is 90
seconds in the transition phase
FREQUENCY- The period of time from the
beginning of 1 contraction to the beginning
of the next contraction; expressed in “every
___ minutes.”
It is the time for checking maternal BP, FHT,
delivering the fetal head in precipitate labor to
prevent lacerations; the time for maternal
sleep and relaxation during labor.
e. Intensity- refers to the strength of a uterine
contraction during acme, can be determined
by palpation
Palpation- placing the hand lightly on the
fundus with the fingers spread; described as
mild, moderate and strong by judging the degree
of indentability /depressability of the uterine wall
during acme.
 When the uterine fundus is very firm and
cannot be indented with fingers, the
intensity is STRONG
 When the fundus is difficult to indent,
the intensity is MODERATE.
 When fundus is tense but can be
indented easily with fingertips, the
intensity is MILD.
Intrauterine Catheter- DIRECTLY measures
the strength of contractions:
 At ACME: intensity ranges from 30 mm
to 55 mm Hg of pressure
 Resting tonus average: 10 mm Hg
Major disadvantage: invasive and requires a
ruptured bag of waters
2. SECONDARY POWERS:
a. Maternal bearing down/ pushing-
readiness for pushing:
 Cervical dilatation: 10 cm; fully dilated
 Fetal station: +1; low enough to
stimulate Ferguson Reflex: maternal
involuntary urge to push stimulated by
stretch receptors in the pelvic floor.
 Correct pushing: Take a deep breath as
soon as the next contraction begins, and
then, with breath held, exert a
downward pressure exactly as though
she were straining at stool.
 Discourage prolonged maternal breath
holding of more than 6 seconds during
pushing. Support involuntary pushing,
grunting, groaning, exhaling, or breath
holding for less than 6 seconds.
 Have 4 or more pushes per contraction.
b. Intra-abdominal pressure: This is another
secondary power. As the woman pushes, the
intra-abdominal pressure increases.
PSYCHOLOGICAL RESPONSE OF THE
MOTHER
1. A pregnant woman’s general behavior and
influences upon her also affect labor progress.
Some FACTORS make labor a meaningful,
positive or negative event:
a. cultural influences – how a society
views childbirth
b. expectations and goals for the
labor process; whether realistic,
achievable, ot otherwise
c. feedback from other people
participating in the labor process
2. Pregnant woman’s psychologic responses to
uterine contractions
 Fear and anxiety affect labor progress.
A woman who is relaxed, aware of, and
participating in the birth process usually
has a shorter, less intense labor
3. Other factors that affect the psychological
response of the mother include:
a. Childbirth preparation process
(classes)- decreased need for
analgesics in labor
-Castillote BSN2 A10

b. Support system
 The husband’s presence during labor
results to less anxiety, less emotional
tension, less pain perception
 The attending nurse should provide a
supporting and caring environment:
respect the client’s/family’s needs and
attitudes and provide therapeutic
communication
4. Anticipation of pain can increase emotional
tension leading to increased pain perception.
d. No clear-cut best position; all have
advantages and disadvantages
e. In the choice of position in labor, consider the
following criteria:
 Maternal physical and psychologic
needs
 Fetal well-being
2. Second Stage of Labor
a. Lithotomy position: most commonly used
in the 2nd stage; favors the healthcare
provider

5. Physiologic basis for discomfort during
labor
a. 1st stage: dilatation of the cervix,
pain from the uterus referred to pain to
lower abdominal wall and thE areas
over the lower lumbar region and
sacrum: lumbosacral pain radiating to
the abdomen
 Ensure equal height of the stirrups
 Pad the stirrups
 Simultaneous placement of the legs on
the stirrups
 Avoid any pressure on the popliteal
region

b. 2nd stage: hypoxia of the uterine

muscles during contraction

c. Stretching of the lower uterine

segment causing pressure on adjacent
structures
POSITION OF THE PARTURIENT

1. First Stage of Labor

a. Left lateral recumbent (LLR) or Left side-

lying position- most comfortable and best for
fetal well-being as this prevents SUPINE
HYPOTENSION SYNDROME (vena caval
syndrome). Avoid supine position.

b. Optimal position may vary nd may range

from sitting, to squatting, to a semi-reclined
position, or to ambulating position.

 If bag of water is intact, may ambulate

 If bag of water has ruptured, may still
ambulate provided the station is at least
station 0 or + stations, to prevent cord
prolapse

c. If with intravenous line, a movable pose

should be used to allow ambulation if not
contraindicated

-Castillote BSN2 A10

SESSION #15
MECHANISMS (CARDINAL MOVEMENTS) of
LABOR
 Involves a number of different
position changes to keep the
smallest diameter of the fetal head (in
cephalic presentation) always
presenting to the smallest diameters
of the birth canal
A. ENGAGEMENT - Engagement is assessed
by vaginal & cervical examination
FLOATING- if the presenting part is not yet
engaged
DIPPING- presenting part is descending but
has not yet reached the ischial spines
- it refers to the relationship of the presenting
part of the fetus to the level of the ischial spines
0 station- at the level of the ischial spines;
synonymous to ENGAGEMENT
-1 to -4 (Minus stations)- presenting part is
above the ischial spines; -4 is FLOATING
+1 to +4 (plus stations)- presenting part is below
the ischial spines
+3 or +4- presenting part is at the perineum &
can be seen if the vulva is separated;
CROWNING; +4, head is at the outlet
B. DESCENT
 It is the downward movement of the
biparietal diameter of the fetal head
to the pelvic inlet
 Full descent- when the fetal head
extrudes beyond the dilated cervix &
touches the posterior vaginal floor
 It is due to pressure on the fetus by the
uterine fundus, causing the mother to
experience a pushing sensation, aided
by contractions
C. FLEXION
 As the fetal head reaches the pelvic
floor, the head bends forward onto the
chest, making the smallest diameter
(SOB) to be presented
 Flexion is aided by abdominal muscle
contractions during pushing
 The head flexes as it touches the pelvic
floor & the occiput rotates about 45°
until it is superior or just below the
symphysis pubis (AP diameter of the
fetal head is now in the AP plane of
them pelvis), the best relationship
between the head & the outlet of the
pelvis
D. INTERNAL ROTATION
 begins at the level of the ischial
spine
 Head enters the pelvis with the fetal
AP diameter (SOB, OM, OF) in a
diagonal or transverse position
because the diameter at the pelvic
inlet is widest from right to left
 It brings the shoulders in the best
position to enter the inlet, putting the
widest diameter of the shoulders
(transverse) in line with the wide
transverse diameter of the inlet
 This position also aligns the fetus in
the optimum position to continue
descent through the pelvic outlet
E. EXTENSION
 As the occiput is born, the back of
the neck stops beneath the pubic
arch & acts as a pivot for the rest of
the head
 The upward resistance from the
pelvic floor causes the head to
extend
 The head extends & the foremost
parts of the head, the face & the
chin, are born.
 Further descent is halted as the
shoulders are too wide to pass
through the pelvic arch at this
position
-Castillote BSN2 A10
F. EXTERNAL ROTATION/ RESTITUTION
Presentation & Position
 Almost immediately after the head is
born, the head rotates (from the AP
position it assumed to enter the outlet)
about 45° back to the diagonal or
transverse position of the early part of
the labor
 This brings the shoulder into an AP
position, best for entering the outlet with
the face turned facing one of the
mother’s thighs
 Anterior portion of the shoulder is born
first, assisted by downward flexion of the
infant’s head
G. EXPULSION
 Once the shoulders are born, the rest of
the body is born easily because of its
smaller size, signifying the end of the
2nd stage of labor
Importance of Determining Fetal
 Presentations other than vertex- implies
CPD, membranes rupture early,
increased risk for fetal anoxia &
meconium staining, long labor
 Presentations other than vertex- implies
CPD, membranes rupture early,
increased risk for fetal anoxia &
meconium staining, long labor
o Abdominal inspection &
palpation (LEOPOLD’S
MANEUVER),
o vaginal examination,
o auscultation of FHT and
o sonography
-Castillote BSN2 A10
SESSION #16 3. Transition Stage

STAGES OF LABOR  Contractions reach their peak of

intensity, occurring every 2 to 3 mins
A. FIRST STAGE- divided into 3 phases:
with a duration of 60 to 90 secs &
latent, active & transitional
causing a maximum dilatation of 8 to 10
1. Latent Phase- 6 to 8 hours cm
 If membranes have not ruptured before,
 Latent or preparatory phase begins at they will rupture due to full dilatation (10
the onset of regular contractions & ends cm)
when rapid cervical dilatation begins  At the end of this phase, both full
 Contractions are mild and short (causing dilatation (10 cm) & full effacement
mild discomfort only), lasting from 20 to (100% or full obliteration of the cervix)
40 secs. will have occurred
 Cervical effacement begins  Woman experiences intense discomfort
 Cervix dilates from 0 to 3 cm accompanied by nausea & vomiting,
 This stage lasts about 6 hours in a feelings of loss of control, anxiety, panic
nullipara & 4.5 hours in a multipara or irritability
 Prolonged latent phase may be due to:  As the woman reaches the end at 10
non-ripe cervix, analgesia, CPD cm, a new sensation, the irresistible
 Encourage walking and making urge to push, occurs.
preparations for birth, frequent emptying  Frequency 2-3 minutes; duration 60-90
of the bladder, chest breathing, time the secs
frequency & duration of contractions
B. SECOND STAGE OF LABOR/ EXPULSIVE
 Frequency q5-30 min; Duration 20-40
STAGE
secs; intensity mild to moderate
2. Active Stage- 3 to 6 hours  Duration 50-90 sec; frequency q 3 to 4
min; intensity is severe
 Cervical dilatation is more rapid  It is the period from full dilatation &
increasing from 4 to 7 cm cervical effacement (unable to feel the
 Contractions are stronger, lasting from cervix) to the birth of the infant
40 to 60secs, occurring approximately  With uncomplicated birth, it takes about
every 3 to 5 mins 1to 2 hours in a nullipara & minutes for
 Active phase lasts about 3 hours in a multiparas
nullipara & 2 hours in a multipara  Contractions are severe at 3 to 4-min
 Frequency is 3 to 5 min.; duration 40-60 intervals lasting for 50 to 90 secs but
secs; intensity moderate with a decreased frequency
 Show (vaginal secretions) & perhaps  The pattern changes to an
rupture of the membranes occur at this overwhelming, uncontrollable urge to
time push or bear down with each contraction
 Contractions are very strong, lasts as if to move her bowels
longer, & begin to cause discomfort
Ferguson reflex- the urge to bear down as
 It can be frightening & dramatic for the
the presenting part presses on the stretch
woman
receptors on the pelvic floor causing release
 Administration of analgesic at this stage
of oxytocin
has no effect on labor progress
 Combination of contractions & the
CARDINAL MOVEMENTS of labor help
expel the fetus

-Castillote BSN2 A10

  As the fetal head touches the internal
side of the perineum, the perineum
begins to bulge & appear tense
 The anus may become everted & stool
may be expelled.
 The vaginal introitus opens & fetal scalp
appears at the opening of the vagina
 At first, the opening is slit-like, then
becomes oval then circular.
 The circle enlarges & this is called
CROWNING
 RITGEN’S MANEUVER
 Episiotomy may be done
C. THIRD STAGE OF LABOR- 3 to 5 mins up
to 1 hour
 Also called PLACENTAL STAGE
 It begins with the birth of the infant &
ends with the delivery of the placenta
 2 separate phases occur:
PLACENTAL SEPARATION &
PLACENTAL EXPULSION
 After birth of the infant, the placenta is
palpated as a firm, round mass just
below the level of the umbilicus.
 After a few minutes of rest, contractions
begin again & the placenta assumes a
discoid shape and retains this shape
until it has separated, about 5 minutes
up to 1 hour after the birth of the infant.
Placental Separation
 Active bleeding on the maternal surface
of the placenta begins with separation;
the bleeding helps push it away from the
attachment site
 As separation is completed, the
placenta sinks to the lower uterine
segment or the upper vagina
Signs of placental separation:
- lengthening of the umbilical cord
-sudden gush of vaginal blood
-change in the shape of the uterus; globular
(CALKIN’S SIGN)- 1st sign
-firm contraction of the uterus
-appearance of the placenta at the vaginal
opening
Placental Expulsion
 After separation, the placenta is
delivered either by the natural bearing-
down effort of the mother or by gentle
pressure on the contracted uterine
fundus by the physician or nurse
(CREDE’S MANEUVER)
 Never apply pressure on a postpartal
uterus in a non-contracted state
because it may cause the uterus to
evert & hemorrhage
 If it does not deliver spontaneously, it
can be removed manually
 After delivery, inspect the placenta to
make sure it is intact & normal in weight
& appearance (15 TO 28
COTYLEDONS)
 With the delivery of the placenta, the 3rd
stage is over
2 TYPES OF PLACENTAL PRESENTATION
SCHULTZE PRESENTATION (80%)
 If the placenta separates first at its
center & lastly at its edges, it will fold
on itself like an umbrella & present
with the FETAL SURFACE, appearing
shiny & glistening from the fetal
membranes
DUNCAN PLACENTA
 If the placenta separates with the
MATERNAL SIDE (raw, red, & irregular
with the cotyledons showing)
 Shiny SCHULTZE, dirty DUNCAN
 Normal blood loss of placental
separation= 300 to 500 ml until the
uterus contracts with enough force to
seal the blood collection spaces
 Commonly, IV Oxytocin (PITOCIN) or
IM Methylergonovine (METHERGINE) is
given to increase contractions &
minimize bleeding
D. FOURTH STAGE OF LABOR
 Lasts from 1 to 4 hours after birth &
initiates postpartum period
 is a stage of recovery & bonding
-Castillote BSN2 A10
  Nursing care:
o Monitor VS q 15 mins. for 1 hour
o Offer emotional support
o Perineal care
o Offer regular diet as soon as
she requests for food
 Encourage full
ambulation as soon as
possible
o Comfort measures
o perineum for REEDA (redness,
edema, ecchymosis,
discharges, approximation)
o Observe for complications:
hemorrhage, bladder distention,
thrombosis
o Encourage voiding because a
full bladder interferes with
contractions
II. MATERNAL AND FETAL RESPONSES TO
LABOR
A. PHYSIOLOGIC EFFECTS OF LABOR ON A
WOMAN
1. CARDIOVASCULAR SYSTEM
a. Cardiac Output- contractions
decrease blood flow to the uterus &
increases blood in maternal circulation
increasing peripheral resistance (↑ BP,
↑Cardiac output by 40% to 50%)
-blood loss with birth (300-500ml)
compensated by increase in blood
volume during pregnancy
b. Blood pressure rises by an average of
15 mmHg with every contraction
2. HEMATOPOIETIC SYSTEM
 Leukocytosis- sharp increase in
circulating WBC’s due to stress and
exertion
 At end of labor, 25,000 to 30,000
cells/mm
3. RESPIRATORY SYSTEM
 ↑RR to supply enough O2
 Observe appropriate breathing patterns
to prevent hyperventilation
4. TEMPERATURE REGULATION
 Slight elevation by 1°F
 Diaphoresis occurs to prevent
excessive warming
5. FLUID BALANCE
 Increase in RR and diaphoresis
leads to insensible water loss
B. PSYCHOLOGICAL RESPONSES OF A
WOMAN TO LABOR
 PAIN- reduces her ability to cope
 FEAR- lack of control and fear of
the outcome
 Cultural Influences-adapt care to
woman’s specific circumstances
III. DANGER SIGNS OF LABOR
A. Maternal Danger Signs:
1. High or Low BP- systolic pressure >140 mm
Hg, diastolic pressure >90 mm Hg or increase of
30 mm Hg may be a sign of PIH
-sudden drop in BP may be the 1st sign of
intrauterine bleeding
2. Abnormal Pulse (PR = 70-80bpm)- >100
bpm may be a sign of hemorrhage
3. Inadequate or Prolonged Contractions-
uterine exhaustion
4. Pathologic Retraction Rings- indentation
across a woman’s abdomen where the upper
and lower segments join, may be a sign of
extreme uterine stress and possible impending
rupture
5. Abnormal Lower Abdominal Contour- with
a full bladder, a round bulge on the lower
abdomen may appear
-danger sign for 2 reasons: bladder may be
injured due to pressure; full bladder may prevent
fetal head descent
-void every 2 hrs. during labor
6. Increasing apprehension- O2 deprivation or
internal hemorrhage
-Castillote BSN2 A10
B. Fetal Danger Signs

1. High or Low fetal Heart Rate- >160 bpm

(fetal tachycardia), < 110 bpm (fetal
bradycardia), decelerations may be a sign of
fetal distress

2. Meconium Staining

 Green color of AF due to loss of

sphincter control may be due to fetal
hypoxia

3. Hyperactivity- sign of hypoxia

4. Oxygen saturation (40% to 70%)- assessed

by a catheter inserted next to the cheek (<40%
is low); plus, acidosis (pH <7.2) suggests fetus is
being compromised

SESSION #17  less dependent, take a strong interest in

POSTPARTAL PERIOD/ PUERPERIUM
 Lat. Puer, “child,” and parere “to
bring forth”
 6-week period after childbirth
 retrogressive (involution of the
uterus & vagina) and progressive
(production of milk for lactation)
 FOURTH TRIMESTER OF
PREGNANCY
I. PSYCHOLOGICAL CHANGES OF THE
POSTPARTAL PERIOD
A. TAKING-IN PHASE
 1st 2 to 3 days postpartum
 passive and dependent
 preoccupied with her own needs
 wants to talk about her pregnancy, labor
and birth
 Touches & explores her baby
 Encourage her to talk about the birth to
help her integrate it into her life
experience
B. TAKING-HOLD PHASE
 3rd to the 10th day
the care of her child and make her own
decisions but still feels insecure about
her mothering skills
 give guidance and demonstrations on
how to care for her child
C. LETTING-GO PHASE
 10 days to 6 weeks
 woman redefines her new role &
motherhood functions are established
 gives up her fantasized image of her
child and accepts her child as a unique
person
DEVELOPMENT OF PARENTAL LOVE &
POSITIVE FAMILY RELATIONSHIPS
 En face position- looking directly at
her newborn’s face with direct eye
contact
 Engrossment- fathers staring at the
NB for long periods of time
 Complete rooming-in- mother and
child are together 24h a day
 Partial rooming-in- infant remains in
the woman’s room most of the time
 Sibling preparation

-Castillote BSN2 A10


POSTPARTUM BLUES/BABY BLUES
 2nd, 3rd postpartal day or within the 1st
2 weeks
 mood swings, anger, tearfulness,
feeling let-down, anorexia, insomnia,
overwhelming sadness, feeling of
inadequacy, mood lability
 related to hormonal changes (sudden
decrease in E/P), fatigue &
psychological stress related to infant
dependency
 Anticipatory guidance, individualized
support, chance to verbalize are
necessary
 resolves spontaneously
II. REPRODUCTIVE SYSTEM CHANGES
A. The UTERUS
 2 processes:
 area where the placenta was
implanted is sealed off to prevent
bleeding and the
 uterus is reduced to its approximate
pregestational size
INVOLUTION- reduction in size of the uterus
after delivery to prepregnant size caused by
uterine contractions
 Immediately after birth, the uterus
weighs about 1,000g; after a week, 50g;
after involution is complete (6 weeks),
50g
FUNDUS- the top portion of the uterus; an
indicator of involution
 after delivery, fundus is palpated
halfway between the umbilicus &
symphysis pubis, at midline or slightly to
the right.
 1 hour after, fundus will rise to the level
of the umbilicus & remain there for 24
hours. From then on, it decreases 1
fingerbreadth per day (1 cm).
 1st postpartal day,1 fingerbreadth below
the umbilicus; on 2nd day, 2
fingerbreadths below the umbilicus, and
so on.
 By the 9th or 10th day, it can no longer
be palpated
 A well-contracted uterus feels firm, like a
grapefruit in size & tenseness; if it is
boggy (soft & flabby), it is not contracted
AFTERPAINS- uterine cramps similar to
menstrual cramps caused by intermittent
uterine contractions after delivery; more
painful in breastfeeding & multiparous
women
Factors that enhance involution
 Uncomplicated labor & delivery
 Breastfeeding
 Early ambulation
 Complete expulsion of placenta &
membranes
 Factors that slow involution
 Prolonged labor & difficult delivery
 Anesthesia
 Grand multiparity
 Retained placental fragments
 Full urinary bladder
 Infection
 Overdistention of the uterus
LOCHIA
 should not contain large clots
 Total volume is 240 to 270 ml, gradually
decreasing daily; increased by exertion
or breast-feeding
 Unexplained increase in amount or
reappearance of lochia rubra is
abnormal
TYPES OF LOCHIA
Lochia Rubra- Dark red, bloody; fleshy,
musty, stale odor that is non-offensive; may
have tiny clots/ 1 to 3 days/ Blood, mucus,
fragments of decidua, epithelial cells, WBC’s,
fetal meconium, lanugo, vernix caseosa
Lochia Serosa- Pink or brownish; watery;
odorless/ 4 to 10 days/ Serum, RBC’s shreds
of decidua, WBC’s, cervical mucus, bacteria
Lochia Alba- Yellow to white; may have
slightly stale odor/ 11 to 21 days, my persist
for 6 weeks in lactating women/ WBC’s.
-Castillote BSN2 A10
decidual cells, epithelial cells, fat cervical
mucus, cholesterol, bacteria
B. The CERVIX
 Soft, irregular & edematous; may
appear bruised with multiple small
lacerations
 Both internal & external os are open
 By the end of 1 week, the external os
has narrowed to the size of a pencil
opening (may admit 1 fingertip) and it
will be firm once again
 The internal os closes as before but the
external os remains slightly open and
slit-like or stellate (star shaped)
C. The VAGINA
 The vagina is soft, edematous, with
greater diameter & multiple small
lacerations
 Low E levels postpartum lead to
decreased vaginal lubrication &
vasocongestion for 6 to 10 weeks, which
can result in painful intercourse
 KEGEL’s exercises will improve the
strength & tone of the vagina
III. SYSTEMIC CHANGES
A. The ABDOMINAL WALL
 Soft & flabby with decreased muscle
tone
 DIASTASIS RECTI- may improve
depending on the physical condition,
number of pregnancies, type & amount
of exercise
B. The HORMONAL SYSTEM
 hCG & HPL are almost negligible by 24
hours by week 1, progestin, estrone &
estradiol are at pre- pregnancy levels
 FSH is low for about 12 days & will
begin to rise and initiate a new
menstrual cycle
 Menstruation usually resumes in 7 to 9
weeks in non-lactating women (90% in
12 weeks); 1st cycle is usually
anovulatory
 Return of ovulation varies from 2 to 18
months
C. The URINARY SYSTEM
 On palpation, a full bladder is felt as
a firm or hard area just above the
symphysis pubis
 Postpartal diuresis/Diaphoresis of 2 to 3
L increases the output in the 1st 12 to
24 hours & accounts for a 5-pound
weight loss
D. The CIRCULATORY SYSTEM
 Blood Volume returns to normal levels
by within 2 weeks, eliminated by
diuresis
 1st 48 hours are the time of greatest risk
for complications for clients with heart
disease
 Bradycardia of 50 to 70 bpm is common
in the 1st 6 to 10 days; tachycardia is
related to blood loss, temperature
elevation or difficult, prolonged birth
 Fibrinogen remains increased for 1
week increasing the risk for
thrombophlebitis
 WBC count is up to 30,000/mm3
especially if the labor is prolonged or
difficult; aids healing & prevents
infection
 Varicosities will recede but won’t
disappear
 Hemoglobin returns to normal in 2 to 6
weeks
E. The GASTROINTESTINAL SYSTEM
 Hunger and thirst are common following
birth
 Risk for constipation increases due
to decreased peristalsis, use of
analgesics, dehydration, decreased
mobility during labor, & fear of pain
from having a bowel movement
 Risk for hemorrhoids increases because
of pushing during the 2nd stage of labor
III. EFFECTS OF RETROGRESSIVE
CHANGES
 Exhaustion due to pregnancy, labor
& delivery
-Castillote BSN2 A10
  Weight loss (19 lbs from delivery to the
5th day postpartum/ initially due to
diuresis, influenced by breastfeeding,
exercise, nutrition
IV. VITAL SIGN CHANGES
Temperature
 Slight increase during 1st 24 hours due
to dehydration; relieved by adequate
fluid intake
 Any woman whose oral temperature
rises above 100.4°F (38°C) excluding
the 1st 24 hours is considered febrile
Pulse
 Normal postpartal range is 50 to 80 bpm
 PR is usually slightly lower than normal
& will return to normal levels at the end
of the week
 A rapid & thready pulse indicates
hemorrhage
 Pulse > 100 bpm should be reported to
the healthcare provider
Blood Pressure
 Assess for orthostatic hypotension
 Monitor if woman has history of
preeclampsia
Respirations
 Normal range is 16 to 24 breaths per
minute
V. PROGRESSIVE CHANGES
LACTATION
 Lactation or formation of breastmilk
begins in a postpartal woman
whether or not she plans to
breastfeed
 Breast milk forms in response to
decrease in E/P levels following delivery
of the placenta (which stimulates
Prolactin release)
 Nipple stimulation leads to release of
OXYTOCIN from the pituitary gland; this
stimulates the release of PROLACTIN
from the pituitary gland which causes
production of milk & the let-down reflex,
release of milk by the contractions of the
alveoli of the breasts
 Primary engorgement- 3rd or 4th day as
the supply of blood & lymph in the
breast is increased & transitional milk is
produced; fades as effectivesucking and
emptying begins
RETURN OF MENSTRUAL FLOW
 With delivery of the placenta, E/P levels
decrease leading to ovulation
 Not breastfeeding- menstrual flow
returns in 6 to 8 weeks
 Breastfeeding- menstrual flow
returns in 3 to 4 mos (lactational
amenorrhea) or in some, during the
entire lactation period
 She may ovulate before menstruation
occurs
NURSING CARE OF A WOMAN & FAMILY
DURING THE 1ST 24 HOURS AFTER BIRTH
POSTPARTUM ASSESSMENT
General Considerations
1. Evaluate prenatal & intrapartal history
for complications
2. Provide privacy & encourage client to
void prior to assessment
3. Position client in bed with head flat for
accurate findings
4. Proceed in a head-to-toe direction
5. Vital Signs
6. Monitor breath sounds & practice deep
breathing & coughing exercises
Assessment
1. BREASTS
 Determine if bottle feeding or breast
feeding
 Palpate for engorgement or tenderness
 Inspect the nipples for redness, cracks
& erectility if nursing
2. UTERUS
 Gently place the non-dominant hand on
the lower uterine segment just above
-Castillote BSN2 A10
 the symphysis pubis; the dominant hand
palpates the fundus
 Palpation should not cause pain
 Determine uterine firmness, height of
the fundus, & ascertain the position of
the fundus in relation to the midline of
the abdomen
 If the uterus is boggy, massage gently
using a gently, rotating motion to induce
contraction; administer oxytocin as
ordered
 The fundal location must descend 1 cm
each postpartal day
 Inspect any abdominal incisions, CS
delivery, or tubal ligation, for REEDA:
redness, edema, ecchymosis,
discharge, and approximation of the skin
edges
3. BLADDER
 The client should void within 6 to 8
hours after delivery; catheterization may
be necessary if delayed & bladder is
distended
 Assess frequency, burning or urgency,
which could indicate UTI
 Evaluate the ability to completely empty
the bladder
 Palpate for bladder distention, if unable
to vid or complete emptying is in
question
4. BOWEL
 Assess for passage of flatus\
 Inspect for signs of distention
 Auscultate for bowel sounds in all 4
quadrants for postoperative patients
5. EPISIOTOMY OR PERINEAL
LACERATIONS
 Inspect the perineum for REEDA
 Episiotomy is usually 1 to 2 in long
 Inspect for hemorrhoids
6.. LOCHIA
 Inspect type, quantity, odor & color
 Correlate findings with expected
characteristics of bleeding
 CS- delivered women may have less
lochia
7. HOMAN’S SIGN
 Pain in the calf upon dorsiflexion of the
foot is a positive sign & may indicate
thrombophlebitis
 Inspect for pedal edema, redness, or
warmth; if abnormal changes are
present, assess pedal pulse
8. EMOTIONAL STATUS
 Assess if the client’s emotions are
appropriate for the situation
 Determine the client’s phase of
postpartal psychological adjustment
 Assess for postpartum blues
9. BONDING
 Describe how the parents interact with
the infant
IMPLEMENTATION
1. PREVENT HEMORRHAGE
 Assess for risk factors
 Keep bladder empty
 Gently massage fundus, if boggy; teach
self-massage of uterus
 Administer OXYTOCIC medications if
ordered; oxytocin (Pitocin),
methylergonovine maleate (Methergine),
ergonovine maleate (Ergotrate)
 Monitor for side effects of oxytocics;
hypotension with rapid IV bolus of
Pitocin, hypertension with Methergine &
Ergotrate
2. PROVIDE COMFORT
 Apply ice to perineum for 20 mins on/10
mins off for 1st 24 hours
 Encourage Sitz bath, warm or cool, TID
& PRN after the 1st 12 to 24 hours
-Castillote BSN2 A10
  Teach client perineal care after every
elimination
 Teach client to tighten buttocks, then sit
and relax muscles
 Apply topical anesthetics or witch hazel
compresses
 Monitor for side effects of morphine
epidural: late- onset respiratory
depression (8 to 12 hours),
3. PROMOTE BOWEL ELIMINATION
 Encourage early & frequent ambulation
 Encourage increased fluids & fiber
 Administer stool softeners; suppositories
are contraindicated is client has a 3rd-
or 4th-degree perineal laceration
involving the rectum
 Teach client to avoid straining; normal
bowel patterns return in 2 to 3 weeks
4. URINARY ELIMINATION
 Encourage voiding every 2 to 3 hrs even
if no urge is felt
 Catheterize, as ordered, for urinary
retention; Foley catheter for 12 to 24
hours after CS
5. PROMOTE SUCCESSFUL INFANT
FEEDING PATTERN
Suppression of lactation & bottle feeding
-utilize snug bra or breast binder continuously
for 5 to 7 days preventing engorgement
-avoid heat & stimulation of breasts
-apply ice packs for 20 min qid, if engorgement
occurs
-encourage demand feedings q 3 to 4 hours,
awakening during the day & allowing to sleep at
night Establishment of lactation & successful
breast-feeding
-utilize well-fitting bra for support
-teach breast care including no use of soap &
air-drying nipples after feedings
-encourage nursing on demand q 2 to 3 hours,
awakening during the day 7 allowing to sleep at
night
-advise mother to nurse 10 to 15 min on 1st
breast until the baby lets go of the 2nd; alternate
the breast used first & rotate positions
-suggest football hold or side-lying position for
moms with CS or tubal ligation to avoid
discomfort
-provide help with positioning, latching-on, &
breaking suction when done nursing
6. PROMOTE REST & GRADUAL RETURN TO
ACTIVITY
 Organize nursing care to avoid frequent
interruptions
 Plan maternal rest periods when baby is
expected to sleep
 Teach woman to resume activity
gradually over 4 to 5 weeks; avoid
lifting, stair-climbing & strenuous activity
 Simple postpartal exercises may be
started: Kegel’s exercises, raising the
chin to the chest, knee rolls, buttocks
lifts
 Increases lochia indicates overexertion;
modify exercise plan
7. PROMOTE ADEQUATE NUTRITIONAL
INTAKE- Add 500 kcal/day to pre-pregnancy
diet; bottle-feedingmothers should return to pre-
pregnancy diet
Fluid intake of 2 liters/day
Continue prenatal vitamins & iron; iron is best
absorbed in the presence of Vitamin C & may
increase constipation
8. PROMOTE PSYCHOLOGICAL WELL-
BEING
 Encourage & support expression of
feelings, positive & negative, without
guilt
 Encourage client to recount birth
experience to be able to integrate
expectations & fantasies with reality
 Provide recognition & praise for self- &
infant-care activities
9. PROMOTE FAMILY WELL-BEING
 Encourage rooming-in, presence of
family members & their participation
-Castillote BSN2 A10
  Advise resumption of sexual activities maternal hormones and diuresis
after episiotomy has healed & lochia has begins on the 2nd to 3rd day of
stopped, about 3 weeks after delivery
 Counsel the couple regarding
contraception before discharge

10. PROMOTE MATERNAL SAFETY Give

RhoGAM or RhIg to Rh (-) mom not sensitized (-
indirect Coomb’s test)

Give rubella vaccine if titer is < 1:8 (0.5 ml SC)

and advise to avoid pregnancy for at least 3
months

Teach postpartum warning signs to be reported:

-bright red bleeding saturating > 1 pad/hr or

passing of large clots

-temp > 100.4°F, chills, excessive pain,

reddened or warm areas of the breast, reddened
or gaping episiotomy, foul-smelling lochia

-inability to urinate; burning, frequency, or

urgency

-calf pain, tenderness, redness or swelling

SESSION #18
VITAL STATISTICS
Weight
 Weight depends on racial,
nutritional, intrauterine & genetic
factors
 Weight in relation to gestational age
should be plotted on a standard
neonatal graph
 Birth weight increases with each
succeeding child in a family
 Average birth weight of a matured
female newborn 3.4 kg (7.5 lbs) and
a matured male newborn is 3.5 kg
(7.7 lbs)
 A newborn loses more than 5% to
10% of birth weight (6 to 10 oz) during
the 1st few days afterbirth since the
newborn is no longer under the
influence of salt and fluid-retaining
 life, voiding and the passing of stool
also reduces the weight.
 After the initial weight loss, the
newborn has 1 day of stable weight
then begins to gain weight
 Breastfed newborn regains birthweight
within 10 days; formula-fed newborn
within 7 days. After this, weight gain is
2 lbs/month
Length
 Average matured female newborn is
53 cm (20.9 in); matured male
newborn is 54 cm (21.3 in)
Head Circumference
 Ave: 34 to 35 cm (13.5 to 14 in)
 A mature newborn with circumference
<33 cm or > 37 cm should be
investigated
 HC is measured with a tape measure
drawn across the center of the
-Castillote BSN2 A10
 forehead & around the most
prominent portion of the posterior
head
Chest Circumference
 Chest circumference is usually 2 cm
(0.75 to 1 in) less than head
circumference
VITAL SIGNS
Temperature
 It is about 99°F (37.2°C) at birth
because they have been confined in
an internal body organ; temperature
falls almost immediately because of
immature temperature-regulating
mechanisms
4 Mechanisms of Heat Loss:
1. CONVECTION- flow of heat from the NB’s
body surface to cooler surrounding air; avoid
drafts such as windows and air conditioners
2. CONDUCTION- is the transfer of body heat
to a cooler solid object IN CONTACT with the
baby (e.g., placing baby on a cold surface); to
avoid heat loss, cover baby with a warmed
blanket or towel
3. RADIATION- transfer of body heat to a
cooler solid object NOT IN CONTACT with
the baby such as a cold window or air
conditioner; move infant as far from the cold
surface as possible
4. EVAPORATION- loss of heat through
conversion of a liquid to vapor; newborn’s
lose heat as amniotic fluid on their skin
evaporates; dry newborn’s as soon as possible
especially their face & hair which will not be
covered with clothing
 Newborn’s lose heat easily because
they lack subcutaneous fat; also,
shivering is rarely seen in NB’s
 Newborn’s conserve heat by constricting
blood vessels & moving blood away
from the skin
 BROWN FAT, a special tissue found
in mature Newborn’s, helps to
conserve heat by increasing
metabolism
 Brown fat is found in the intrascapular
region, thorax & perirenal area.
 Mechanical measures to conserve heat:
drying & wrapping the newborn’s,
placing them in a warmed crib, or drying
them & placing them under radiant
warmers
 KANGAROO CARE- placing a
newborn against the mother’s skin
which helps transfer heat from the
mother to the newborn
 Newborn’s temperature stabilizes at
98.6°F within 4 hours after birth
 A newborn with a bacterial infection may
run a subnormal temperature unlike
adults
Pulse
 In utero, PR = 120 to 160 bpm;
immediately after birth, as rapid as 180
bpm; within 1 hour, the NB settles down
to sleep & the pulse rate stabilizes to an
average of 120 to 140 bpm
 HR is slightly irregular due to immature
cardiac regulatory centers in the
medulla
 Transient murmurs are common due to
the incomplete closure of the fetal
circulation shunts
 Femoral pulses may be palpated but
radial & temporal pulses are difficult to
palpate
 Absence of femoral pulses suggests
possible coarctation of the aorta
 Heart rate is always determined by
listening for an apical heartbeat for 1 full
minute
Respiration
 Respiratory rate in the 1st few minutes
after birth may be as high as 80
breaths/min. As respirations stabilize, it
settles to 30 to 60 breaths per minute at
rest.
 Respirations are likely to be irregular,
with short periods of apnea (without
cyanosis) sometimes called PERIODIC
RESPIRATIONS
-Castillote BSN2 A10
  Breathing primarily involves the
diaphragm and abdominal muscles
 Coughing & sneezing reflexes are
Gastrointestinal System
present at birth to clear the airway
 Newborns are obligate nose breathers
Blood Pressure
 Blood pressure is about 80/46 mm Hg at
birth; by the 10th day, it rises to 100/50
mm Hg though readings are usually
inaccurate
 Blood pressure cuff width must be no
more than 2/3 the length of the upper
arm or thigh
PHYSIOLOGIC FUNCTION
Cardiovascular System
 Clamping of the umbilical cord forces
the neonate to take in O2 through the
lungs→ ↓pressure in the chest
promoting closure of the ductus
arteriosus; ↑pressure on the left side of
the heart closes the foramen ovale.
 Umbilical vein ductus venosus and u.
arteries no longer receive blood, the
blood within them clots & the vessels
atrophy within the next few weeks
 Peripheral circulation remains sluggish
for the 1st 24 hours; acrocyanosis
(cyanosis in the hands & feet) and cold
feet are common
 Prolonged coagulation or prothrombin
time due to low levels of Vitamin K
(necessary for synthesis of Factors II,
VII IX and X)
 It takes 24 hours for flora to accumulate
in the intestines & for Vitamin K to be
synthesized
 Vitamin K (AQUAMEPHYTON) is
administered into the vastus lateralis
muscle immediately after birth
Respiratory System
 Initial breath is initiated by a
combination of cold receptors, lowered
partial pressure of O2 (pO2),
INCREASED Pco2 as high as70 mm Hg
before the 1st breath
 Within 10 minutes after birth, good
residual volume is established
 10 to 12 hours after birth, vital capacity
is established
 It is usually sterile at birth but within
24 hours, bacteria are present from
airborne sources, vaginal secretions
at birth, hospital linens, or from
contact with the mother’s breast
 Normal flora in the intestines are
necessary for the synthesis of Vitamin K
 Stomach capacity is about 60 to 90 ml
 A newborn has limited ability to digest
starch & fat because pancreatic
enzymes, lipase & amylase remain
deficient for the 1st few months
 Newborn regurgitates easily because of
an immature cardiac sphincter.
 Immature liver function leads to lowered
glucose & serum protein levels
 MECONIUM- 1st stool of NB & is
usually passed within 24 hours after
birth; it is tarlike, sticky, blackish green
and odorless formed from mucus,
vernix, lanugo, hormones &
carbohydrates accumulated in utero
 If (-) stool passage by 24 to 48 hours,
suspect meconium ileus, imperforate
anus, bowel obstruction
 2nd to 3rd day, TRANSITIONAL
STOOL which is green & loose, is
passed; it resembles diarrhea
 4th day, breast-fed babies pass 3 to 4
light yellow stools per day which are
sweet-smelling because breast milk
is high in lactic acid
 Formula-fed babies pass 2 to 3 bright
yellow, more odorous, stools
 Newborn under phototherapy light have
bright green stools due to increased
bilirubin secretions
 Clay-colored (gray) stools are
associated with bile duct obstruction
 Blood-flecked stools usually indicate
anal fissure
 If mucus is mixed with stool or the stool
is watery & loose, a milk allergy, lactose
intolerance, or some other condition is
suspected
-Castillote BSN2 A10

Urinary System
 The average newborn voids within 24
hours after birth; otherwise, should be
examined for urethral stenosis or absent
kidneys or ureters
 Males should void with enough force to
produce a small projected arc; females
should produce a steady stream.
 NB kidneys do not concentrate urine
well, producing light-colored & odorless
urine
 NB single voiding is only about 15 ml,
specific gravity ranges from 1.008 to
1.010
 Daily urine output for the 1st 1 or 2 days
is about 30 to 60 ml. 1st voiding may be
pink or dusky because of uric acid
crystals formed in the bladder in utero
 Diapers can be weighed to determine
the amount and timing of voiding
Immune System
 Newborn’s have difficulty producing
antibodies against antigens until about 2
months of age & are therefore prone to
infection. Thus, immunizations are not
given t infants younger than 2 months of
age
 Newborns are born with passive
antibodies (Ig G) from the mother that
crossed the placenta (antibodies vs
polio, measles, diphtheria, pertussis,
chickenpox, rubella & tetanus
 Newborns are routinely given Hepatitis
B vaccine during the 1st 12 hours after
birth
 Any Health Care Practitioner with
Herpes simplex eruptions should not
care for newborns until the lesions have
crusted
Neuromuscular System
 Newborn exhibits neuromuscular
function by moving their extremities,
attempting head control, strong cry, &
newborn reflexes since the nervous
system is still immature
Newborn Reflexes:
1. Blink Reflex
Purpose: to protect the eyes
Stimulus: shining a strong light on an eye,
sudden movement toward the eye
Reaction: rapid eye closure
2. Rooting Reflex.
Purpose: to help the newborn find food; for
nourishment
Stimulus: cheek is brushed or stroked near the
mouth
Reaction: the newborn will turn the head in the
direction of the stimulus
*Disappears at about the 6th week of life when
the eyes focus steadily
3. Sucking Reflex.
Purpose: to help the newborn find food
Stimulus: When the newborn’s lips touch the
mother’s breast or a bottle
Reaction: the baby sucks to take in food
*Diminishes in 6 months
*Disappears immediately if never stimulated (eg.
TEF); maintained by offering non-nutritive
sucking such as a pacifier
4. Swallowing Reflex.
Purpose: for nourishment
Stimulus: food that reaches the posterior
portion of the tongue is automatically swallowed
*Gag, cough, sneeze reflexes are also present
to maintain a clear airway when normal
swallowing does not keep the pharynx free of
obstructing mucus
5. Extrusion Reflex.
Purpose: prevents swallowing of inedible
substances
Stimulus: substance placed on the anterior
portion of the tongues
Reaction: Newborn pushes away the substance
with the tongue
-Castillote BSN2 A10
*Disappears at 4 months of age
6. Palmar Grasp Reflex
Newborn grasps an object placed in their
palm by closing their fingers on it
*Disappears at about 6 weeks to 3 months of
age; grasps meaningfully at 3 months of age
7. Step (Walk)-in-Place Reflex.
Newborn is held in a vertical position with
their feet touching a hard surface will take a
few, quick, alternating steps.
*Disappears by 3 months; by 4 months, babies
can bear a good portion of their weight
unhindered by this reflex
8. Placing Reflex.
Similar to step-in-place but it is elicited by
touching the anterior surface of the
newborn’s leg against a hard surface such
as the edge of a bassinet or table.
The newborn makes a few quick, lifting motions,
as if to step onto the table, because of the reflex
9. Plantar Grasp Reflex.
When an object touches the sole of the
newborn’s foot at the base of the toes, the
toes grasp n the same manner as the fingers
do.
* It disappears by 9 mos. in preparation for
walking
10. Tonic Neck Reflex/Boxer Reflex/Fencing
Reflex.
In a supine position, the head is usually
turned to 1 side; the arm & the leg on the
side toward which the head turns extend,
and the opposite arm & leg contracts.
Purpose: stimulates eye coordination since the
extended arm moves in front of the face.
*May signify handedness
*Disappears on the 2nd to 3rd months of life
11. Moro Reflex/Startle Reflex.
Stimulus: loud noise or by jarring of the
bassinet or by holding newborn in a supine
position & allow the head drop backward 1 inch
Response: Newborn abducts & extends arms &
legs, fingers assume a “C” position; finally
swinging the arms into an embrace position &
pull up the legs against the abdomen
(adduction)
Purpose: like trying to ward off an attacker then
covering up to protect himself
*It is strong for the 1st 8 weeks & fades by the
end of the 4th or 5th month at the same time as
the infant can roll away from danger
12. Babinski Reflex.
Stimulus: the side of the sole of the foot is
stroked in an inverted “J” curve from the heel
upward
Response: Newborn fans the toes (+ Babinski
sign)
*In adults, the opposite response is normal
(flexing of the toes)
*It remains positive (toes fan) until at least 3
months then replaced by the adult response
13. Magnet Reflex.
Stimulus: pressure is applied to the soles of the
feet of a newborn lying in a supine position
Response: Newborn pushes back against the
pressure.
*Magnet, Crossed Extension & Trunk
Incurvation reflexes are tests of spinal cord
integrity.
14. Crossed Extension Reflex.
Stimulus: 1 leg of newborn lying supine is
extended & the sole of the foot irritated by
rubbing with a sharp object such as a thumbnail
Response: Newborn raises the other leg &
extends it, as if trying to push away the hand
irritating the 1st leg.
15. Trunk Incurvation Reflex.
Stimulus: Newborn lies in a prone position &
touched along the paravertebral area by a finger
-Castillote BSN2 A10
Response: Newborn flexes the trunk & swing
the pelvis towards the touch
16. Landau Reflex.
Stimulus: Newborn is held in a prone position
with a hand underneath, supporting the trunk
Response: Newborn must demonstrate some
muscle tone; may not be able to lift the head or
arch the back but must not sag into an inverted
“U” position (poor muscle tone)
17. Deep tendon Reflex.
Stimulus: patellar reflex is stimulated by tapping
the patellar tendon with the tip of the finger.
Response: lower leg moves perceptively if the
reflex is intact; test for spinal nerves L2 through
L4
18. Biceps Reflex
Stimulus: biceps reflex is stimulated by placing
the thumb of your left hand on the tendon of the
bicep’s muscles on the inner surface of the
elbow; tap the thumb as it rests on the tendon.
Response: The tendon may be felt contracting
rather than being observed; test for spinal
nerves C5 & C6
The Senses- already developed at birth
HEARING.
-A newborn is able to hear even in utero
VISION.
-May have been seeing light & dark in utero for
the last few mos. of pregnancy as the as the
uterus & abdominal wall were stretched thin.
-demonstrates sight by blinking at a strong
light or following a bright light or toy a short
distance with their eyes; cannot follow past
midline & lose track of objects easily
-Newborn’s focus on black or white objects best
at a distance of 9 to 12 inches
-pupillary reflex or the ability to contract the pupil
is present from birth
TOUCH.
-well developed at birth; demonstrated by
quieting at a soothing touch & by positive
rooting & sucking reflex & by reaction to
painful stimuli.
TASTE.
-Newborns has the ability to discriminate
taste, since tastebuds are developed &
functioning even before birth
- In utero, the fetus will swallow amniotic fluid
more rapidly if sweetened by glucose & less if
bitter flavor is added.
SMELL.
-present in newborn’s as soon as the nose is
clear of mucus & amniotic fluid
- Newborn’s turn toward their mother’s breast
partly because of recognition of the smell of
breast milk & partly as a manifestation of the
rooting reflex.
PHYSIOLOGIC ADJUSTMENT TO
EXTRAUTERINE LIFE
Periods of reactivity- periods of irregular
adjustment in the 1st 6 hours of life
(Desmond)
1. 1st Period of reactivity- 1st phase lasting for
about 30 minutes; baby is alert & exhibits
exploring, searching activity, often making
sounds; HR & RR are rapid
2. Next is a quiet, resting period- heart rate and
respiratory rate are slow, the newborn typically
sleeps for about 90 minutes.
3. 2nd period of reactivity- between the 2nd &
6th weeks of life, when the baby wakes, often
gagging or choking on mucus that accumulated
in the mouth; alert & responsive to the
environment.
 Periods of reactivity indicates that the
Nb is healthy & adjusting well to the
extrauterine life.
APPEARANCE OF A NEWBORN
SKIN
Color
-Castillote BSN2 A10
  Most have a ruddy complexion due to
increased circulation of RBCs in blood
vessels & decreased subcutaneous fat
 Pale & cyanotic- infants with poor
CNS control
 Gray color- indicates infection
 Generalized mottling of the skin, bluish
appearance of the lips, hands & feet are
common from immature peripheral
circulation
ACROCYANOSIS- blueness of hands & feet
is normal in the 1st 24 to 48 hours after birth
Central Cyanosis- or cyanosis of the trunk
indicates decreased oxygenation
 Suction the mouth of a newborn (if the
newborn does not cry or cyanotic)1st
before the nose, because suctioning the
nose 1st may trigger a reflex gasp,
possibly leading to aspiration if there is
mucus in the posterior throat
HYPERBILIRUBINEMIA- leads to jaundice &
occurs on the 2nd to the 3rd day of life due
to breakdown of fetal RBC’s (PHYSIOLOGIC
JAUNDICE)
CEPHALHEMATOMA- collection of blood
under the periosteum of the skull bone; also
causes release of Indirect Bilirubin
 Intestinal obstruction prevents
evacuation of stool & intestinal flora
breaks down bile into its basic
components leading to release of
Indirect Bilirubin; early feeding of
newborn promotes intestinal movement
& excretion of meconium & helps
prevent Indirect Bilirubin build up.
 Treatment for physiologic jaundice is
rarely necessary except for early
feeding to speed passage of stool
 Some breast-fed babies may have more
difficulty converting IB because breast
milk contains PREGNANEDIOL
(metabolite of progesterone) which
depresses action of glucoronyl
transferase
PALLOR- usually the result of anemia caused
by:
(1) excessive blood loss when the cord was
cut
(2) Inadequate flow of blood from the cord to
the infant at birth
(3) fetal-maternal transfusion
(4) low iron stores due to poor maternal
nutrition
(5) blood incompatibility
 HARLEQUIN SIGN- due to immature
circulation, a newborn lying on his or
her side appears red on the
dependent side of the body & pale on
the upper side; transient only & fades
with change of position, kicking or crying
vigorously
Birthmarks
 HEMANGIOMA- vascular tumor of the
skin
a. Nevus Flammeus- macular purple or dark-
red lesion (sometimes called port-wine stain)
usually appearing on the face or thighs
-those above the nose bridge tend to fade,
-can be removed by laser therapy though they
may reappear
-Stork’s beak mark- lighter pink patches at the
nape of the neck which do not fade
b. Strawberry Hemangiomas- elevated areas
formed by immature capillaries & endothelial
cells; some are present at birth while some
appear up to 2 weeks after birth
-associated with high Estrogen levels of
pregnancy
-may increase in size up to 1 year of age, then
they tend to be absorbed & shrink in size; by 7
years old, 50% to 75% have disappeared
-hydrocortisone ointment may speed the
disappearance of the lesions
-surgery is rarely recommended because it may
lead to secondary infection
-Castillote BSN2 A10
c. Cavernous hemangioma- dilated vascular
spaces, usually raised, resembling
strawberry hemangiomas but do not
disappear with time
MONGOLIAN SPOTS- collections of pigment
cells (melanocytes) that appear as slate-gray
patches across the sacrum or buttocks &
possibly n the arms or the legs
-common in Asians, S. Europeans, or Africans
-disappear by school age
Forceps marks
Vernix Caseosa
 White, cream cheese-like substance
that serves as a skin lubricant,
noticeable on the skin of a newborn
 Yellow vernix- due to bilirubin
 Green vernix- meconium staining
 Before the 1st bath, wear gloves when
handling the NB to prevent exposure to
body fluids
Skin Turgor
Lanugo
 Fine, downy hair that covers the
shoulders, back, upper arms,
forehead & ears of the newborn
 Post-mature infants rarely have lanugo
 It is rubbed away by the friction of
bedding & clothes against the skin; by 2
weeks of age, it has disappeared
Desquamation
 Within 24 h after birth, skin becomes
extremelydry especially on the palms
& soles resulting to areas of peeling
HEAD
similar to sunburn
 It usually needs no treatment
Milia
 Plugged or unopened sebaceous
gland appearing as pinpoint white
Fontanelles
papules appear on the cheeks or
across the bridge of the nose
 Disappear by 2 to 4 weeks of age as the
sebaceous glands mature & drain
 Teach parents to avoid squeezing or
scratching to prevent infection
Erythema Toxicum/ Flea-bite rash
 Newborn rash usually appearing in the
1st to 4th day of life, some up to 2 weeks
of age.
 It begins with a papule, increases in
severity to become erythema by the 2nd
day & disappears by the 3rd day
 It is caused by the newborn’s
eosinophils reacting to the
environment as the immune system
matures.
 It requires no treatment
 Circular or linear contusions
matching the rim of the forceps
blades n the infant’s cheek;
disappears in 1 to 2 days along with the
edema
 Closely asses the facial nerve to
determine any potential nerve
compression
 Newborn skin should feel resilient if the
underlying tissue s well-hydrated
 If a fold of the skin is grasped
between the thumb & fingers, it
should feel elastic; when released,
should fall back to form a smooth
surface
 Poor turgor is seen in those who
suffered severe malnutrition in utero,
those with difficulty sucking at birth or
those with metabolic disorders such as
adrenogenital syndrome
 Newborn’s head is 1⁄4 of the total body
length; in an adult, 1/8 of the total height
 The fore head is large & prominent, the
chin appears to recede & quivers easily.
 Anterior fontanelle is found at the
juncture of the frontal & parietal
bones; diamond-shaped, measures 2
to 3 cm in width & 3 to 4 cm in length
 Anterior Fontanelle is felt as a soft spot,
neither indented nor bulging
-Castillote BSN2 A10
  Anterior Fontanelle normally closes at
12 to 18 months of age
 Posterior fontanelle is found at the
junction of the parietal bones & the
occipital bone; triangular in shape &
measures 1 cm in length
 Posterior Fontanelle closes by the end
of the 2nd month
Sutures
 They are the separating lines of the
skull and may override during
passage through the birth canal.
 Molding subsides in 24 to 48 hours
 Wide separation of suture lines
suggests increased ICP, hydrocephalus,
subdural hemorrhage
 Fused suture lines prevent head from
expanding with growth
Molding
 Molding may be so extreme the head
appears like a dunce cap but shape
will be restored in a few days
Caput Succedaneum
 It is the edema of the scalp at the
presenting part of the head
 The edema crosses suture lines & is
gradually absorbed & disappears about
the 3rd day of life & requires no
treatment
Cephalhematoma
 It is a collection of blood between the
periosteum of a skull bone & the
bone itself
 It is caused by the rupture of
periosteal capillaries due to pressure
at birth
 It usually appears 24 hours after birth
 The swelling is usually severe, well-
outlined as an egg shape; may be
discolored (black & blue) because of the
presence of coagulated blood
 It is confined to an individual bone so
the swelling stops at the suture line
 It sometimes takes weeks for the
cephalhematoma to be reabsorbed
Craniotabes
 It is a localized softening of the
cranial bones caused by pressure of
the fetal skull against the mother’s
pelvic bone in utero
 it is common in 1st-born infants because
of the lower position of the fetal head in
the pelvis during the last 2 weeks of
pregnancy in the primiparous women
 the skull is so soft that the pressure of
the examining finger can indent it; bone
returns to its normal shape after
pressure is removed
 The condition resolves after a few
months
EYES
 Lacrimal ducts are not fully mature until
3 months of age; therefore, crying is
initially tearless
 Irises are gray or blue, sclera appears
blue due to its thinness; eyes assume
permanent color between 3 & 12
months of age
 Small subconjunctival hemorrhage
sometimes appears due to pressure
during childbirth, appearing as a red
spot on the sclera usually in the inner
aspect of the eye or as a red ring
around the cornea
 Bleeding is slight, requires no treatment
& is completely absorbed within 2 to 3
weeks
 Edema around the orbit remains for the
1st 2 to 3 days until the kidneys are
capable of evacuating fluid more
efficiently
 White pupil suggests congenital cataract
MOUTH
 NB’s mouth should move evenly;
otherwise, check for cranial nerve injury
 EPSTEIN’S CYST- 1 or 2 small, round,
glistening, well-circumscribed cysts
on the palate, a result of the extra
load of Calcium deposited in utero;
require no treatment & disappear
spontaneously within 1 week
-Castillote BSN2 A10
  THRUSH- a Candida albicans
infection appearing as white or gray
patches on the tongue & sides of
cheeks
 NATAL TEETH- evaluate for stability;
all teeth not covered by gum
membrane should be removed
because they can loosen & may be
aspirated
NECK
 It is short, chubby, with creased skin
folds & head should rotate freely
 CONGENITAL TORTICOLLIS- caused
by injury to the sternocleidomastoid
muscle during birth manifested by
rigidity of the neck
 In newborn’s whose membranes were
ruptured >24h before birth, nuchal
rigidity suggests meningitis
 Thymus gland will triple in size by 3 yrs
of age & remains the same size till 10yo
then shrinks
CHEST
 When 2 years old, the chest
measurement will exceed that of the
head
 WITCH’S MILK- breasts secrete a
thin, watery fluid as an influence of
the mother’s hormones but these
hormones clear in about 1 week
 Chest circumference is approximately 2
inches smaller than the head
 RR- 30 to 60 breaths per minute
 SUPERNUMERARY NIPPLES- extra
nipples usually found below & in line
with the normal nipple
 Grunting suggests respiratory distress
syndrome
 A high crowing sound on inspiration
suggests stridor or immature tracheal
development
ANOGENITAL AREA
 Anal patency is tested by gently
inserting the tip of the little finger, gloved
& lubricated
 Anal patency is tested by gently
inserting the tip of the little finger, gloved
& lubricated
Male Genitalia
 The scrotum is edematous & has rugae,
deeply pigmented in dark-skinned
newborn’s
 If 1 or both testicles are missing,
suspect cryptorchidism; may be caused
by agenesis, ectopic testes (testes
cannot enter closed scrotal sac) or
undescended testes (vas deferens or
artery is too short to allow testes to
descend)
 CREMASTERIC REFLEX- elicited by
stroking the internal side of the thigh
causing the testis on that side to move
up upward (absent in NB’s < 10 days
old)
 The penis appears small, approximately
2 cm long
EPISPADIAS- urethral opening is at the
dorsal side
HYPOSPADIAS- urethral opening is at the
ventral side
 Circumcision should not be done if
epispadias or hypospadias is present
(foreskin may be used in the repair)
Female Genitalia
 Vulva may be swollen due to maternal
hormones
 PSEUDOMENSTRUATION- mucus
vaginal secretion, sometimes blood-
tinged
EARS
 Pinna tends to bend easily but strong
enough to recoil
 The level of the top part of the external
ear should be on a line drawn from the
inner canthus to the outer canthus of the
eye & back across the side of the head;
ears set lower are found in infants with
trisomy 18 & 13
 Skin tags in front of the ear may be
associated with kidney or chromosomal
-Castillote BSN2 A10
 abnormalities or of no reason at all; may
be removed with ligation when the child
is 1-week old
 Preauricular dermal sinus appear as
pinpoint-size opening directly in front of
the ear; may be removed surgically
when the child is near school age
 Test hearing by ringing a bell held 6 in
from each ear; newborn blink, stop
crying, be startled in response.
NOSE
 Test for CHOANAL ATRESIA by closing
the mouth & compressing 1 naris at a
time with the fingers. Note any
discomfort or distress with breathing.
ABDOMEN
 It is normally slightly protuberant
 If scaphoid or sunken, it suggests
missing abdominal contents or
diaphragmatic hernia
 Bowel sounds should be present within
1 hour after birth
 Edge of the liver is usually palpable 1 to
2 cm below the right costal margin; the
spleen 1 to 2 cm below the left costal
margin
 After cord cutting, count the cord (AVA);
1 artery is associated with a congenital
heart or renal abnormality
 After the 1st hour, umbilical stump
begins to dry & shrink, turning brown;
2nd to 3rd day, black
 Stump falls off by day 6 to 10 leaving a
granulating area that heals in 1 week
 Moist or odorous cord suggests
infection; treat to prevent septicemia
 PATENT URACHUS- a canal that
connects the bladder to the
umbilicus as manifested by
moistness at the base of the cord
caused by urine flow
 Check for umbilical hernia; if < 2 cm, it
closes on its own by school age
 Newborn kidneys are the size of a
walnut; right kidney is lower than the left
 ABDOMINAL REFLEX- stroke each
quadrant of the abdomen to cause
the umbilicus to wink in that direction
(not demonstrable before the 10th day of
life)
BACK
 Spine appears flat in the lumbar &
sacral areas; curves appear only after
the child is able to sit & walk
 SPINA BIFIDA OCCULTA or DERMAL
SINUS- pinpoint opening, dimpling or
sinus tract in the skin
 NB typically assumes its position in
utero
EXTREMITIES
 Arms & legs appear short, hands are
plump
 Fingernails are soft & smooth,
sometimes extend over the fingertips
 Test upper extremities for muscle tone
by unflexing the arm for 5 seconds. If
tone is good, arm immediately returns to
its flexed position.
 When the arms are at the sides, the
fingertips should cover the proximal
thigh; unusually short arms may signify
ACHONDROPLASTIC DWARFISM
 SIMIAN CREASE- a single crease on
the palm (normally 3 creases) plus
unusual curvature of the little finger
are associated with Down syndrome
 If arm hangs limp or is unmoving, it
suggests birth injury (to a clavicle,
brachial or cervical plexus or fracture of
a long bone)
 SYNDACTYLY- webbing of fingers or
toes
 POLYDACTYLY- extra digits
 Soles of the feet are covered
approximately 2/3 by creases; if less,
suspect immaturity
 In a supine position, both hips can
flexed & abducted (180°) that the knees
touch or nearly touch the surface of the
bed
 If hip joint locks 160 to 170°, hip
subluxation (shallow, poorly-formed
acetabulum) is suggested
 Hold the infant’s leg with fingers on the
greater & lesser trochanters then abduct
the hip; if subluxation is present, a
-Castillote BSN2 A10
 “clunk” of the femur head striking the
shallow acetabulum CAN BE HEARD
(ORTOLANI’S SIGN).
 If the hip can be felt slipping from the
socket, this is BARLOW’S SIGN

SESSION #19
I. DEFINITION OF TERMS
 GROWTH- generally used to denote
an increase in physical size or
QUANTITATIVE CHANGE; measured
as weight and height
 DEVELOPMENT- is used to indicate
an increase in skill or ability to
function (a QUALITATIVE CHANGE);
can be measured by observing a child’s
ability to perform certain tasks (eg. How
well a child picks up small objects such
as raisins), by recording a parent’s
description of a child’s progress, or by
using standardized tests such as the
DENVER II
 MATURATION is synonymous to
development.
 PSYCHOSEXUAL DEVELOPMENT is
a specific type of development that
refers to developing instincts or
sensual pleasure (FREUDIAN
THEORY)
 PSYCHOSOCIAL DEVELOPMENT
refers to ERIKSON’S STAGES OF
PERSONALITY DEVELOPMENT
 MORAL DEVELOPMENT is the ability
to know right from wrong and to
apply these to real-life situations
(KOHLBERG)
 COGNITIVE DEVELOPMENT refers to
the ability to learn or understand
from experience, to acquire and
retain certain knowledge, to respond
to a new situation, and to solve
problems (PIAGET’s COGNITIVE
DEVELOPMENT THEORY)
II. STAGES OF GROWTH AND
DEVELOPMENT
1. PRENATAL PERIOD- conception to birth
 Germinal- conception to 10 days
gestation
 Embryonic- 10 days to 8 weeks
gestation
 Fetal- 2 months to birth
2. INFANCY PERIOD- birth to 1 year
 Newborn/neonatal period- birth to 1
month
 Infancy- 1 month to 12 months
3. CHILDHOOD PERIOD- 1 year to 12 years
 Toddler- 1 year to 3 years
 Preschool- 3 years to 6 years
 Schoolage- 6 years to 10 years
 Puberty- 10 years to 12 years
4. ADOLESCENCE- 12 years to 19 years
 Early adolescence- 12 years to 16
years
 Late adolescence- 16 to 19 years
III. RATES OF GROWTH
1. INFANCY- most RAPID period of growth
 Birth weight doubles: 6 months
 Birth weight triples: 12 months
2. TODDLER- slow, plateau
 Trunk grows faster than other tissues
3. PRESCHOOLER- slow, uniform
 Trunk grows faster than other tissues;
legs also grow fast
4. SCHOOLER- slow, uniform growth
 Limbs grow most rapidly
 Bones grow faster than muscles and
ligaments- tendency to fracture
-Castillote BSN2 A10
5. ADOLESCENCE- rapid growth, in spurts
both in height & weight
 Trunk grows faster than other tissues
 Girls are ahead by 2 years in growth
spurt
 Growth spurt lasts for 3 years
 At age 9, boys and girls are the same in
size; at 12, girls are bigger than the
boys
IV. PRINCIPLES OF GROWTH AND
DEVELOPMENT
1. Growth and development are continuous
processes from conception until death
Ex. – at all times a child is growing now cells
& learning new skills
- BW triples and height increase by 50% at 1
year-old
2. Growth and development proceed in an
orderly sequence
Ex. – growth in height proceeds in only 1
sequence- from smaller to larger
- development proceeds in a predictable
order (sitting before creeping then stand
before walking and then proceed to running)
3. Different children pass through the
predictable stages at different rates
Ex. – some walk at 9 mos. while some at 14
mos. (all stages have a range of time)
4. All body systems do not develop at the
same rate
5. Development is cephalocaudal
Ex. – Newborn can lift only the head when in
a prone position. By 2 mos., he can lift the
head and chest off the bed; by 4 mos., the head,
chest & part of the abdomen; by 5 mos., can
turn over; by 9 mos., can crawl; by 1 yr, can
stand or walk
6. Development proceeds from proximal to
distal body parts
Ex. – Newborn makes little use of the arms
and legs; by 3 to 4 mos., can support the upper
body weight onthe forearms and can scoop up
objects with the hand; 10 mos., pincer-like grasp
to pick up small objects
7. Development proceeds from gross to
refined skills
Ex. – 3 yo colors with a large crayon; 12-year-
old can write with a fine pen
8. There is an optimum time for initiation of
experiences or learning
Ex. – cannot learn tasks until nervous system is
mature enough to allow that particular learning
-those not given the opportunity to learn
tasks at target times may have more
difficulty than the usual child learning the
task later on (child in a body cast at 12 mos.
old) because the child has passed the time of
optimal learning
9. Neonatal reflexes must be lost before
development can proceed
Ex. – infant cannot grasp with skill until the
grasp reflex has faded nor stand steadily until
the walking reflex hasfaded
-neonatal reflexes are replaced by purposeful
movements
-A great deal of skill and behavior is learned by
practice
V. Measurement Tools to Assess progress of
growth and development
A. Chronological age: assessment of
developmental tasks related to birth date
B. Mental age: assessment of cognitive
development
1. measured by a variety of standardized
intelligence tests (IQ)
2. results from at least 2 separate testing
sessions needed before an assessment is made
3. uses toys and language based on mental
rather than chronological age
C. Denver Developmental Screening Test
(DDST)
1. Generalized assessment tool; measures
gross motor, fine motor, language; and
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personal-social development from newborn- 6
years
2. does not measure intelligence
D. Growth parameters
1. Bone age: X-ray of tarsals and carpals;
determines degree of ossification
2. Growth charts: norms are expressed as
percentile of height, weight, head circumference
for age; any child who crosses over multiple
percentile line needs further evaluation
VI. FACTORS INFLUENCING GROWTH AND
DEVELOPMENT
1. GENETICS
 eye color, height potential, learning
style, temperament
a. GENDER
o girls are usually born lighter and
shorter; by pre-puberty, girls
surge ahead (puberty is 6 mos. to
1 yr. earlier than boys); by the
end of puberty (14 to 16 yrs.),
boys again tend to be taller and
heavier
b. HEALTH
o Those who inherit a genetically-
transmitted disease may not grow
as rapidly or develop as fully as a
healthy child
c. INTELLIGENCE
o Children with high intelligence do
not generally grow faster than
others but tend to advance faster
in skills
o Sometimes, the child with high
intelligence falls behind in physical
skills because he/she spends more
time with books or mental games
2. TEMPERAMENT
 It is the usual reaction pattern of an
individual, or an individual’s
characteristic manner of thinking,
behaving, or reacting to stimuli in the
environment
 It is an inborn characteristic set at birth
Reaction Patterns (Chess and Thomas)
a. Activity Level- some are constantly
on the go while others move little and
are docile
b. Rhythmicity- rhythms or schedules
in physiologic functions; some are
predictable while some have erratic
routines
c. Approach- refers to a child’s
response on initial contact with a
new stimulus; some are unruffled,
others demonstrate withdrawal, are
fussy and react fearfully
d. Adaptability- it is the ability to
change one’s reaction to stimuli over
time
e. Intensity of Reaction- some react
with their whole being (tantrums)
while some have a mild or low-
intensity reaction
f. Distractability- those who can
easily shift attention to a new
situation are easily managed; some
cannot be distracted, stubborn, willful or
unwilling to compromise
g. Attention Span and persistence-
ability to remain interested in a
particular project or activity;
persistence means they keep trying to
perform an activity even when they fail
h. Threshold of response- intensity
level of stimulation that is necessary
to evoke a reaction
i. Mood Quality- one who is always
happy and laughing has a positive
mood quality
Categories of Temperament
1. The Easy Child
-easy to care for” with predictable rhythmicity,
approach and adapt to new situations readily,
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have a mild to moderate intensity of reaction,
have an overall positive mood quality; 40% to
50%
2. The Difficult Child
- “difficult” with irregular habits, negative mood
quality, withdraw rather than approach new
situations; 10%
3. Slow-To-Warm-Up Child
-overall, fairly inactive, respond mildly and adapt
slowly to new situations, and have a general
negative mood
3. ENVIRONMENT
a. SOCIOECONOMIC LEVEL
 Health care and nutrition are affected
b. PARENT-CHILD RELATIONSHIP
 Children who are loved thrive better
than those who are not
 Quality time spent is more important
than quantity
 Loss of love and care may interfere with
a child’s desire to eat, improve and
advance
c. ORDINAL POSITION IN THE FAMILY
 The position of the child and the size of
the family have some bearing on the
growth and development of the child
 An only child or the eldest generally
excels in language development
because conversations are mainly with
adults
 Children learn by watching other
children so an only child or an eldest
child may not excel in other skills
d. HEALTH
 Diseases from environmental sources
can influence G&D
 RHD, decrease in hearing for infants
cared for in the NICU (exposed to loud
noises)
4. NUTRITION
 The quality of a child’s nutrition during
the growing years (including prenatally)
has a major influence on his/her health
and stature
 Poor maternal nutrition may limit growth
& intelligence potential.
 Children with inadequate nutrient intake
show inadequate physical growth and
prevents them from learning at their best
intellectual level
 Those who eat too many carbohydrates
tend to be obese and develop motor
skills more slowly
 Nutrition influences susceptibility to
diseases and development of chronic
illness
VII. SIGNIFICANT PERSONS
1. INFANCY: MOTHER, mother-substitute or
primary caregiver
2. TODDLER: PARENTS; mother and father
3. SCHOOLER: teacher, peers of the same
sex, neighbors, classmates
4. ADOLESCENCE: PEERS (greatest
determinant/influencing factor of his behavior),
models of leadership. Partners of same &
OPPOSITE SEX, adults other than parents are
idolized, sexual models
VIII. FEARS OF CHILDREN
A. INFANCY: fear of STRANGERS; starts at 6
mos when infant recognizes parents; peaks at 7-
8 mos
B. TODDLERS: Fear of SEPARATION
Stages of separation anxiety:
1. PROTEST- cries loudly
2. DESPAIR- less active, monotonous voice
3. DENIAL- silent, difficulty forming close
relationships
C.PRESCHOOLER:
CASTRATION/MUTILATION
*Illogical fears: GHOSTS, INANIMATE objects,
DARK (universal fear of children)
D. SCHOOLER: Fear of
DISPLACEMENT/REPLACEMENT, disease &
DEATH (permanent separation from loved ones)
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E. ADOLESCENCE: Fear of losing Identity: X. ERIKSON’S THEORY OF PSYCHOSOCIAL
acne, obesity, body odor, homosexuality, DEVELOPMENT- ERIK ERIKSON (1902-1996)
fear of the UNKNOWN, disease and death
(altered identity); unfulfilled dreams; fears  It stresses the importance of culture
death the most & society in the development of
personality
IX. FREUD’S PSYCHOANALYTIC  A person’s social view of himself is
THEORY/PSYCHOSEXUAL THEORY more important than instinctual
(Sigmund Freud 1856-1939) drives in determining behavior.
 At each stage, there is a conflict
 Described adult behavior as being the
between 2 opposing forces. The
result of instinctual drives that have a
resolution of each conflict, or
primarily sexual nature (LIBIDO) from
accomplishment of the developmental
within the person and the conflicts that
task or that stage, allows the individual
develop between these instincts
to go on to the next phase of
(represented in the individual as ID),
development
reality (the EGO), and society (the
 INFANT (TRUST VS. MISTRUST)-
SUPEREGO)
infants whose needs are met as they
 He described child development as a
arise, cuddled played with view the
series of (PSYCHOSEXUAL STAGES)
world as a safe place; if care in
in which a child’s sexual gratification
inconsistent, inadequate or rejecting, it
becomes focused on a body part
fosters a basic mistrust; this task arises
 INFANT PERIOD (ORAL phase)- stage
again at each successive stage of
of ID (biologic pleasure principle); development
infants suck for enjoyment or relief
 TODDLER (AUTONOMY VS. SHAME
from tension and for nourishment:
OR DOUBT)- autonomy builds on new
o 0-6 mos- oral passive
motor & mental abilities; toddlers need
o 7-18 mos- oral aggressive
to do what they are capable of doing, at
(teething)
their own pace and time; if they are not
 TODDLER (ANAL PHASE)- stage of
allowed to do things they want to do,
the EGO; focus on anal region as they
they will doubt their ability and stop
begin toilet training; children find
trying
pleasure in both retention and
 PRESCHOOLER (INITIATIVE VS.
defecation
GUILT)- it is learning how to do
o part of toddler’s self-discovery,
things on their own and not merely
exertion of independence
respond to or imitate the actions of
 PRESCHOOLER (PHALLIC PHASE)- others. Encourage opportunities for
stage of the SUPEREGO;
motor play, answer questions
masturbation is common,
(intellectual initiative), do not inhibit
exhibitionism fantasy or play activity. Those who do
o OEDIPAL COMPLEX- son’s
not develop initiative may later have
attachment to mother and
limited brainstorming and problem-
jealousy towards the father
solving skills, waiting for clues or
o ELECTRA COMPLEX-
guidance from others before acting
daughter’s
 SCHOOLAGE CHILD (INDUSTRY VS.
 SCHOOL-AGE (LATENT PHASE)- INFERIORITY)- The task is how to do
strict SUPEREGO; libido is diverted things well; success or failure in
into concrete thinking school or community settings have a
 ADOLESCENT (GENITAL PHASE)- it lasting impact
is the establishment of new sexual
 ADOLESCENT (IDENTITY VS. ROLE
aims and the finding of new love CONFUSION)- they must bring
objects
everything they have learned about
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 themselves and integrate these
different images into a whole that
makes sense
 YOUNG ADULT (INTIMACY VS.
ISOLATION)-intimacy is the ability to
relate well with other people, not only
the opposite sex but also with one’s
own sex to form lasting friendships
 MIDDLE-AGED ADULT
(GNERATIVITY VS. STAGNATION)-
extend their concern from just
themselves and their families to the
community and the world, become
politically active, work to solve
environmental problems, participate
in far-reaching communities or world-
based problems; those without
generativity stagnate and become self-
absorbed with a narrow perspective and
lack ability to cope
 OLDER ADULT (INTEGRITY VS.
DESPAIR)- those with integrity feel
good about their life choices; those
with despair wish life would begin
again so things could turn out
differently
SUMMARY OF FREUD’S AND ERIKSON’S
THEORIES OF PERSONALITY
DEVELOPMENT
FREUD’S STAGES
Infant: ORAL stage: explores the world by
using mouth, esp the tongue: Oral stimulation
using pacifiers; don’t discourage thumbsucking;
breastfeeding provides more stimulation due to
increased effort
Toddler: ANAL Stage: learns to control
urination & defecation: Help achieve toilet
training without undue emphasis on its
importance; continue when hospitalized
Preschooler: PHALLIC Stage: learns sexual
identity through awareness of genital area:
Accept sexual interest like fondling of genitals,
as normal; help parents answerquestions about
birth or sexual differences
School-age: LATENT Stage: child’s personality
development appears to be nonactive or
dormant: Help child have positive experiences
so self-esteem continues to grow & child
prepares for the conflicts of adolescence
Adolescent: GENITAL Stage: adolescent
develops sexual maturity & learns to establish
satisfactory relationships with the opposite sex:
Provide opportunities for the child to relate with
opposite sex; allow child to verbalize feelings
about new relationships
ERIKSON’S STAGES
TRUST VS MISTRUST-learns to love & be
loved; Provide primary caregiver, experiences
that add to security like touch, soft sounds,
provide visual stimulation
AUTONOMY VS. SHAME – learns to be
independent; Provide opportunities for
decision-making by offering choices of clothes to
wear or toys; praise for ability to make decisions
rather than the correctness of the decision.
INITIATIVE VS. GUILT- learns how to do
things (basic problem-solving) & that doing
things is desirable; Provide opportunities for
exploring new places or activities; use clay,
water, finger paints
INDUSTRY VS INFERIORITY- child learns
how to do things well; Provide opportunities
such as allowing child assemble & completea
short project so that child feels rewarded for
accomplishment
IDENTITY VS. ROLE CONFUSION- learn who
they are and what kind of person they will be
by adjusting to a new body image, seeking
emancipation from parents, choosing a
vocation, & determining a value system;
Provide opportunities to discuss feelings about
events important to him/her. Offer support &
praise for decision making
XI. PIAGET’S THEORY OF COGNITIVE
DEVELOPMENT-JEAN PIAGET (1896-1980)
4 stages of development, within each stage
are finer units or schemas
1. INFANT 0 to 2 yrs (SENSORIMOTOR
STAGE)- practical intelligence, at first through
their senses, using reflex behavior; later, they
learn people are entities separate from objects;
primary refers to activities related to a child’s own
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body while circulatory reaction shows repetition of 4. SCHOOL-AGE CHILD (CONCRETE
behaviors OPERATIONAL THOUGHT)- discover
concrete solutions to everyday problems ad
-secondary refers to activities separate from a recognize cause and effect relationships; as
child’s body (hitting a mobile, making it move); early as 7 yo
infant also learns permanence (peek-a-boo,
search for hidden objects, parent is the same -inductive reasoning- from specific to general (toy
regardless of outfit, learn where their body stops is broken; toy is made of plastic; all plastic toys
and their bed, parent or toy begin break easily)

-final phase of infant year (coordination of 5. ADOLESCENT (FORMAL OPERATIONAL

secondary reactions)- exhibit goal-directed THOUGHT)
behavior
-capable of thinking in terms of possibility- what
2. TODDLER (TERTIARY CIRCULAR could be (ABSTRACT THOUGHT)-rather than
REACTION & INVENTION OF NEW MEANS & being limited to what already is (CONCRETE
START OF PREOPERATIVE PERIOD) THOUGHT)

-tertiary circular reaction- use trial and error to -able to use scientific reasoning
discover characteristics of objects and events
-Understands deductive reasoning (from general
-invention of new means- able to think through to specific)- plastic toys break easily; this toy is
actions or mentally project solutions to a problem plastic; it will break easily
-preoperational thought- relearn on a
conceptual level some lessons mastered as
infants; using symbols to represent objects; draw
conclusions only from obvious facts they see
(Daddy is shaving therefore going to work just like
yesterday)

3. PRESCHOOLER

-intuitive thought (substage of preoperational

thought)-tend to look at an object and see only 1
characteristics or centering (banana is yellow,
medicine is bitter) which contributes to lack of
CONSERVATION (ability to discern truth, though
physical properties change) or REVERSIBILITY
(ability to retrace steps) as in pouringbeads into
differently-sized containers wherein they
conclude that there is a change in the amount of
beads

-role fantasy (how children would like something

to turn out)

-assimilation (taking in information and

changing it to fit their existing ideas)

-magical thinking- personification of nonliving

things
-egocentrism- perceiving one’s thoughts are
better or more important than those of others

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SESSION #20
GROWTH AND DEVELOPMENT OF AN
INFANT
I. Physical Growth
A. Weight
 During the 1st 6 months, the infant
typically averages a weight gain of 2
lbs./month
 During the 2nd 6 mos., weight gain is 1
lb/month
B. Height
 Infants increase in height during the
1st year by 50% or grows from an
average birth length of 20 in to 30 in
 Infant growth is most apparent in the
trunk during the early months; during the
2nd half, it becomes more apparent as
lengthening of the legs
C. Head Circumference
 HC increases rapidly reflecting rapid
brain growth. By the end of the 1st
year, the brain has reached 2/3 of its
adult size
D. Body Proportion
 Chest circumference is less than that
of the head by about 2 cm
 Cervical, thoracic and lumbar vertebral
curves develop as infants hold up their
head, sit, and walk
E. Body Systems
 CV System- HR slows from 120- 160
bpm to 100-120 bpm by the end of the
1st year
 Kidneys remain immature and not as
efficient at eliminating body wastes as in
the adult
 Immune system becomes functional by
at least 2 months of age
 The ability to adjust to cold is mature by
6 months of age
F. Teeth
 1st baby tooth/ milk tooth/deciduous
teeth (lower central incisor) erupt at 6
months of age
 12 months: have 8 teeth, lower &
upper central and lateral incisors
 24 months: 16 teeth
 2 1⁄2: with complete milk teeth- 20 teeth
 Late preschool: eruption of 1st
permanent teeth (first molars)
 6 years: brags about DANCING TEETH
 12 YEARS: with all permanent teeth
except FINAL MOLARS (27-28 teeth)
 17-21 years: complete permanent
teeth: 32
 SCHOOL AGE: to be checked for
loose teeth before any surgery
 CARE of teeth:
1. brush & floss (with parent’s help)
2x a day
2. limit concentrated sweets
3. if H2O is not fluorinated,
supplements can be given 0.25 to
0.5 mg/day
4. Don’t allow a bottle of milk or juice
to bed-BOTTLE MOUTH CARIES
5. 1ST DENTAL VISIT AS SOON AS
ALL PRIMARY TEETH ARE OUT (2
1⁄2 years)
 PERMANENT TEETH
1. 6-7 yrs.: 4 “six-year-molars”
2. 12-13 yrs.: 4 additional molars
3. 17-21 yrs..: 4 molars (“wisdom
teeth”)
II. PLAYS AND GAMES IN CHILDREN
A. INFANT
1. Solitary play- plays with body or toys
2. Toys: rattles, crib mobiles, teether, pacifier,
squeeze toys, musical boxes, large, cuddly toys,
colorful balls
B. TODDLER
1. Parallel play- plays alone in the presence
of other children: no sharing
2. Toys:
a. push and pull toys (BEST)
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b. Play telephone- age of language training
c. outlets for aggressive behavior: play hammer,
drum, pots & pans, balls
d. throwing and retrieving games (ball)
e. building blocks: build tower of 2 blocks at 12-
18 mos.,
4 blocks at 18 mos. to 2 yrs.., and 8 blocks at 2
1⁄2 years
C. PRESCHOOLER
1. COOPERATIVE PLAY: plays with others,
can be with large group of boys & girls
2. TOYS: play house, coloring books, clay,
cutting & pasting tools, superheroes, costumes,
dress-up dolls, ball (throws and catches balls at
5 yrs.; rides tricycle at 3, bicycle at 7 yrs.)
D. SCHOOLER
1. COMPETITIVE PLAY: plays with peers of
the same sex; games have rules where
winning is desired
2. TOYS: Quiet games like reading, painting,
radio listening, TV watching; table games:
scrabble, chess; bicycle (at 7 yrs.); handicrafts
(late schoolers), school sports
E. ADOLESCENCE
1. Leisure, recreation activities: parties, outings,
picnics, movies, fantasy, DAYDREAMING,
telephone conversation, reading romance
novels, sports games, hobbies
III. PROMOTING INFANT SAFETY
Accidents are a leading cause of death in
children from 1 month through 24 years of age
1. Aspiration Prevention
 Round, cylindrical objects are more
dangerous (carrot, pea, hotdog)
because it can totally obstruct the
airway
 Do not prop feeding bottles
 Children < 5 should not be offered
peanuts or popcorn
2. Fall Prevention- 2nd major cause of infant
accidents
 Do not leave infant unattended on a
raised surface
 Be prepared for infant to roll over at 2
months
 Crib rails should be 2 3/8 inches apart,
narrow enough so a child cannot put his
head between them
3. Car Safety
 Infants up to 20 lbs. should be placed in
a rear- facing seat in the back seat
because an inflating air bag could
suffocate them
4. Safety with Siblings
 Do not leave infants unattended with
children < 5 yrs. of age
5. Bathing & Swimming safety
 Do not leave infant unattended in a tub
6. Childproofing
 Check for possible sources of lead
(paint) since infants begin teething at 5
to 6 months
 Remove all poisonous substances from
bottom cupboards
IV. PROMOTING NUTRITIONAL HEALTH
 The best food during the 1st 12 months
of life (and the only food necessary for
the 1st 6 months) is breast milk
 Due to extremely rapid growth, high
protein, high calorie intake is needed
 Breast fed infants gain less weight than
formula-fed infants
A. Introduction of Solid food
 Delaying feeding of solid foods until 4 to
6 months prevents the kidneys from
being overwhelmed by the high solute
load
 Extrusion reflex fades by 3 to 4 mos. In
preparation for the introduction of solid
food.
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Schedule for introducing solid food
0 to 3 mos.
-Feeding only breast milk or formula for 1st year
-Hold infant when feeding & never prop bottle
when feeding
-limit water intake to 1⁄2 oz. to 1 oz. at a time
-avoid use of honey or corn syrup
-allow non-nutritive sucking
4 to 6 mos.
-introduce solid foods without salt or sugar &
iron-fortified cereal, 1 food at a time
-avoid use of juice or sweetened drinks
-feed from a spoon only
7 to 9 mos.
-introduce finger foods & cup when infant is able
to sit up
-have infant join family at mealtimes
-allow self-feeding, with observation to prevent
choking
-offer fluids after solids
-introduce limited amounts of diluted juice in a
cup
-avoid sugary desserts & soda
10 to 12 mos.
-offer 3 meals & healthy snacks
-begin to wean from bottle & begin table foods
-avoid fruit drinks & flavored milk
-allow infant to feed self with spoon
B. Sequence of Introducing Solids
1. RICE CEREALS
 Hypoallergenic, easy to digest
 Do not give it from the bottle to prevent
aspiration and allow learning to eat with
a spoon
2. VEGETABLES (7 mos.)
 Iron content is higher than fruits and
therefore given before fruits
3. FRUITS
 Offered 1 month after beginning
vegetables (8 mos.)
 Offer a selection so infant is exposed to
different tastes & textures
4. MEAT (9 MOS)
 Beef & pork have more protein than
chicken; offer them first
 meat is usually added as part of the
evening meal in place of cereals
5. EGG YOLKS (10 mos.)
 the yolks contain the bulk of iron in eggs
 may be prepared by hard-boiling then
mashing; soft-boiling is not
recommended because Salmonella may
not be killed and thorough cooking
makes it easier to digest
 whole eggs are given at 12 mos.
6. TEETHING FOODS (6 to 7 mos.)
C. Establishing Healthy Eating Patterns and
Promoting Development in Daily Activities
1. WEANING
 infant can drink from a cup at 9 mos.
 Sucking reflex begins to diminish at 6 to
9 mos., the right time to wean the infant
 Choose 1 feeding a day to introduce
weaning
2. SELF-FEEDING
 At 6 mos. of age, introduce the use of a
spoon
3. BATHING
 The frequency of bathing depends on
the weather
 Some need frequent washing of the
scalp to prevent SEBORRHEA (cradle
cap)
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4. DIAPER –AREA CARE
 Change diapers frequently, about every
2 to 4 hours; wash the skin & allow to
dry and apply ointment
5. CARE OF TEETH
 Use toothpaste after the tooth eruption
 Initial check-up is made at 2 or 2.5 years
of age & continues at 6-month intervals
6. SLEEP
 Most require 10 to 12 hours of sleep at
night and 1 or several naps during the
day
V. PARENTAL CONCERNS AND PROBLEMS
RELATED TO NORMAL INFANT
DEVELOPMENT
1. TEETHING
 High fever, seizures, vomiting or
diarrhea and earache are NEVER
normal signs of teething
 Teething rings may be refrigerated to
provide soothing coolness against
tender gums
2. THUMBSUCKING
 The sucking reflex peaks at 6 to 8
months, whereas thumb-sucking peaks
at about 18 mos.
 Thumb sucking is normal, does not
deform the jaw line as long as it stops
by school age.
3. USE of PACIFIERS
 Parents should attempt to wean a child
from a pacifier any time after 3 mos. of
age
 Use of pacifiers has been linked to
increased incidence of otitis media
 Be vigilant to prevent strangulation from
the strap or aspiration
4. HEAD BANGING
 It is normal if it begins during the 2nd
half of the 1st year through to the
preschool period, associated with
naptime or bedtime and lasts under 15
minutes
5. SLEEP PROBLEMS
For eliminating or coping with night waking:
 Delay bedtime by 1 hour
 Shorten afternoon naps
 Do not respond immediately to infants at
night so they can have time to fall back
to sleep on their own
 Provide soft toys or music to allow them
to play quietly alone
6. CONSTIPATION
 Foods with bulk such as fruits or
vegetables, apple juice or prune juice,
add more fluids
 If it persists, check for other possible
conditions
7. LOOSE STOOLS
 Infants with associated signs such as
fever, cramping, vomiting, anorexia,
decrease I voiding and weight loss must
be evaluated
8. COLIC
 Colic is a paroxysmal abdominal pain
that occurs generally in infants < 3 mos.
of age
 The infant cries loudly, pulls up the legs
against the abdomen, face flushed, fists
clench and the abdomen become tense
 The cause is unclear, maybe from
overfeeding or swallowing too much air
or the formula is hard to digest
 Assess the feeding patterns, the diet
and bottle-feeding methods
 Give small, frequent feedings, bubble
frequently
 In most infants, it disappears at 3 mos.
because it is easier to digest food &
easier to maintain an upright position
9. SPITTING UP
 Formula-fed babies do it more often
than breastfed babies
 Spitting up (rolling down the chin) 2 to 3
times a day is normal
-Castillote BSN2 A10
  Burp baby thoroughly, sit infant on an
infant chair for 30 mins after feeding to
decrease spitting up

10. DIAPER DERMATITIS

 Diaper rash occurs if the diaper change

is infrequent causing irritation from
stools and from the ammonia in urine
 Change diapers frequently, apply A & D
or Desitin ointment, and exposing the
diaper to air

11. MILIARIA

 Prickly heat rash occurs often in warm

weather or when babies are
overdressed or sleep in overheated
rooms
 They appear as clusters of pinpoints,
reddened papules with occasional
vesicles and pustules surrounded by
erythema appearing on the neck first
spreading upward to the ears and face
and downward to the trunk
 Bathe 2x a day during hot weather,
eliminate sweating to prevent further
eruption

12. BABY-BOTTLE SYNDROME

 Decay occurs because while an infant

sleeps, liquid from the propped bottle
continuously soaks the upper front teeth
and the lower back teeth (lower front
teeth are covered by the tongue)
 Never put the baby to sleep with a bottle

13. OBESITY IN INFANTS

 Obesity is a weight greater than the 90th

to 95th percentile on a standardized
height/weight chart
 It occurs when there is an increase in
the number of fat cells due to excessive
calorie intake
 Formula should not be more than 32 oz
daily; add a source of fiber to the diet;
avoid refined sugars

-Castillote BSN2 A10

SESSION #21
GROWTH AND DEVELOPMENT OF A
TODDLER
 SQUAT, “POT-BELLIED” appearance
because of less well-developed
abdominal muscles & short legs
A. Anthropometric Measurements
1. WEIGHT:
 Weight gain= 1.8-2.7kg (4-6 lbs.)/year
 Average weight (2yo) = 12 kg (27 lbs.)
 Birth weight X 4 at 21/2 yrs. Old
2. HEIGHT:
 increase of 3 inches/yr. (mainly in the
LEGS
 Ave height at 2 yrs. old = 34 in (50%
adult height)
3. HC (Head Circumference) = CC (Chest
Circumference) by 1 to 2 yrs old
4. CC > HC during toddler years
B. Distinct Characteristics and Traits of
Toddlers
 NEGATIVISM: “NO”
 Development of EGO
 TEMPER TANTRUMS
 RITUALISM
 DAWDLING
 EGOCENTRICITY/SELFISHNESS
C. Psychosocial Development
 AUTONOMY VS SHAME & DOUBT
 PRE-CONCEPTUAL PHASE (2-4 yo)-
 animism, magical thinking, concrete,
literal
 Vague idea about GOD
 REWARD & PUNISHMENT
 DIFFERENTIATION- separate
individual
 Withstand DELAYED GRATIFICATION
 TRANSITIONAL OBJECT
D. NUTRITION
 PHYSIOLOGIC ANOREXIA-picky,
fussy
 GRAZING, NIBBLING
 RITUALISTIC- use same plate,
utensils
 CHOKING- avoid large, round foods
 FOOD JAGS- make food appealing,
offer variety
E. Parental Concerns During the Toddler
Years
 Toilet training
 Ritualistic behavior
 Negativism
 Discipline
 Separation anxiety
 Temper tantrums
F. Nursing Diagnoses: Toddler Growth and
Development
 Deficient knowledge related to best
method of toilet training
 Risk for injury related to impulsiveness
of toddler
 Interrupted family process related to
need for close supervision of 2-year-old
 Readiness for enhanced family coping
related to parents’ ability to adjust to
new needs of child
GROWTH AND DEVELOPMENT OF A
PRESCHOOL CHILD
BIOLOGIC DEVELOPMENT
 Average weight (3 years old) = 14.6 kg
(32lbs.)
 Average weight gain = 5 lbs./yr.
 Average HEIGHT INCREASE= 6.75-7.5
cm (2.5-3 in)/yr.
 PHYSICALPROPORTIONS: slender,
sturdy, graceful, agile, posturally-erect
SOCIAL/MORAL DEVELOPMENT
 ASSOCIATIVE PLAY
 IMAGINARY PLAYMATES
 SEX Education at 5yo from parents
 Fear of the DARK; SLEEP TERRORS
 LYING, TELLS TALES
 Stuttering
-Castillote BSN2 A10
EMOTIONAL DEVELOPMENT

 Oedipus and Electra complexes

 Gender roles
 Socialization
Nursing Diagnoses for Preschoolers

 Health-seeking behaviors related to

developmental expectations
 Risk for injury related to increased
independence outside the home
 Delayed growth and development
related to frequent illness
 Risk for imbalanced nutrition, more than
body requirements, related to fast food
choices
 Risk for poisoning related to
maturational age of child
 Parental anxiety related to lack of
understanding of childhood
development

SESSION #22
GROWTH AND DEVELOPMENT OF A
SCHOOL-AGE CHILD
BIOLOGIC DEVELOPMENT
 The school age child is a sturdy,
complicated individual with the
ability to communicate,
conceptualize in a limited way &
become involved in complex social &
motor behavior.
o Height & weight increase is
SLOW& STEADY
o Proportional changes: slimmer,
longer legs, varying proportion &
lower center of gravity; posture
improves, fat diminishes & is
redistributed
o UGLY DUCKLING STAGE –
early years
o PREADOLESCENCE- from
middle of childhood to 13yo
o PUBERTY- 10 in girls, 12 in
boys
SOCIAL/MORAL DEVELOPMENT
 LATENCY (FREUD)
 INDUSTRY VS INFERIORITY- positive
reinforcement
 PEER GROUP- secret codes, rules
 BEST FRIENDS
 BULLYING
 Not yet ready to abandon parental
control; parents as ADULTS, not PALS
 COMPETITIVE PLAY
 QUIET GAMES- collecting, reading,
handicraft, board games, computer
games, music, sports
 EGO mastery through play
MORAL & SPIRITUAL DEVELOPMENT
 REWARD AND PUNISHMENT
 Concepts of Heaven & Hell
 Concept of punishment to fit the crime
COGNITIVE DEVELOPMENT
CONCRETE OPERATIONS
 From making judgments from what
they see (Perceptual Thinking) to
making judgments based on what
they reason (CONCEPTUAL
THINKING)
-Castillote BSN2 A10
  CLASSIFICATION
 ORDERING
 REVERSIBILITY-refers to the ability
to recognize that numbers or objects
can be changed and returned to their
original condition. For example, during
this stage, a child understands that a
favorite ball that deflates is not gone but
can be filled with air again and put back
into play
 CONSERVATION is the concept of
things staying the same even though
other elements change, which is
based on rational thinking.
DEVELOPMENTAL CONCERNS:
 CHEATING
 STEALING/SHOPLIFTING- 7 years-old
 Early childhood stealing is best
handled without a great deal of
emotion.
 Shoplifting must be taken seriously
by parents.
 Parents should set good examples
 HANDEDNESS- established at 6
years-old
 SPEECH DIFFICULTIES
 PREPARATION FOR PUBERTY
 SEX Education- HCP as resource
person
 SCHOOL STRESS
 Violence or terrorism
o Assure children they are safe.
o Observe for signs of stress.
o Do not allow children or
adolescents to view footage of
traumatic events repeatedly.
o Watch news programs with
children; explain the situation
portrayed.
o Prepare a family disaster plan;
designate a “rally point” to meet
if ever separated.
irregularities, uncontrollable
aggressiveness, and possible cancer.
 Teach to recognize tobacco advertising
manipulation; caution against
experimenting with smokeless tobacco.
 Role model excellent nonsmoking health
behavior.
PROBLEMS OF SCHOOLERS
 STEALING/SHOPLIFTING (7years)-
 CHEATING
 HANDEDNESS- established at 6
years old
 SPEECH DIFFICULTIES
 PREPARATION FOR PUBERTY
 SEX Education- HCP as resource
person
 DRUG EXPERIMENTATION
 SCHOOL STRESS
Nursing Diagnoses: School-Age Children
 Health-seeking behaviors related to
normal school-age growth and
development
 Readiness for enhanced parenting
related to improved family living
conditions
 Anxiety related to slow growth pattern of
child
 Risk for injury related to deficient
parental knowledge about safety
precautions for a school-age child

Recreational drug use

 Suspect if child regularly appears

irritable, inattentive, or drowsy.
 Counsel against use of steroids;
highlight future cardiovascular

-Castillote BSN2 A10

SESSION #23 MORAL DEVELOPMENT

GROWTH AND DEVELOPMENT OF AN  INTERNALIZED SET OF MORAL

ADOLESCENT PRINCIPLES- refers to moral code
DEFINITIONS: SEXUAL MATURATION IN GIRLS
ADOLESCENCE- begins with gradual  THELARCHE- breast development (9-
appearance of 2ary sex characteristics at 11 to 13 1⁄2)
12 years old & ends with cessation of body  ADRENARCHE- pubic hair
growth at 18 to 20 yrs old  MENARCHE- ist menstruation 2 yrs
after changes (9 1⁄2 to 12 years old)
PUBERTY- the maturational, hormonal & growth
processes that occur when the reproductive  OVULATION- 6 to 14 mos after
organs begin to function & the secondary sex MENARCHE
characteristics begin to develop (3 stages)  Growth spurt
 Widening of the hips
PREPUBESCENCE- 2 years before puberty  Vaginal secretions increase
 Axillary hair
PUBERTY- sexual maturity is achieved;
menarche SEXUAL MATURATION IN BOYS
POSTPUBESCENCE-1-2 yrs after puberty  enlargement & thinning, reddening &
3 PHASES OF ADOLESCENCE: increasing looseness of scrotum (9
1⁄2-14 yo)
EARLY ADOLESCENCE- 11-14 yrs old  Pubic hair, axillary & facial hair
 Penile enlargement
MIDDLE ADOLESCENCE- 15 to 17 yrs old
 Increasing muscularity
LATE ADOLESCENCE- 18 to 20 yrs old  Voice changes
 GYNECOMASTIA
SOCIAL DEVELOPMENT  Growth spurt
 IDENTITY VS ROLE CONFUSION  NOCTURNAL EMISSIONS
 Easily influenced into forming concept of  SPERMATOGENESIS
self; choose ROLE MODELS & avoid PHYSICAL GROWTH
Labeling
 PEER GROUP influence  ACNE
 Vacillates between considerable  APOCRINE SWEAT GLANDS active
maturity &childlike behavior  GROWTH SPURT- extremities & neck
 MOOD SWINGS first
 AMBIVALENCE bw independence &
PLAYS AND GAMES
fear of responsibilities

COGNITIVE DEVELOPMENT  LEISURE/RECREATIONAL

ACTIVITIES
 ABSTRACT THINKING- no longer  PARTIES, OUTING, PICNICS, MOVIES
restricted to the real & actual  FANTASY & DAYDREAMING
(CONCRETE) but also considers the  TELEPHONE CONVERSATIONS
possibilities  COMPUTER GAMES
 FORMAL OPERATIONAL AGE  READING ROMANCE NOVELS
 Scientific reasoning  SPORTS
 Can imagine thinking other than their  HOBBIES
own
-Castillote BSN2 A10
PROBLEMS WITH ADOLESCENTS CAUSES OF INJURIES

 Fatigue, poor posture  MOTOR VEHICULAR ACCIDENTS

 ACNE VULGARIS  SPORTS ACCIDENTS
 SUICIDE  DROWNING
 DRUG EXPERIMENTATION  ALCOHOL
 ALCOHOLISM  DRUGS
 SUICIDE
 TEENAGE PREGNANCY

-Castillote BSN2 A10

-Castillote BSN2 A10