Class Notes - Term 2 - MCN Lec

TERM
NCM107
BSN TRANSES
2
FETAL CIRCULATION → The ductus arteriosus, like the foramen ovale functionally closes with
establishment of respiration (as early as 1 hour) for about 1 to 3 days and
anatomically closes in a few months about 2 to 3 months becoming
1. Oxygenated blood from the placenta passes to the ligamentum arteriosum.
umbilical vein (1 left vein that contains the most amount
of oxygenated blood at its entry into the liver) → If ductus arteriosus fails to close, it will become anacyanotic heart disease -
patent ductus arteriosus (PDA) –with machinery-like murmurs as an important
→ closes at birth with cord clamping and becomes sign.
ligamentum teres.
MILESTONE OF FETAL DEVELOPMENT
→ From the umbilical vein, a small amount of
blood goes to the liver to nourish the liver (and
not for the blood to be detoxified). STAGES OF INTRAUTERINE DEVELOPMENT
→ Most of the blood in the umbilical vein goes to the inferior vena cava through A. THE OVUM
the ductus venosus which closes at birth with cord clamping and becomes
ligamentum venosum. → From fertilization to 2 weeks
2. From the inferior vena cava, blood goes to the right auricle and is shunted to the
→ The period of pre- differentiation
left auricle by way of the foramen ovale, thus bypassing the lungs.
of organs
→ It functionally closes with the establishment of respiration (as early as 1 hour)
about 1 to 3 days and anatomically closes in a few months (about 2 to 3 → When the ovum is exposed to a
months). teratogen, the ‘all or none’ law
applies, meaning the ovum is
3. From the left auricle, blood goes to the left ventricle to the aorta and lower body damaged and is out in spontaneous
parts. abortion or it is not affected at all
and continues to grow normally.
4. From the hypogastric arteries (branches of the aorta), the right and left umbilical
arteries receive unoxygenated blood which is directed back to the placenta for
B. THE EMBRYO
oxygenation and purification.
→ The umbilical arteries close at birth with cord clamping and later become → From 2 weeks to 2 months
umbilical ligaments.
→ The period of organ differentiation (organogenesis).
5. Blood from the body's upper parts enters the heart
through the superior vena cava (SVC). And from
→ Most Dangerous Period: A teratogen introduced at this stage may result in
the SVC, it goes to the right auricle then to the
severe organ malformation and dysfunction.
right ventricle and to the pulmonary artery.
6. From the pulmonary artery, a small amount of blood

goes to the lungs to nourish the lungs, but most
of the blood is shunted to the aorta by way of the ductus
arteriosus (bypassing the lungs).
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2
3. Reproductive system
4. Musculo-skeletal system
5. Urogenital system, except the bladder
C. ENDODERM / ENTODERM
→ the inner layer; develops into:
1. Linings of gastrointestinal tract from pharynx to rectum
C. THE FETUS 2. Liver, pancreas, thyroid, parathyroid
3. Respiratory tract
→ From 8 weeks to birth
4. Bladder, thyroid, thymus (for immunity building)

→ The period of post-differentiation of organs
→ When exposed to a teratogen, a malformation is least likely to occur. If ever the fetus is
affected, the effects will most likely be alteration in size or function but not in form.
EMBRYONIC GERM LAYERS

A. ECTODERM
→ the outer layer; develops into:

1. Nervous system
2. Hair, nails, skin epidermis, sebaceous and sweat glands
INTRAUTERINE GROWTH AND DEVELOPMENT
3. Salivary glands, mucous membrane of mouth
4. Epithelium of nasal oral passages
B. MESODERM AGE DEVELOPMENT
→ the middle layer; develops into: 4 WEEKS → All systems in the rudimentary form
1. Dermis → Beginning formation of eyes, nose, GIT; Heart

chambers are formed; heart beating (14 days); with
arm and leg buds.
2. Cardiovascular system
[TRANSES] MIDTERMS: CARE FOR MOTHER AND CHILD, ADOLESCENT (WELL CLIENTS)
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8 WEEKS → Head large in proportion to the body 36 WEEKS → Lecithin/ sphingomyelin ratio 2:1 (L/S)
→ Neuromuscular development----some movements; → Nails firms; with definite sleep/wake pattern; lanugo
Rapid brain development; External genitalia appear. disappearing; survival same as term
12 WEEKS → Placenta is fully formed and functioning 40 WEEKS → Full term with good muscle tone and reflexes
→ Kidneys develop; secrete urine; centers of → Little lanugo; if male, testes in scrotum; the age at time
ossification in most bones; with sucking and of EDC; with other characteristic features of the
swallowing; sex distinguishable; FHT detected by newborn.
ultrasound (10-12 weeks)
16 WEEKS → More human appearance

DEVELOPMENT AND FUNCTIONS OF THE PLACENTA AND FETAL
→ Quickening---multigravida; meconium in bowels; MEMBRANES
external genetalia obvious; scalp hair develops;
formed ayes, nose, ears; FHT by fetoscope D. THE PLACENTA
20 WEEKS → With vernix caseosa and downy lanugo TYPES OF PLACENTAL DELIVERY
→ Quickening stronger, felt by primigravida; FHT audible 1. SCHULTZE MECHANISM

using stethoscope; Bones hardening
→ More common; present in 80% of cases
24 WEEKS → Body well proportioned
→ Shiny, “clean” bluish side is first delivered.
→ Skin red and wrinkled; hearing established; eyebrows,
eyelashes recognizable; when born may breathe, but → Less external bleeding because blood is usually concealed behind the
usually doesn’t placenta.
28 WEEKS → Viable; immature if born at this time → The type where separation starts at the center, then to the edges causing an
inverted umbrella shape.
→ Surfactant production begins; body is less wrinkled;
with iron storage; nails appear; pupillary membrane 2. DUNCAN’S MECHANISM
has just disappeared from the eyes
→ less common; present in 20% of cases
32 WEEKS → Subcutaneous fats begin to deposit
→ Rough, “dirty,” reddish maternal side out first.
→ Skin is smooth and pink; more reflexes present; with
iron and calcium storage; good chance of survival if → More external bleeding, so it appears “bloody”
delivered
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4. Maternal Side: divided into irregular lobes; consists of fibrous tissue with sparse
NOTES vessels confined mainly to the base
→ The amount of blood loss in delivery (whether the placenta is 5. Average weight at term – 500 gm
delivered by Schultz or Duncan’s mechanism) is 250 to 300 ml.
6. Feto-placental weight ratio at term – 6:1
→ Blood loss of 500ml or above is considered POSTPARTAL
HEMORRHAGE, the leading cause of maternal mortality. B. PLACENTA IS FORMED BY THE UNION OF THE CHORIONIC VILLI AND DECIDUA
BASALIS
→ Umbrella shaped placenta delivered sideways.
→ Decidua: The endometrium in pregnancy; thickens in pregnancy with depth of 5 to 10
mm.
1. Decidua Basalis: portion of decidua directly beneath the site of implantation,

under the embedded ovum
2. Decidua Capsularis: the portion overlying the developing ovum; separates ovum
from the rest of the uterine cavity; most prominent by 2nd month
3. Decidua Vera / Decidua Parietalis: lines the remainder of the uterus
PLACENTAL STRUCTURE
A. DIMENSION
1. Discoid: 15 to 20 cm in diameter and 2 to 4 cm in thickness
2. Location: in the uterus, anteriorly or posteriorly near the fundus
3. Fetal Side: covered with amnion: beneath it the fetal vessels course with the
arteries passing over the veins.
→ Initially, the decidua capsularis and decidua vera are separated by a space because the
gestational sac does not fill the entire uterine cavity; by the fourth month, the growing
a. Amnion: 0.02 to 0.5 mm in thickness; a sac that engulfs the growing sac fills the uterine cavity.
fetus.
LAYERS OF DECIDUA BASALIS AND DECIDUAS VERA
b. Amniotic fluid: clear fluid that collects within the amniotic cavity.
A. Zona Compacta: uppermost/surface layer made up of compact cells
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B. Zona Spongiosum: middle, spongy layer; with glands and small blood vessels ▪ Diffusion: oxygen, carbon dioxide, water and electrolytes move
from greater to lesser concentration
C. Zona Basalis: lowest most/basal layer
▪ Facilitated transport: glucose
→ The zona basalis and zona spongiosum together form the functional layer (zona functionales).
▪ Active transport: amino acid, calcium, iron
→ Implantation is up to the level of spongiosum.
▪ Pinocytosis (The process by which extracellular fluid is taken
→ The zona basalis remains after delivery/placental separation. into a cell.): fat, gamma globulin, albumin
▪ Leakage allows fetal and maternal blood to mix slightly because

of placental defects; normally, there is no mixture of fetal and
maternal blood
2. Excretory with the amniotic fluid as the medium of excretion
3. Respiratory organ of the fetus
4. The placenta acts as a protective barrier to some substance and

organisms like heparin and bacteria; ineffective for virus, alcohol,
nicotine, antibiotics, depressants and stimulants.
→ Decidua Aging: Nitabuch’s layer, a zone of fibrinoid degeneration, is where invading 5. Endocrine: secretes hormones estrogen, progesterone, human chorionic
trophoblast meets the decidua. This layer is usually absent whenever the decidua is gonadotropin (HCG), and human placental lactogen (HPL ), also called
defective chorionic somatomammotropin (HCS).
C. PLACENTAL MATURITY a. Estrogen and progesterone’s major source of production after

the first 2 months is the placenta.
→ 12 weeks or 3 months
b. Human chorionic gonadotropin (HCG)
→ functions most effectively through 40 to 41 weeks
• Secreted as early as 8 to 10 days after fertilization;
detected in serum as early as the time of implantation
→ may be dysfunctional beyond 42 weeks. by the most sensitive pregnancy test, the
radioimmunoassay (RIA); and detected in urine 10
D. PLACENTAL FUNCTIONS days (2 weeks) after missed period by simple
pregnancy test
→ transports nutrients and water-soluble vitamins to fetus
• Functions: prolongs the life of the corpus luteum;
1. Fluid/gas transport serves as basis for pregnancy tests
• The hormone found elevated in excessive vomiting

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• Normal value: 400,000 I.U./24 hours → Placenta with 3 complete or almost complete lobes
c. Human chorionic somatomammotropin (HCS) orHuman 5. Battledore placenta

Placental Lactogen (HPL)
→ Insertion of the cord at the placental margin
• Secreted by third week after ovulation
• Influences somatic cellular growth of fetus; resembles

the growth hormone
• The principal diabetogenic factor as it is the major

insulin antagonist, 6. Velamentous insertion of cord / Placenta velamentosa
or glucose sparing
hormone → Umbilical vessels separate in the membranes at a distance
from the placental margin which they reach surrounded only
• Prepares the breast by a fold of amnion.
of the mother for
lactation 7. Cord loops
SOME PLACENTAL / CORD ABNORMALITIES → When cord coils around portions of the fetus, usually the
neck (nuchal cord).
1. Placenta succenturiate
8. Cord torsion
→ One or small accessory lobes are developed in the membranes; of clinical
significance because retention in the uterus after placental expulsion may result in → Twisting of the cord resulting from fetal movements; when marked, may affect fetal
maternal hemorrhage. circulation.
2. Placental infarcts 9. Cord knots
→ Fibrinoid degeneration of the → False knots: result from kinking of the vessels to accommodate to the length of the
trophoblast, calcification, and ischemic cord
infarction; of diverse origin; most
common placental lesion
→ True knots: result from active movements of the fetus
3. Placental bipartita THE UMBILICAL CORD / FUNIS

→ Placenta with 2 complete or almost complete lobes A. LENGTH: 55 cm, 1 inch across at term
4. Placental tripartite B. PARTS:

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1. One left umbilical vein: carries oxygenated blood to the fetus 1. Serves as a protective cushion/shock absorber
2. Two umbilical arteries (left and right): carry deoxygenated blood from fetus to 2. Separates fetus from membranes allowing symmetrical growth and free movement
placenta
3. Acts as a medium of excretion
3. Wharton’s jelly, gelatinous substance
4. Serves as fetal drink (If there is an abnormality in the deglutition center of the brain or if
a. Wharton’s Jelly: Specialized connective tissue, an extension of the there is esophageal atresia that the fetus could not swallow, amniotic fluid
amnion; surrounds the umbilical cord to prevent cord compression. accumulates(polyhydramnios).
b. The blood volume in the cord also helps prevent cord compression. 5. Serves as a specimen for periodic diagnostic exams to determine fetal wellbeing or its
absence
c. The cord extends from the fetal surface of the placenta to the fetal
umbilicus. 6. Maintains fetal temperature
d. Function: to transport oxygen and nutrients to the fetus and to return 7. Equalizes uterine pressure and prevents marked interference with placental circulation
metabolic wastes including carbon dioxide from the fetus to the placenta during labor
COMMON TERATOGENS AND THEIR EFFECTS

THE AMNIOTIC FLUID
TERATOGENS
→ Clear, straw-colored fluid in which the fetus floats.
→ something that can cause or raise the risk for a birth defect in a baby. They are things
→ ORIGIN: both fetal and maternal; amniotic epithelium maternal serum and in later part that a mother may be exposed to during her pregnancy.
(10th week), fetal urine; constantly being replaced so there is no “dry labor” in
premature rupture of the bag of water. → TERATOGENESIS: the dysgenesis of fetal organs as evidenced either structurally or
functionally (Moore,1988)
→ AMOUNT: 500 to 1,000 mL at term;
→ MANISFESTATIONS: The typical manifestations of teratogenesis are restricted growth
o polyhydramnios - excessive amount of amniotic fluid, greater than 1,000 to or death of the fetus, carcinogenesis, and malformations (Schardein, 1993), defined as
1,500 mL; defects in organ structure or function. These abnormalities vary in severity and major
malformations may be life-threatening, or may have cosmetic functional effects and
o oligohydramnios – amount less than 300 to 500 mL. require major surgery
→ REACTION: neutral to alkaline (pH 7 to &.25) → SAFETY RISK: Because any medication can present
risks in pregnancy, and because not all risks are known,
the safest pregnancy-related pharmacy is as little
→ ABNORMAL COLORS: green-tinge in a non-breech presentation is a sign of fetal
pharmacy as possible. Prescribing drugs for women
distress; golden-colored fluid may be found in hemolytic disease.
during the antenatal and postnatal period is a balancing
act and that no risk-free alternatives exist (Misri &
AMNIOTIC FLUID FUNCTIONS
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Kendrick,2007). Each drug should be assessed, and its risks and benefits should be D risk to fetus
weighed.
Category Contraindicated; benefit does not outweigh risk
→ PATERNAL EXPOSURE: Exposure to medications may alter the quality, size, shape, X
performance, and production of sperm. This observation suggests that drug exposure in
the male may put the fetus at risk. Animal studies have shown that maternal teratogenic
DRUGS WITH PROVEN TERATOGENIC EFFECTS
exposure may lead to pregnancy loss or failure of the embryo to develop, but no
evidence shows that paternal exposure directly increases the risk of birth defects Drugs Teratogenic Effects
(Austin et al., 1994, Chatenoud et al.1998).
Anticholinergic drugs Neonatal meconium ileus
→ SAFETY GUIDES IN PREGNANCY
Antithyroid Fetal & neonatal goiter, Hypothyroidism
1. For any ailment seek medical attention. Take only prescribed drugs. drugs(Prophylthiouraci,
methimazole)
2. Do not self medicate.
Cyclophosphamide CNS malformation, secondary cancer
3. Do not take over-the-counter (OTC) drugs including vitamins and minerals
Diethylstilbestrol Vaginal cancer, other genitourinary defects in male or
4. Do not take alcohol no matter how slight. female offspring
→ The US Federal Drug Administration (FDA), the government agency that Hypoglycemic drugs Neonatal hypoglycemia
oversees the safety of drugs, provides the most widely used system to
grade the teratogenic effects of medications. It assigns a safety category
Methotrexate CNS and limb malfunctions
for medications using a 5-letter system: A, B, C, D, and X (FDA, 2007).
THE FDA CATEGORIES FOR LABELING OF PRESCRIPTION DRUGS TO NSAIDs Constriction of ductus arteriosus, necrotizing enterocolitis
INDICATE THE RISKS OF THEIR USE IN PREGNANCY
Phenytoin Growth retardation, CNS defects
Psychoactive Drugs Neonatal withdrawal syndrome when given in late

(barbiturates, opiods, pregnancy
Category Fetal risk not revealed in controlled studies in humans benzodiazepines)
A
Tetracycline Teeth staining/ defects, bone defects
Category Fetal risk not confirmed in studies in human but has been
B shown in some studies in animals Thalidomide Limb defects/ shortening, internal organ defects
Category Fetal risk revealed in studies in animals but not established Warfarin (coumadin) Skeleton & CNS defects ** Heparin is the anticoagulant of
C or not studied in humans; may be used if benefits outweigh choice in pregnancy; does not pass through placental
risk to fetus membrane
Category Fetal risk shown in humans; use only if benefits outweigh
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SPECIAL CONCERN: TERATOGENIC EFFECTS OF DRUGS

Chlamydia Conjunctivitis, pneumonia
DRUGS POSSIBLE EFFECTS ON FETUS

Drug Abnormality
Warfarin Underdeveloped nasal tissue,
Thalidomide Phocomelia, multiple defects abnormal long bone growth, CNS
defects
Anti-neoplastic Multiple defects, fetal death Inhalants Problems similar to those of fetal
Drugs alcohol syndrome; premature labor
Androgens Virilization, esophageal, cardiac defects Accutane/ Vitamin A Facial, Ear, heart deformities
Progestins Virilization of female fetus Streptomycin Deafness
Stilboestrrol Vaginal carcinoma Penicillin Skin Disorders
Tetracycline Tooth deformities

Tetracyclines Discoloured teeth, bone defects
Diet pills Low birth weight
Warfarin Nose, eye, hand defects, growth retardation
Phenytoin Cleft lip/ palate, microcephaly, hypoplastic

phalanges INTRAPARTAL CARE
TERATOGENS AND THEIR POSSIBLE EFFECTS ON FETUS INTRAPARTAL PERIOD

MATERNAL DISEASES POSSIBLE EFFECTS ON FETUS
→ DESCRIPTION: A series of physiologic and mechanical processes by which all the
products of conception – the baby, placenta, and fetal membranes – are expelled from the
Cancer Fetal or Placental tumor birth canal. Labor is also called travail, accouchement, parturition and confinement. The
woman in labor is called the parturient.
Toxoplasmosis Brain swelling, spinal abnormalities
THEORIES OF LABOR ONSET
Chicken Pox Scars, eye damage
A. UTERINE MYOMETRIAL IRRITABILITY / UTERINE STRETCH THEORY
Parvovirus Anemia
Hepatitis B Hepatitis
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→ This is considered as the most acceptable theory. When the uterine muscles get → Signs of lightening
stretched with fetal growth and increasing amniotic fluid, it results to irritability and
contractions to empty the contents of the uterus. - Relief of dyspnea
B. LOW PROGESTERONE THEORY / PROGESTERONE DEPRIVATION THEORY - Relief of abdominal tightness
→ Labor is said to start when progesterone (a uterine muscle relaxant) decreases and - Increased frequency of urination, varicosities, pedal edema because of
uterine muscle stimulants increase in late pregnancy. pressure on bladder and pelvic girdle
C. OXYTOCIN THEORY - Shooting pains down the legs because of the pressure on the sciatic nerves
→ The pressure of the fetal head on the cervix in late pregnancy stimulates the posterior - Increased amount of vaginal discharge
pituitary gland to secrete oxytocin which causes uterine contraction.
B. INCREASED BRAXTON HICKS CONTRACTIONS 3 TO 4 WEEKS BEFORE LABOR
D. ESTROGENIC, FETAL HORMONE, AND PROSTAGLANDIN THEORIES
1. False labor contractions; Irregular
→ All these have a stimulating effect on uterine musculature causing uterine contractility.
2. Do not dilate the cervix
E. THEORY OF AGING PLACENTA
3. Abdominal discomfort
→ As the placenta matures, more pressure is exerted on the fundal portion, the usual
placental site, and the most contractile portion of the uterus. It is believed that the 4. Relieved by walking, enema
resultant diminished blood supply to the area causes contraction.
5. Generally painless but may be quite uncomfortable
PREMONITORY SIGNS OF LABOR
C. INCREASED MATERNAL ENERGY/BURST OF ENERGY BECAUSE OF HORMONE
A. LIGHTENING EPINEPHRINE
→ descent/dipping, dropping of the presenting part to the true pelvis. D. SLIGHT DECREASE IN MATERNAL WEIGHT BY 2 TO 3 POUNDS,1 TO 2 DAYS
BEFORE LABOR
→ Engagement is not exactly the same as lightening. The head is said to be
“engaged” when the largest diameter of the presenting part passes through the → Before labor, there is a drop in the blood level of progesterone, a water-retaining
pelvic inlet or pelvic brim. hormone, causing excretion of retained fluid.
→ Onset: E. SHOW
o Primigravida: lightening occurs earlier, 2 weeks before labor → blood-tinged mucus discharged from cervix shortly before or during labor
o Multigravida: lightening occurs either a day before labor or on the day of F. RIPENING OF THE CERVIX
the labor
→ becomes as soft as butter
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G. RUPTURE OF THE BAG OF WATER 3. Specifically referring to the cervical external os (A cervical dilation of 3 cm means
the cervical external os is 3 cm open).
→ an occasional sign
4. 10 cm is a fully dilated cervix – the end of the first stage of labor
→ Rupture of the bag of waters is an indication for hospitalization.
B. EFFACEMENT
H. PROGRESSIVE FETAL DESCENT
→ thinning and obliteration of the cervical canal
→ Increased backache and sacroiliac pressure due to fetal pressure
1. Expressed in percentage (%)
TRUE vs. FALSE LABOR
2. Described as “thinning”, “shortening” or “narrowing”
CRITERIA TRUE LABOR FALSE LABOR 3. 100% effaced cervix is a fully effaced cervix where the cervical canal has
become paper-thin or already absent
Contractions Regular, progressive Irregular, non-progressive
4. 75% cervical effacement means the cervix has become ¼ of its original
Discomfort Lumbo-sacral radiating to the Abnormal length; 50% effaced means the cervix has become ½ of its original length;
front; increasing intensity and25% cervical effacement means the cervix is still ¾of its original length.
Cervix Dilated; MOST IMPORTANT No Dilation

sign
Abdominal
Walking Intensifies contractions No effect on contraction
Enema Intensifies Contractions No effect on contraction
Show Present and increasing Absent

COMPONENTS OF LABOR PROCESS
CERVICAL CHANGES
→ The five important factors or components that affect the process of labor are
A. DILATATION
1. powers, primary, and secondary;
→ progressive, opening/widening of the cervical os
2. passenger, the fetus and placenta;
1. Expressed in centimeters (cm)
3. passageway (birth canal), the soft birth canal (cervix and vagina), and the
2. Described as “opening”, “widening”, “enlarging”, or “increase in diameter” bony birth canal (true pelvis);
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4. position of the mother; and
5. psychologic response of the mother.
POWER
→ Primary Power: Uterine Contractions
→ Characteristics
o involuntary, rhythmical, regular activity of uterine musculature
o occurs intermittent by allowing for a period of uterine relaxation between

contractions → uterine and maternal rest and restoration of
→ Effects of contractions
uteroplacental circulation → sustained fetal oxygenation
o Increased maternal BP due to increased peripheral arteriole pressure →

Check maternal blood pressure BETWEEN contractions for accurate results.
o Myometrial contractions constrict blood vessels decreasing uteroplacental

circulation.
o Prolonged uterine contractions can cause fetal hypoxia.
o Cervical dilation during the first stage
o Contractions with pushing/bearing down, expel the fetus and the placenta
→ Purposes during the second and third stages of labor, respectively
o propel presenting part downward/forward → Phases of uterine contractions
o effacement of the cervix – thinning out, pulling up, shortening of the cervical o increment (crescendo): the phase of increasing or “building up” of
canal contraction; the first phase; the longest phase
o dilatation of the cervix – opening, widening, enlarging, increasing in o acme (apex): the height/peak of uterine contractions
diameter of the cervical os from 0 to 10 cm.
o decrement (decrescendo): the phase of decreasing contraction: “letting up”
the last/end phase
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▪ When 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
o From A – B: DURATION
o DIRECTLY measures the strength of contractions
▪ The period from the beginning increment to the completion of
decrement of the same contraction; expressed in “seconds.” The • at acme: Intensity ranges from 30 mm to 55 mm Hg. Of
maximum duration under normal circumstances is 90 seconds pressure
(Varney,1980), found during the transition phase and the second
stage of labor. • resting tonus average: 10 mm Hg.
o From A – C: FREQUENCY ▪ Major disadvantage: invasive and requires a ruptured bag of waters
▪ The period of time from the beginning of one contraction to the ▪ When the uterus contracts, the following uterine changes occur:
beginning of the next contraction; expressed in “every ____minutes.”
• Upper uterine segment becomes thicker and shorter.
o From B – C: INTERVAL
• Lower uterine segment becomes thinner and longer
▪ The period from the decrement of the first to the increment of the
second contraction. → Secondary Powers
o Maternal bearing down / pushing – readiness for pushing:

The time for checking maternal BP, FHT, delivering
the fetal head in precipitate labor to prevent o Cervical dilation: 10 cm; fully dilated
lacerations; the time for maternal sleep and
o Fetal station: +1; low enough to stimulate Ferguson reflex
relaxation during labor.
▪ maternal involuntary urge to push stimulated by stretch
→ Intensity receptors in the pelvic floor.
o refers to the strength of uterine contraction during acme; can be determined by o Correct pushing: Take a deep breath as soon as the next contraction
palpation. begins, and then with breath held, exert a downward pressure exactly as
though she were straining at stool.
o Palpation – placing the hand lightly on the fundus with the fingers spread;
described as mild, moderate, strong by judging the degree of indentability/ o Discourage prolonged maternal breath, holding of more than 6 seconds,
depressability of the uterine wall during acme. during pushing. Support involuntary pushing, grunting, groaning, exhaling,
or breath-holding for less than 6 seconds.
▪ When the uterine fundus is very firm and cannot be indented with fingers,
o Have four or more pushes per contraction.
the intensity is STRONG.
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o Intra-abdominal pressure: This is another secondary power. As the

woman pushes, the intra-abdominal pressure increases.
PASSENGER
→ The passenger is the fetus. The body part of the fetus that has the widest diameter
is the head, so this is the part least likely to be able to pass through the pelvic ring.
→ Whether a fetal skull can pass depends on both its structure (bones, fontanelles,
and suture lines) and its alignment with the pelvis.
→ Structure of the Fetal Skull: → Diameters of the Fetal Skull
o The cranium, the uppermost portion of the skull, is composed of eight bones. o The shape of a fetal skull causes it to be wider in its anteroposterior diameter
than in its transverse diameter.
o The four superior bones—the frontal (actually two fused bones), the two parietal, and the
occipital—are the bones that are important in childbirth. o To best fit through the birth canal, a fetus must present the smaller diameter
(the transverse diameter) to the smaller diameter of the maternal pelvis;
o The other four bones of the skull (sphenoid, ethmoid, and two temporal bones) lie at the base of otherwise, progress can be halted and birth may not be accomplished.
the cranium so are of little significance in childbirth because they are never presenting parts.
▪ Sagittal suture joins the two parietal bones of the skull
▪ Coronal suture is the line of juncture of the frontal bones and the two parietal bones.
▪ Lambdoid suture is the line of juncture of the occipital bone and the two parietal bones.
▪ Suture lines are important in birth - allow the cranial bones to move and overlap,
molding or diminishing the size of the skull so that it can pass through the birth canal
more readily.
→ Molding
▪ Anterior fontanelle (sometimes referred to as the bregma) lies at the junction of the
o Molding is a change in the shape of the fetal skull produced by the force of
coronal and sagittal sutures; diamond shaped; anteroposterior diameter measures
uterine contractions pressing the vertex of the head against the not-yet-dilated
approximately 3 to 4 cm; its transverse diameter, 2 to 3 cm; closes at 12 to 18 months
cervix.
of age
o Pressure causes them to overlap and molds the head into a narrower and
▪ Posterior fontanelle lies at the junction of the lambdoidal and sagittal sutures;
longer shape; Common when the brow is the presenting part. Parents can be
triangular shaped; smaller than the anterior fontanelle measuring approximately 2 cm;
reassured that molding only lasts a day or two and is not a permanent
closes at about 2 months of age.
condition.
→ Fetal Presentation and Position
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o Two other factors play apart in whether a fetus is lined up in the best position → Station
to be born: fetal presentation and position.
o refers to the relationship of the presenting part of a fetus to the level of the
o Attitude describes the degree of flexion a fetus assumes during labor or the ischial spines.
relation of the fetal parts to each other.
o When the presenting fetal partis at the level of the ischial spines, it is at a
▪ A fetus in good attitude is in complete flexion: the spinal column is 0station (synonymous with engagement).
bowed forward, the head is flexed forward so much that the chin
touches the sternum, the arms are flexed and folded on the chest, o Above spines is noted as (-); Below spines is noted as (+).
the thighs are flexed onto the abdomen, and the calves are pressed
against the posterior aspect of the thighs.
→ Fetal Lie
o is the relationship between the long(cephalocaudal) axis of the fetal body and
the long (cephalocaudal) axis of a woman’s body; in other words, whether the
fetus is lying in a horizontal (transverse) or a vertical (longitudinal) position
→ Engagement
→ Fetal presentation
o refers to the settling of the presenting part of a fetus far enough into the pelvis
to be at the level of the ischial spines, amid point of the pelvis.
o denotes the body part that will first contact the cervix or be born first. This is
determined by a combination of fetal lie and the degree of fetal flexion
o Descent to this point means that the widest part of the fetus has passed (attitude).
through the pelvis inlet or the pelvic inlet has been proved adequate for birth.
o Types of Fetal Position:
o No engagement in labor (primipara) means complication such as
Cephalopelvic disproportion.
1. Cephalic Presentation - most frequent type of presentation; the fetal
head is the body part that will first contact the cervix.
Engagement is assessed by vaginal or cervical examination. “Floating”
means non-engaged;
During labor, the area of the fetal skull that contacts the cervix
often becomes edematous from the continued pressure against it.
“Dipping” means descending but has not reached Ischial spines. This edema is called a caput succedaneum
16
Complete Longitudinal Good (full The fetus has

flexion) thighs flexed on
TYPE LIE ATTITUDE DESCRIPTION the abdomen;
both the
Vertex Longitudinal Good (full The head is sharply flexed, buttocks and the
flexion) making the parietal bones or the tightly flexed feet
space between the fontanelles present to the
(the vertex) the presenting part. cervix.
This is the most common
presentation and allows the
suboccipitobregmatic diameter to Frank Longitudinal Moderate Attitude is
present to the cervix moderate
because the hips
are flexed but
Brow Longitudinal Moderate Because the head is only
the knees are
(military) moderately flexed, the brow or
extended to rest
sinciput becomes the presenting
on the chest.
part
The buttocks
alone present to
Face Longitudinal Poor The fetus has extended the head the cervix
to make the face the presenting
part.
Footing Longitudinal Poor Neither the
thighs nor lower
From this position, extreme legs are flexed;
edema and distortion of the face If one-foot
may occur presents, it is a
single-footing
The presenting diameter is so breach; if both
wide that birth may be present, it is a
impossible double-footling
breach
Mentum Longitudinal Poor The fetus has completely
hyperextended the head to 3. Shoulder Presentation - a fetus lies horizontally in the pelvis so that the
present the chin. longest fetal axis is perpendicular to that of the mother. The presenting
part is usually one of the shoulders (acromion process), an iliac crest, a
The widest diameter hand, or an elbow.
(occipitomental) is presenting.
As a rule, a fetus cannot enter
the pelvis in this presentation
2. Breech Presentation - the buttocks or the feet are the first body parts
that will contact the cervix.
17
FACE PRESENTATION (MENTUM)
LMA, left mentoanterior RMA, right mentoanterior
LMP, left mentoposterior RMP, right mentoposterior
LMT, left mentrotransverse RMT, right mentotransverse

→ Types of Fetal Position
SHOULDER PESENTATION (ACROMION PROCESS)
o Fetal Position is the relationship of the presenting part to a specific quadrant of a
woman’s pelvis. LAA, left scapuloanterior RAA, right scapuloanterior
o For convenience, the maternal pelvis is divided into four quadrants according to the LAP, left scapuloposterior RAP, right scapuloposterior
mother’s right and left: (a) right anterior, (b)left anterior, (c) right posterior, and (d)
left posterior.
o In a vertex presentation, the occiput is the chosen point; in a face presentation, it is

the chin(mentum); in a breech presentation, it is the sacrum; and in a shoulder
presentation, it is the scapula or the acromion process.
o Represented with 3 acronym letter: Middle letter (fetal landmark); First letter
(landmark is pointing to the mother’s right (R) or left (L)); Last letter (landmark
points anteriorly (A), posteriorly (P), or transversely (T)).
VERTEX PRESENTATION (OCCIPUT)

→ Mechanisms (Cardinal Movements) of Labor
LOA, left occipitoanterior ROP, right occipitoposterior
o Passage of a fetus through the birth canal involves several different position
LOP, left oocipitoposterior ROA, right occipitoanterior changes to keep the smallest diameter of the fetal head (in cephalic
presentations) always presenting to the smallest diameter of the pelvis. These
position changes are termed the cardinal movements of labor: Engagement,
LOT, left occipitotransverse ROT, right occipitotransverse
descent, flexion, internal rotation, extension, external rotation, and expulsion.
(EDFIRE-ERE)
BREECH PRESENTATION (SACRUM)
1. Engagement
LSaA, left sacroanterior RSaA, right sacroanterior
o This is a mechanism by which the greatest transverse diameter of the fetal
LSaP, left sacroposterior RSaP, right sacroposterior head (biparietal diameter) passes through the pelvic inlet; head fixed in the
pelvis.
LSaT, left sacrotransverse RSaT, right sarcotransverse
18
2. Descent o Flexion results in the smallest anteroposterior diameter of the fetal head
(suboccipitobregmatic diameter: 9.5 cm.)
o This is the first requisite for the birth of the baby; the progression of the fetal
head through the pelvis.
a. May occur earlier in a nulliparous woman; before labor
b. Usually begins with engagement in a multiparous woman
c. The degree of descent is measured by station.
d. Four forces to descent: 3. Internal rotation
▪ Amniotic fluid pressure, thus, some obstetrician select to rupture the o This mechanism is the turning of the fetal head from left to right, aligning it
bag of water with an amniotone (amniotomy) to enhance labor with the long axis of the maternal pelvis and causing the occiput to move
progress anteriorly toward the symphysis pubis.
▪ Direct pressure of the contracting fundus/uterus upon breech a. In internal rotation, the fetal skull rotates from transverse to anteroposterior at
pelvic outlet; associated with descent.
▪ Effects of contractions on the diaphragm and abdominal muscle
contraction b. After internal rotation, the occiput is just under the symphysis pubis.
▪ Fetal body extension and straightening c. Not accomplished until the head is engaged; occurs mainly during the second
stage of labor.
2. Flexion
4. Extension
o This mechanism occurs when the head meets resistance from the cervix, o This is the delivery of the head in vertex presentation or when the head leaves
pelvic floor and pelvic walls causing the head to flex so that the chin is brought the pelvic outlet.
in contact with the chest.
19
a. There is gradual emergence of the occiput under the symphysis pubis,

followed by the face and then by the chin.
Safety Alert: As soon as the head is out, even before the

chest is born, the mouth and then the nose are
suctioned gently and shallowly using bulb syringe in order
to prevent meconium aspiration.
b. The duration of the extension is

controlled by the attending 5. External rotation
practitioner; breaking of the bag of
waters is done if it has not broken to o As a continuation of restitution, the shoulders align to the anteroposterior diameter,
prevent aspiration of fluids. An causing the fetal head to continue to rotate. The trunk navigates through the pelvic
episiotomy may be done by the cavity with the anterior shoulder descending first
physician to prevent tearing the
perineum, shorten the second stage or 6. Expulsion
lessen trauma to the fetal head.
o Once the shoulders are born, the rest of the baby is born easily and smoothly
• A clean surgical perineal incision, the episiotomy, is done because of its smaller size. This movement, called expulsion, is the end of the
primarily to prevent lacerations. pelvic division of labor.
• The median episiotomy is not commonly done as it easily a. Gentle but firm downward pressure/traction of the head is done to deliver the
extends to the anal region increasing the risk for sepsis anterior shoulder. Then, the head is gently raised to deliver the posterior
shoulder, and the entire body follows without much difficulty. The head is the
• Nursing Measures Promoting Gradual Extension (RPI): biggest part of the baby; after the head passes out, the rest of the body
follows with no difficulty.
a. Ritgen’s Maneuvers
b. When the entire body of the baby emerges from the birth canal, birth is
complete. This is the time of birth recorded and entered in the birth certificate.
• promote gradual extension 20. An
obstetric procedure used to control
delivery of the fetal head. It involves
PASSAGE
applying upward pressure from the
coccygeal region to extend the head → The passage refers to the route a fetus must travel from the uterus through the cervix
during actual delivery. and vagina to the external perineum. Because the cervix and vagina are contained
inside the pelvis, a fetus must also pass through the bony pelvic ring.
• Panting and not pushing during
crowning• Interval delivery of the head
(between contractions) to eliminate the
primary power uterine contractions
20
→ The diagonal conjugate (the anteroposterior diameter of the inlet) and the transverse
diameter of the outlet. At the pelvic inlet, the anteroposterior diameter is the narrowest
diameter; at the outlet, the transverse diameter is the narrowest.
→ If the fetus is the cause of the disproportion, itis often because the fetal head is
presented to the birth canal at less than its narrowest diameter, not because the fetal
head is actually too large.
1. Soft passages: cervix, vagina, perineum; maybe affected by lacerations

1. Gynecoid: normal female pelvis; ideal for childbearing; circular.
2. Bony passage: the pelvis. Problems of the bony pelvis that can influence the
progress of labor include contracted pelvis due to avitaminos D or rickets in 2. Android: wedge – or heart-shaped; associated with worse pregnancy/labor outcome,
childhood, and cepalo-pelvic disproportion (CPD) – the leading cause of primary usually results to difficult forceps delivery or caesarean section; resembles the male
caesarian section. pelvis.
→ The effects of hormone of pregnancy –estrogen and relaxin – on pelvic joints: 3. Anthropoid: narrow, oval-shaped, with sacrum usually straight making it deeper than
the other types, resembles ape pelvis.
o Soften the pelvic cartilage and increase the strength and elasticity of pelvic
ligaments 4. Platypelloid: rarest; flat gynecoid-shaped with a short AP diameter and a wide
transverse diameter; may still allow vaginal birth
o Separate pelvic joints slightly; some movement of pelvic joints giving bigger
room for the fetus o Main causes of abnormal pelvic measurements:
o Relax the symphysis pubis → slight separation as pregnancy progresses → 1. Heredity

allowing room for the fetal head (Littleton & Engebretson, 2006)
2. Poor nutrition (vitamin D deficiency/rickets in childhood)
→ Division of Pelvis:
3. Infections (poliomyelitis, TB of the bone)
1. False pelvis: upper, larger but shallow division that supports the uterus in the
abdominal cavity during pregnancy. “No significance on Obstetrics.” 4. Poor posture and exercise habits
2. True pelvis: lower, curved, smaller portion important in childbearing; the canal 5. Accidents (fractured pelvis)
through which the fetus must pass in the birth process (Seidel, Ball, Dains, &
Benedict, 2003) POSITION OF THE PARTURIENT
→ Types of Pelvis 1. First Stage of Labor
o The left lateral recumbent (LLR) is most comfortable and best for fetal well-
being as supine position. this prevents supine hypotensive syndrome or vena
caval syndrome.
21
o The optimal position may vary and may range from sitting, to squatting, to a ii. expectations and goals for the labor process; whether realistic, achievable, or
semi-reclined position, or to ambulating posture. otherwise
▪ If bag of water is intact; may ambulate. iii. feedback from other people participating in the birthing process
▪ If bag of water has ruptured: may still ambulate, provided the station 2. Pregnant women’s psychologic responses to uterine contractions.
is at least station 0, or the + stations, to prevent cord prolapsed.
o Fear and anxiety affect labor progress. A woman who is relaxed, aware of and
o If with an intravenous line, a movable should be used to allow ambulation if so participating in the birth process usually has a shorter, less intense labor
desired and if not contraindicated. (Stein & Miller,2000).
o No clear-cut best position: all have advantages and disadvantages 3. Other factors that affect psychologic response ofthe mother include:
o In the choice of position in labor, consider the following criteria: i. Childbirth preparation process (classes)
▪ Maternal, physical, and psychologic needs ▪ Considered as a valuable tranquilizer during the birth process
decreased need for analgesics in labor (Williams, Kramma & O’Brian,
▪ Fetal well-being 1997)
2. Second Stage of Labor ii. Support system
o Lithotomy position: most commonly used in the second stage; favors the ▪ The husband’s presence in the labor and delivery unit can provide
care provider emotional support less anxiety less emotional tension less pain
preceptor
▪ Ensure equal height of the stirrups.
▪ The attending nurse should provide a supporting and caring
environment; respect the client’s/family’s needs and attitudes
▪ Pad the stirrups.
provide therapeutic communication.
▪ Simultaneous placement of the legs on the stirrups
▪ Previous experiences
▪ Avoid any pressure on the popliteal region.
4. Anticipation of pain can increase emotional tension increased pain preceptor
PSYCHOLOGIC RESPONSE OF THE MOTHER/PSYCHE
5. Even though perception of childbirth pain is greatly influenced by a lot of factors such as
psychosocial factors, there is a physiologic basis for discomfort during labor (Olds,
1. A pregnant woman’s general behavior and influences upon her also affect labor
London & Ladewig, 1988)
progress. Some FACTORS that make labor a meaningful, positive or negative event
were identified by Clark & Alfonso (1978).
o Women who manage best in labor typically are those who have a strong
sense of self-esteem and a meaningful support person with them.
i. cultural influences integrating maternal attitudes; how a particular society
views childbirth
22
o Women without adequate support can have an experience so frightening and ▪ Supine position on 2nd stage of labor could lead to Hypotension.
stressful they can develop a posttraumatic stress syndrome (Tam & Chung,
2007) ▪ Upright or LLR could make pushing more effective in 2nd stage of
labor and could avoid Hypotension. (Gupta, Hofmeyr, & Smyth,
ASSESSMENT AND NURSING DIAGNOSIS FOR INTRAPARTAL 2009)
CLIENTS
2. Hemopoietic System
→ Because labor is such an intense process, it has systemic physiologic effects on both a
woman and her fetus. o The major change in the blood-forming system that occurs during labor is the
development of leukocytosis, or a sharp increase in the number of circulating
PHYSIOLOGIC EFFECTS OF LABOR ON A WOMAN white blood cells, possibly as a resultof stress and heavy exertion.
→ LABOR is a local process that involves the abdomen and reproductive organs, but its o At the end of the labor, WBC = 25,000 to 30,000cells/mm3 (N=5000 to 10,000
intensity is so great that almost all body systems are affected by it. cells/mm3).
1. Cardiovascular System 3. Respiratory System
o Labor involves strenuous work and effort andrequires a response from the o Whenever there is an increase in cardiovascular parameters, the body
cardiovascular system. responds by increasing the respiratory rate to supply additional oxygen.
o Cardiac Output. o Total oxygen consumption increases by about100% during the second stage
of labor.
▪ Each contraction greatly decreases blood flow to the uterus because
the contracting uterine wall puts pressure on the uterine arteries. o Using appropriate breathing patterns during labor can help avoid severe
hyperventilation.
▪ Uterine Contraction means increase peripheral blood flow.
4. Temperature Regulation
▪ The work of pushing during labor may increase cardiac output by as
much as 40% to50% above the pre-labor level. o The increased muscular activity associated with labor can result in a slight
elevation (1° F) in temperature.
▪ The average blood loss with birth (300 to500 mL) is not detrimental
to most women because of the blood volume increase. o Diaphoresis occurs with accompanying evaporation to cool and limit excessive
warming.
▪ Immediately after birth, with the weight and pressure removed from
the pelvis, blood from the peripheral circulation floods into the pelvic 5. Fluid Balance
vasculature, momentarily dropping blood pressure in the vena cava.
o Because of the increase in rate and depth of respirations (which causes
o Blood Pressure. moisture to be lost with each breath) and diaphoresis, insensible water loss
increases during labor.
▪ With the increased cardiac output caused by contractions during
labor, systolic blood pressure rises an average of 15 mm Hg with o Fluid balance is further affected if a woman eats nothing but sips of fluid or ice
each contraction. Extreme high blood pressure could be a pathologic. cubes or hard candy.
23
o IVF is needed. PSYCHOLOGICAL RESPONSES OF A WOMAN TO LABOR

6. Urinary System → LABOR can lead to emotional distress because it represents the beginning of a major
life change for a woman and her partner.
o Kidneys begin to concentrate urine to preserve both fluid and electrolytes.
→ Pain reduces the ability to cope and may make her short-tempered or quick to criticize
o Specific gravity may rise to a high normal level of 1.020 to 1.030. things around her.
o (trace to 1 protein) to be evident in urine because of the breakdown of protein. → Admitting her quickly to a birthing room: free from outside interference, control breathing
patterns, reduce pain in early contractions and for coping strategies.
o Pressure of the fetal head as it descends in the birth canal against the anterior
bladder –reduce bladder tone and sensibility. 1. Fatigue
7. Musculoskeletal System o A woman is generally tired from the burden of carrying so much extra weight.
o Relaxin, an ovarian-released hormone, has acted to soften the cartilage o Most women do not sleep well during the last month of pregnancy (Beebe &
between bones. Lee, 2007).
o 1 week before labor, further softening of bones happen, such symphysis pubis o Most women experience backache, and when baby kicks, it awakens them
and the sacral/coccyx joints to become even more relaxed and movable,
make it stretchable to2cm.
o Lack of sleep can make perception difficult.
o Increased back pain or irritating, nagging pain at the pubis may happen.
o Fatigue can make the process of labor loom as an overwhelming,
unendurable experience unless they have competent support people with
8. Gastrointestinal System them.
o The gastrointestinal system becomes fairly inactive during labor – due to flow 2. Fear
of blood concentrated to other organs and pressure on digestive system by
the uterine contractions.
o Women appreciate a review of the labor process early in labor as a reminder
that childbirth is not a strange, bewildering event but a predictable and well-
9. Neurologic and Sensory Responses documented one.
o The neurologic responses that occur during labor are responses related to o It may make her begin to worry that her infant may die or be born with an
pain (increased pulse and respiratory rate). abnormality.
o Early stage of labor, uterine contraction and cervical dilation cause discomfort o Explain that labor is predictable, but also variable, to limit this kind of fear.
and that pain registered at uterine and cervical nerve plexuses (at the level of
the 11th and 12ththoracic nerves).
o Be sure to explain that contractions last a certain length and reach a certain
firmness, but painless during relaxation periods.
o At the moment of birth, the pain is centered on the perineum as it stretches to
allow the fetus to move past it. Perineal pain is registered at S2 to S4 nerves.
3. Cultural Influences
24
o Cultural factors can strongly influence a woman’s experience of labor. 3. Integumentary System
o Today, women are educated to help plan their care. o Minimal petechiae or ecchymotic areas on a fetus (particularly the presenting
part).
o This makes her response to pain, her choice of nourishment, her preferred
birthing position, the proximity and involvement of a support person, and o There may also be edema of the presenting part (caput succedaneum).
customs related to the immediate post partal period individualized (Price,
Noseworthy, &Thornton, 2007). 4. Musculoskeletal System
o To make labor a positive experience, be prepared to adapt your care to the o The force of uterine contractions tends to push a fetus into a position of full
woman’s specific circumstances, such as make arrangements to flexion, the most advantageous position for birth
accommodate her beliefs or customs if possible, or making an arrangement
with an interpreter if language/communication will be a barrier
5. Respiratory System
PHYSIOLOGIC EFFECTS OF LABOR TO A FETUS
o The process of labor appears to aid in the maturation of surfactant production
by alveoli in the fetal lung.
→ Although a fetus is basically a passive participant in labor, the pressure and circulatory
changes that occur with contractions cause detectable physiologic changes
o The pressure applied to the chest from contractions and passage through the
birth canal helps to clear it of lung fluid.
1. Neurologic System
FETAL ASSESSMENT DURING LABOR
o Uterine contractions exert pressure on the fetal head, so the same response
that is involved with any instance of increased intracranial pressure occurs.
FETAL RESPONSES
o Early deceleration – Head compression; FHR decreases by 5bpm when
contraction reached40mmHg.
o Take note: On early labor contractions, the FHR will increase. If the KEY NOTE/TECHNIQUE
contractions became intense and reached 40mmHg or more, FHR will start to
decelerate or slow by 5 bpm. It is still considered normal. → EARLY DECELERATION – HEAD COMPRESSION
2. Cardiovascular System → LATE DECELERATION – PLACENTA PERFUSION
o Term fetus is unaffected by the continual variations of heart rate that occur → VARIABLE DECELERATION – CORD COMPRESSION (ROTATED C = <ORD)
with labor.
o During a contraction, the arteries of the uterus are sharply constricted and the
filling of cotyledons almost completely halts. It could lead to consequential
hypoxia.
o Increased fetal ICP serves to keep the circulation to avoid below normal fetal
oxygen supply
25
→ Early Decelerations – Monitor FHR, Oxygen therapy
→ Late Decelerations – Monitor FHR, LLR Position
→ Variable Decelerations – Monitor FHR, LLR Position
DANGER SIGNS OF LABOR
→ Wide variation exists among individuals in their patterns of labor contractions and in
maternal responses to labor and birth. Certain signs, however, indicate that the course
of events is deviating from normal.
MATERNAL DANGER SIGNS
1. High or Low Blood Pressure
o Increased BP during 2nd stage of labor is normal.
PATHOPHYSIOLOGY o BP=140/90 mmHg or increased systolic by30mmHg and increased diastolic by

15mmHgis reportable.
EARLY DECELERATION
o Hypotension is reportable = possible for intrauterine hemorrhage.
→ Head is compressing the fetal head during uterine contractions, that lead to decrease
FHR. FHR is decreased during acme of contractions. (Normal reaction) o Watch out for clinical signs of shock, such as apprehension, increased pulse rate,
and pallor.
LATE DECELERATION
2. Abnormal Pulse
→ During uterine contractions, there is a delay reaction of the FHT, FHT starts to
decrease/slow when the contractions is in decrement. Placenta perfusion is affected o Normal = 70 to 80 bpm
during uterine contractions, and it cause delay on the reaction of the fetus.
o Slight increased on 2nd stage of labor can happen.
VARIABLE DECELERATION
o A maternal pulse rate greater than 100 bpm during the normal course of labor
→ During uterine contractions, there is irregularity of the FHR. FHR increase and decrease should be reported; can be a sign of hemorrhage.
before, during and after uterine contractions.
3. Inadequate or Prolonged Contractions
NURSING INTERVENTION
o If they become less frequent, less intense, or shorter in duration, this may indicate
uterine exhaustion (inertia). CS procedure may be necessary.
→ For all decelerations, always check FETALHEART TONE/FHT/FHR before any
interventions.
26
o Period of relaxation should happen to fill the intervillous of placenta for adequate o Using an approach such as, “You seem more and more concerned. Could you
supply of oxygen and nutrients. tell me what is worrying you?” may be helpful
o As a rule, uterine contractions lasting longer than 70 seconds should be reported, o Increased Apprehension could be a sign of oxygen deprivation or intrauterine
may compromise fetal well-being hemorrhage.
4. Pathologic Retraction Ring FETAL DANGER SIGNS
o Bandl’s ring - An indentation across a woman’s abdomen, where the upper 1. High or Low Fetal Heart Rate
and lower segments of the uterus join, may be a sign of extreme uterine stress
and possible impending uterine rupture. o As a rule, an FHR of more than 160 bpm (fetal tachycardia) or less than 110
bpm (fetal bradycardia) is a sign of possible fetal distress.
o When auscultating FHR, assess abdomen.
o A sign of late or variable deceleration pattern, an irregular pattern that could
give a false sense of security on FHR.
2. Meconium Staining
o Meconium staining, a green color in the amniotic fluid, it reveals that the fetus
has had loss of rectal sphincter control, allowing meconium to pass into the
amniotic fluid.
o It may indicate that a fetus has or is experiencing hypoxia, which stimulates

the vagal reflex and leads to increased bowel motility.
o Fetus in breech position experiences meconium staining due to pressure on

5. Abnormal Lower Abdominal Contour the buttocks area.
o If a woman has a full bladder during labor, around bulge on her lower anterior o Further evaluation is needed
abdomen may appear. This is danger because
3. Hyperactivity
− may cause injury to the bladder due to fetal head pressure.
o Ordinarily, a fetus is quiet and barely moves during labor.
− descent of the fetal head may be interrupted by the full bladder
o Fetal hyperactivity may be a sign that hypoxia is occurring, because frantic
o Woman should be encouraged to void every 2 hours motion is a common reaction to the need for oxygen.
6. Increasing Apprehension 4. Oxygen Saturation
o A woman who is becoming increasingly apprehensive despite clear o Oxygen saturation in a fetus is normally 40%to 70%.
explanations of unfolding events may only be approaching the second stage
of labor.
27
o If a fetus is assessed for oxygen saturation level by a catheter inserted next to ii. Active phase: cervix 4 to 8 cm; complete effacement
the cheek, a low oxygen saturation level (under 40%) or if fetal blood was
obtained by scalp puncture, the finding of acidosis (blood pH 7.2) suggests o Contractions: moderate
that fetal well-being is becoming compromised.
STAGES OF LABOR o Duration: 45 to 60 seconds
o Frequency: q3 to 5 minutes
1. THE FIRST STAGE – DILATATION STAGE.
o Maternal behavior: less talkative, more anxious, may not want
a) Description: This is the stage from the onset of the first true labor contraction up to to be alone, fears losing control; restless; increasing in anxiety
full cervical dilatation. with malar flush (skin warm and flushed)
b) Power: Uterine contractions o Drugs for comfort (best given during the active phase when
cervix is about 4 to 6 cm. to avoid fetal depression)
o Maternal problem: may hyperventilate. Hyperventilation in

pregnancy is due to the direct effect of progesterone on the
respiratory center in the brain; during labor, hyperventilation is
related to uneven breathing pattern with uncontrolled breathing
during contractions, and rapid breathing over a prolonged
period of time causing an imbalance in carbon dioxide and
oxygen; too much carbon dioxide is expired and too much
oxygen remains in the body.
o Signs: Tingling sensation or numbness of the nose or lips,

fingertips, or toes; pallor, dizziness, lightheadedness; spots
c) 3 Phases of the First Stage: Latent, active, and transition phases before the eyes; or, carpopedal spasms (spasm of hand and
feet)
i. Latent phase: cervix 1 to 4 cm. dilatation; usually complete effacement in
primigravidae o Nursing interventions
o Contractions: mild • Encourage woman to slow her breathing and take

shallow breaths
o Duration: 30 seconds, average
• Offer client a paper-bag where she can breathe into,
o Frequency: over 10 minutes (can be 5 to 8 min.) or instruct her to breathe into her cupped hands until
signs abate.
o Maternal discomfort: backache, abdominal cramps
• Stay with the woman to keep her at ease.
o Nursing interventions: proper positioning –side; backrub;
support system can include husband stay with client to provide • Effect of unmanaged hyperventilation: Respiratory
support alkalosis - the mother in the active phase of labor may
28
benefit from breathing and relaxation techniques and • Provide psychologic comfort: Don’t leave the client
proper coaching to prevent hyperventilation alone; help focus on task; inform of progress; be
understanding of her irritability.
d) Nursing implementation
iii. Transition phase: cervix 8 to 10 cm
a. First stage of labor
o Contractions: strong
• On admission to the labor unit:
o Duration: 60 to 90 seconds
• Greeting. Introduce self.
o Frequency: q2 to 3 minutes
• Admit client. Orient to physical setting .Review common
o Maternal behavior: with increased perspiration, nausea and procedures so the patient knows what to expect.
vomiting, cramps, restlessness, panic, irritability, amnesia at
intervals, has lost control of labor, tends to push during • Take history. Determine:
contractions, with circumoral pallor, and increased show.
o Gravidity / Parity
o The mother in the transition phase may have a strong desire to
push but she should not! Pushing when the cervix is not yet fully
o EDC
dilated can result to caput succedaneum. To eliminate the
tendency to push with contractions, Lamaze technique suggest
pant-blow pattern of chest breathing during the transition phase. o Last meal
o Maternal problems: backache, pressure on bladder and o Allergies

rectum, and leg trembling
o Onset of labor: onset, frequency, duration of
o Nursing interventions: contractions
• Provide physical comfort with dry linens and cool o Status of the bag of waters
clothes.
o Intent to breastfeed
• Clean up vomitus.
o Assess client’s knowledge about labor, whether or not
• Provide backrub she had childbirth preparations.
o Take initial vital signs and FHT.

• Coach on breathing techniques: Pant-blow pattern
of breathing in the transition phase.
• Do Leopold’s Maneuvers (LM): empty bladder, flex knees.
warm hands
29
o LM 1 – palpate fundus; check for breech or cephalic; o Temperature: every 4 hours if in normal range; every
usually breech – soft, globular, non-ballotable hour if above 37.5 C. or if membranes rupture. The
leading complication of prolonged rupture of the bag
o LM 2 – palpate sides of the abdomen; check for of water is infection
smooth resistant back and irregular, small fetal parts
of the fetus. The area of the fetal back is the best site o FHR: every 30 minutes in the latent phase, and every
for FHT auscultation. 15 minutes in the active and transition phases if
normal characteristic are present. If with electronic
o LM 3 – palpate area just above the symphysis pubis; fetal monitor, assess for reactive non-stress test
check for cephalic or breech, usually cephalic – check (NST).
position and mobility of the head
• Prevent SHS (supine hypotensive syndrome): position client on
o LM 4 – palpate the midline, downwards and just about left lateral recumbent.
2 inches from the Poupart’s ligaments; check for
position and descent of the head including degree of • Provide physical and psychologic comfort and support.
flexion
o Comfort measures: assisting with positional change,
• Perineal preparation; observe principles of asepsis. keeping clean and dry, promoting sleep and adequate
rest
• Render enema if ordered – never a routine procedure. Done to
prevent: o Distraction is one of the methods to increase
relaxation and cope with discomfort of labor when
o Infection contractions are mild to moderate.
o Retardation of labor progress • Forms of distraction include:
o Postpartum discomfort o Conversation
• Obtain specimens for lab tests: urine for sugar (negative in o Light activities as reading, card playing, table games
labor), protein (negative), acetone(negative), blood for
hemoglobin (Hgb),Hematocrit (Hct), white blood cells o Ambulation not only distracts effectively but also
(WBC),venereal disease research laboratory (VDRL),cross enhances labor progress
matching.
o Concentration on a pleasant experience
• Monitoring: uterine contractions (progress of labor), bladder,
FHT, perineum – show, rupture of bow, presenting part, bulging, o Visualization. The woman can visualize her body or
cord prolapsed ,bleeding; ability to manage pain perineum relaxing (Morton, 1983)
o BP, PR, and RR: every hour in the latent and active • Massage: effleurage, a light abdominal stroking, may be used
phases and every 30 minutes in the transition phase if in the first stage of labor to maintain relaxation of the abdominal
in normal range. muscle; effective formild and moderate pain
30
• Back pain associated with labor may be relieved by firm • With need to bear down so she pushes with uterine contractions
pressure on lower back or sacral area. In the presence of an spontaneously
abdominal position, occipitoposterior position, backache is
unusually severe. To manage, repose the mother to her side • Perineum bulges; grunting sounds
and with a fisted hand, apply a counter sacral pressure.
• Increased bloody show; with leg cramps
• Promote safety: monitor for danger signals:
• Bag of water (BOW) ruptures
o Strong or weak contractions (hypertonic or hypotonic
uterine inertia)
• The early second stage is the best time for the BOW to rupture; first
nursing action after rupture of the BOW: check the FHT.
o Bleeding (placenta previa, abruption placenta, uterine
rupture)
d. Nursing implementation
o Passage of meconium-stained amniotic fluid in
cephalic presentation (fetal distress). • Continue to offer psychological support; inform of progress
(Salustiano, 2002)
o Severe headache, dizziness, blurring of vision
(pregnancy induced hypertension) o P – raise
o R – eassurance
2. THE SECOND STAGE OF LABOR: DELIVERY STAGE
o E – ncouragement
a. Description: from fully dilated cervix to the delivery or expulsion of the baby
o I – nform mother of progress

b. Powers: primary and secondary powers –
o S – upport system
• Contractions: strong; duration: 60 to 90 seconds; frequency: q2 to 3
minutes; same features as those of transition phase
o T – ouch
• Spontaneous pushing with contractions; panting at intervals and at
crowning time • Assist / Coach: Bear down only when needed, during contractions.
• Crowning is the hallmark of the second stage. • Monitor FHT at intervals (midway between contractions). If there is
continuous fetal heart electronic monitor, check FHT during and after
a contraction; be alert for late decelerations.
• When the head crowns, the mother pants and does not push to
affect gradual extension of fetal head to prevent meconium
aspiration and perineal lacerations. • When to transfer patient to delivery room?
c. Maternal behavior: progresses from irritability to participation, eagerness, o Primigravida: cervix 10 cm. with certain degree of bulging
and excitement. with contractions
o Multigravida: cervix 8 to 9 cm.

31
• Proper position: Lithotomy. Some considerations: o warm the newborn as the mother’s abdomen has the same temperature as
the incubator.
o Padded stirrup
o contract the uterus because of the baby’s weight; and
o No pressure on popliteal region
o promote mother-child closeness or bonding
o Equal height of legs
• Show baby to mother; ensure eye-to-eye contact for bonding; verbalize similarities;
o Simultaneous placing of legs on the stirrup allow touching, stroking.
o Alternate positions: Fowler’s, side-lying, or squatting, as • Proper identification is done before transferring newborn to the nursery or before
desired, indicated, or supported by unit policy separating from the mother; a legal and ethical responsibility of the nurse
• Perineal preparation: front to back motion • LEBOYER TECHNIQUE (Leboyer, 1976):
• Provide assistance to the health provider in attendance, or assist o A birthing technique that eases the newborn’s transition to extrauterine life
with delivery as indicated: and provides a soothing and tender approach to delivery.
• With extension of the head, right away: o Stimuli in the delivery room are reduced: room is dimmed, noise kept to a
minimum.
o Feel the nape for any cord coil (lift cord and pass over the
head of the baby if present, double clamp and cut if tight.) • All the measures employed in Leboyer techniques are toward attaining one goal: to
reduce the stress of the birthing process by stimulating the intrauterine environment –
dim, warm, free, and secured.
o Clear mouth and nose with shallow suctioning using a bulb
syringe to prevent meconium aspiration.
• Delivery involves:
o Sliding of finger under each axilla; avoiding touching the head.
o Avoiding suctioning.
o Placing the newborn on his abdomen on the mother’s bare abdomen with the
newborn’s spine kept curves similar to fetal position.
• With expulsion: delay clamping and cutting of the umbilical cord until cord pulsations o Stroking of the newborn by the mother in a gentle massaging motion.
disappear (Leboyer, 1976). Observe the other principles of Leboyer Technique as
indicated. o Delaying clamping of the cord until all pulsations have ceased; this helps the
newborn’s initial respiratory efforts as well as preventing anoxia at the time of
• Dry and wrap infant in a warm towel to keep him warm. Placing the wrapped newborn birth.
on the maternal abdomen can:
32
o Drying and wrapping the newborn in layers of warm blankets with the head d. Types of placental delivery
and hands left free to move and play.
a. Schultze Mechanism more common; present in 80% of cases
o Laying the newborn on his side and leaving him alone to experience the new
environment. • Shiny, “clean” bluish side is first delivered.
3. THE THIRD STAGE OF LABOR PLACENTAL STAGE • Less external bleeding because blood is usually
concealed behind the placenta.
a. Description: The placental stage is the period from the delivery of the
baby to the delivery of the placenta. • The type where separation starts at the center, then to
the edges causing inverted umbrella shape
b. Powers
b. Duncan’s Mechanism: less common, present in20% of cases.
• Strong uterine contractions in third stage cause placental
separation from uterine wall. • Rough, “dirty”, reddish maternal side out first.
• When placenta is fully detached, maternal pushing can affect • More external bleeding, so it appears “bloody”.
final delivery of the placenta.
o The amount of blood loss in delivery (whether
c. Signs of placental separation placenta is delivered by Schultz or Duncan’s
mechanism)is 250 to 300 mL. Blood loss of
• Calkin’s sign – first sign; when uterus changes in shape (from 500 mL. or above is considered POSTPARTAL
discoid to globular) and consistency (from soft to firm) HEMORRHAGE, the leading cause of maternal
mortality.
• Uterus becomes mobile – it rises up into the uterus
• Umbrella shaped placenta delivered sideways.
• Immediately after placenta detaches, the fundus is at midway
between the symphisis pubis and umbilicus, then rises to the
level of the umbilicus – midline.
• Displacement of the uterus to the sides would mean distended

bladder, so the first to do if the uterus is not in the midline is to
feel the lower abdomen for a distended bladder; stimulate
voiding if bladder is distended. e. Nursing implementation
• Sudden gushing of blood – distinguish between the normal • Observe the principle of placental delivery stage: watchful
sudden gushing of blood and the abnormal ‘increasing bleeding.’ waiting (watch and wait for signs of placental separation) and
not doing fundal pressure with pull at the cord, especially if the
uterus is relaxed, as these actions could cause inversion of the
• Slight lengthening of the cord – most definitive sign that the uterus, a leading cause of hemorrhage in the third stage of
placenta has detached labor.
33
• Gradual delivery of the placenta • If allowable by hospital policies, allow mother time with infant to
promote attach mentor bonding; breastfeed right on the delivery
• Inspect the placenta for completeness (First nursing action after table.
placenta is delivered).
4. THE FOURTH STAGE OF LABOR: RECOVERY STAGE
• Complete cotyledons
a. Description: The period of recovery, stabilization or homeostasis; usually
• Complete cord vessels: 1 vein, 2 smaller arteries 1 to 2 hours (Cunningham, et al., 2001; Kain & Hall, 2000) or most up to
4 hours (Olds et al., 1988; Littleton &Engebretson, 2006)
• Complete membranes
b. Power: Uterine contractions prevent bleeding from placental site.
• Feel the fundus for contraction or firmness. The term “soft”,
“boggy”, and “non-palpable” mean uterine atony. The initial c. Nursing implementation
activity of the nurse is to massage fundus until firm. Ice cap may
be applied to further contract the uterus but never hot water bag • Monitor VS every 15 minutes until stable; report abnormal
fluctuations.
• Inject ordered oxytocin after placental delivery
• Blood loss during delivery averages 250 mL.with the normal
• Commonly used drugs: upper limit of 500 mL. (Littleton &Engebretson, 2006). Post
partal bleeding is defined as the lost of 500 mL. of blood or
more.
o Methylergonovine maleate-Methergine
• Because of the blood loss and the lifting of the gravid uterus
o Ethylergonovine maleate-Ergotrate
from surrounding vessels, blood is redistributed into venous
beds
• Action to increase uterine motor activity by direct stimulation
• This results to a moderate drop in both systolic and diastolic
o Target: uterine musculature pressure, increased pulse pressure, and slight to moderate
tachycardia (Albright et al., 1986).
• Indication: to prevent postpartum bleeding from uterine atony
and subinvolution • Palpate fundus every 15 minutes; check fundal height, position
in relation to the umbilicus, and consistency.
• Evaluation of its effects: look for a firm fundus.
• Before any fundal palpation is done, ask the mother to void to
• Side effects: nausea, vomiting, dizziness, headache, ensure an empty bladder. This will not only promote maternal
hypertension, tinnitus, hypersensitivity comfort but will favor accurate findings from palpation.
• Assess VS, presence of lacerations, complete placenta, • In the recovery stage, the fundus is firm, midline, and at the
bleeding, Lower legs level of umbilicus.
o If relaxed, massage until firm. Do not over massage

as this can tire the uterine muscles, causing relaxation.
34
o If displaced to the side, the first nursing action is to • Check episiotomy wound or lacerated wound for bleeding, hematoma, or edema. Ice
feel the lower abdomen for distended bladder. When bag to perineum immediately after delivery (and in the first 24 hours) can reduce edema
the bladder is distended, stimulate voiding. and swelling.
• Assess lochia. In the fourth stage, lochia is bright red and can
saturate 1 to 2 perineal pads in one hour. A reddish color may
be maintained for more than two weeks; but when it persists for
more than 2 weeks, it indicates either the retention of small
portions of the placenta or imperfect involution of the placental
site or both (Cunningham et al.,1989).
• Promote sleep and comfort.
• Keep warm. Chills are common in the fourth stage of labor, Causes of chills:
o Maternal excitement
o Sudden drop in maternal hormones

Parameter Rubra Serosa Alba
o Release of intra-abdominal pressure
Color Red Brownish White

o Fetal blood in circulation.
Amount Moderate Scanty Slight

• Give partial bath, peri-care (front to back), change wet linens.
• Assess for after pains; reassure it is secondary to uterine contractions; icecap for relief
DURATION OF LABOR or analgesic as ordered.
Time Present 1-3 days 4-10 days (lower 10-14 days (upper • Provide nourishment as the woman maybe thirsty and hungry
limit: ave. 7days) limit: 21 days)
• Check for bladder distension; determine first voiding and voiding pattern, A full bladder
displaces the uterus to the side, a factor to uterine atony. Labor Stage Primigravida Multigravida
• Checking the perineum; note general appearance, redness, swelling, bruising, vaginal FIRST STAGE: 8-10 hours (ave: 9 hours) 5 hours
and suture line bleeding.
1. Latent Phase (0-4
• Administer oxytocin medications if ordered. Check BP before and at intervals after; cm cervix)
monitor fundal contraction and lochia after administration 6 hours 4 hours
35
TIME TO CONTACT THE HEALTH CARE PROVIDER OR GO TOTHE HOSPITAL (when labor
2. Active Phase (4-8 2 hours 1 hour begins)
cm cervix)
1. When contractions are regular and becoming increasingly frequent: duration 30 seconds
Transitional phase (8-10 cm and occurring every 5 minutes.
cervix); the most difficult for
the mother 2. When show is present.
SECOND STAGE Mean: 50 minutes (1 hour) 20 minutes 3. When the bag of water ruptures. The rupture of the bag of water is always an indication
for seeking medical help.
Most difficult for the fetus (1/2 hour)
THIRD STAGE 5-10 MINUTES 5-10 minutes
The average duration of the

third stage is minutes
ESSENTIAL PROCEDURES AND ASSESSMENT OF NEWBORN

NURSING CARE OF A FAMILY WITH A NORMAL NEWBORN
FOURTH STAGE The period of recovery, stabilization or homeostasis; usually 1-2
hours (Cunningham, et al. 2001; Kain & Hall, 2000) at most up → Newborns undergo profound physiologic changes at the moment of birth (and, probably,
- MOST to 4 hours (Olds et al. 1988; Littleton & Engebretson, 2006) psychological changes as well), as they are released from a warm, snug, dark, liquid-
DANGEROUS for filled environment that has met all of their basic needs into a chilly, unbounded, brightly
the mother lit, gravity-based, outside world.
When the fundus falls to → Within 24 hours, neurologic, renal, endocrine, gastrointestinal, and metabolic functions
contract and remains atonic must be operating competently for life to be sustained.
inspire of management, the
woman can hemorrhage--- the
leading cause of maternal → Providing immediate care to the newborn
mortality
36
o After the birth of the infant, every effort should be exerted to support him in his o There are four processes by which the newborn loses heat at birth:
first minutes, hours, and days of his life. The quality of the immediate care
afforded the newborn spells the state of his health or well-being later in life. ▪ Evaporation: Loss of heat as liquid leaves the newborn’s body.
IMMEDIATE CARE ESSENTIALS ▪ Conduction: Loss of heat from newborn’s warm body to cool
surface in direct contact, like the weighing scale, admitting table, and
→ In the care of mothers and their newborns, health workers and medical practitioners unlined crib.
should be guided by the Standard Essential Newborn Care Practices Guidelines (DOH
A.O 25, 2009; WHO Clinical Practice Pocket Guide, 2009). These newborn care ▪ Convection: Loss of heat to cool air.
guidelines are time-bound interventions which begin at the time of perineal bulging until
the first week of life:(next slide) ▪ Radiation: Loss of heat to cool surfaces NOT in contact with the
newborn, like the walls, floor, and ceiling. Most of the newborn’s heat
A. A. In the second stage of labor, at the time of perineal bulging, immediate care of is lost by radiation.
the newborn begins by ensuring a warm and infection-free environment. This can
be attained through the following:
1. Ensuring a draft-free and warm environment. Using a room thermometer, check

and keep room temperature between 25 to 28°C. A warm environment minimizes
newborn loss of heat to cool air (convection) and cool walls, floors, and ceiling
(radiation).
2. Washing hands with clean water and soap. Handwashing is the single most
important method of preventing nosocomial infections during delivery, whether in
the home, in lying-in clinics, or hospitals.
3. Putting on double gloves just before delivery. One set of gloves is for delivery of
the baby, and the other set is for cord clamping and cutting.
B. Within the first 30 seconds after birth, provide the newborn with warmth to
prevent hypothermia through the following: FACTORS TO HEAT LOSS
Wet newborn skin surface: Cooler air currents in the presence of:
1. Use a clean, dry cloth to thoroughly dry the baby, wiping from the eyes, to the face, After delivery when the newborn is wet Air-conditioned rooms: delivery room,
head, front and back, arms and legs in a cephalocaudal (head-to-toe) direction. with amniotic fluid; during bath; or after nursery, or private room of mother
This way, heat loss by evaporation is prevented. urine/stools passage when diapers are left
unchanged for a long period
2. Remove the wet cloth. The presence of wet clothing against the newborn’s skin • Touching the newborn with • Oxygen by mask
causes loss of heat by conduction and evaporation. chilled hands
• Use of cool and unlined scales, • Removal from incubator for
3. Do a quick check of newborn’s breathing while drying. Normal breathing is quiet, examination table, and crib procedures done without a
nasal, abdominal, synchronized, shallow, and rapid with the rate of 30 to60 bpm. source of added heat (i.e.,
overhead radiant warmer, drop
light)
→ Mechanisms of Heat Loss
• Use of stethoscopes or blood • Cooler walls of an incubator
37
pressure cuffs *Most of the newborn’s heat is lost C. After 30 seconds of thorough drying with the newborn breathing or crying:
through radiation
1. Facilitate bonding between mother and her newborn through skin-to-skin contact
KEEPING THE NEWBORN WARM (SSC) to reduce likelihood of infection and hypoglycemia.
• Factors Predisposing to Heat Loss a. Place newborn prone on the mother’s abdomen or chest, SSC. The prone
position helps draining of secretions and clearing of air passages. The top
priority in the immediate care of the newborn is still AIRWAY. The SSC keeps
A. Large body surface area for cooling compared to body weight/volume.
the newborn warm by conduction as the temperature of the woman in labor is
higher than that of her baby.
B. Increased cooling from evaporation of moisture from the skin.
• As soon as the baby is securely positioned on the mother, palpate
C. Immature thermogenesis/temperature-regulating mechanism. the abdomen to exclude a second baby, or multiple births.
D. Cool temperature in the delivery room and nursery (68-72°F or 21°C), resulting in heat • If there is a second baby, get help.
loss by convection and radiation.
• Deliver the second newborn.
E. Limited ability or inability to shiver.
• Manage like the first baby.

• Effects of Cold Stress
b. Cover the back of the newborn with a blanket and the head with a bonnet or a
o Subjecting the newborn to cold stress can result in:
cap. Do not separate the newborn from the mother; but if the newborn must
be separated from the mother, place him/her on a safe and warm place close
▪ Increased brown fat metabolism causing an increase in fatty acids in to the mother.
circulation thus resulting to metabolic acidosis; and
c. Place the identification band around the ankle
▪ Increased activity/metabolic rate leads to more utilization of glucose and
oxygen resulting to hypoglycemia and respiratory distress.
• Identification is done immediately after birth before the newborn is separated from the
mother.
• Major Effects of Cold Stress
o The greatest disadvantage of hospital delivery is the presence of risk of
o If a newborn is exposed to cold, four major complications may result: exchanging babies. For this reason, the newborn must first be identified before he
is transferred to any place away from the mother. In some institutions, the newborn
A. Hypoxia, which can lead to respiratory distress; is identified before the cord is cut.
B. Hypoglycemia, when blood glucose is less than 30mg/dl (Normal serum glucose in o Home deliveries do not require identification. However, high-risk babies must first
newborn: 30-50mg/dl); be identified before transported to the nearest hospital.
C. Metabolic acidosis; and o By DOH order (A.O 25, 2009) and WHO guidelines (2009), the use of an ankle
band is sufficient to identify the newborn and there is no need for foot printing. The
D. Infection: hypoxia, hypoglycemia, and metabolic acidosis are predisposing factors use of a universal stamp pad for foot printing has been identified as a potential
to infection. source of infection-causing microorganisms
38
D. Within 1 to 3 minutes after delivery or while on SSC, the essential newborn care CAUTION: The presence of an incomplete number of vessels warrants reporting to
focuses on cord care: the physician so the newborn can be thoroughly assessed for congenital defects of
the kidneys/renal system.
1. Delay cord clamping or implement non-immediate cord clamping to reduce the
incidence of anemia in term newborns and intraventricular hemorrhage (IVH) in • Observe for oozing of blood.
pre-term newborns.
o In the first 24 hours, the cord should be inspected for bleeding
a. Remove the first set of gloves immediately prior to cord clamping. called omphalanghia as the newborn has poor blood
coagulation due to absence of vitamin K.
b. Clamp and cut the cord after cord pulsations have stopped (typically at 1-3
minutes) • After cord clamping, inject 10 U oxytocin intramuscularly (IM) to the
mother.
OXYTOCIN (PITOCIN)
- Increases availability of intracellular calcium thereby increasing myometrial

contraction; also binds to oxytocin receptors in the deciduas (highly
specialized endometrium in pregnancy) and myometrium, further increasing
uterine contractions.
▪ Put ties around the cord at 2 cm and 5 cm from the newborn’s abdomen. - Given AFTER PLACENTAL DELIVERY intramuscularly, 10 to 20 U, or
intravenously, 20U (range 10 to 40 U) in 1 L dextrose 5% lactated Ringer’s
• The longer is left of the cord stump the longer is drying and solution or 1 L lactated Ringer’s solution (Littleton & Engerbretson, 2006);
dropping off time. This implies more risk to local bacterial given intramuscularly, 10 U AFTER CORD CLAMPING (DOH A.O 25, 2009;
infection of the cord called omphalitis. WHO, 2009).
- Nursing implementation:
o Monitor the rate of IV oxytocin flow accurately. Too rapid infusion of

the drug may cause tachycardia, hypertension or hypotension, and
antidiuretic effect which may be manifested in oliguria, water
intoxication, fluid overload, headache, nausea, and vomiting.
▪ Cut between ties with sterile instrument to prevent tetanus neonatorum.
o Assess the bladder frequently. A full bladder can displace the uterus
• The cord should be examined carefully for the presence of to the side and a displaced uterus cannot contract well.
three vessels: one umbilical vein (left), and two smaller
umbilical arteries (right and left). The presence of incomplete o Monitor VS and record I&O. Report abnormalities.
cord vessels requires referral for further investigation for a
possible renal disorder. E. Essential newborn care within 90 minutes focuses on breastfeeding and eye care:
1. Provide support of early breastfeeding by facilitating newborn’s early initiation to

breastfeeding and transfer of colostrum.
39
a. Leave the newborn on the mother’s chest in SSC. ▪ Erythromycin or tetracycline ointment: apply 1 cm from inner to outer
canthus of each eye.
b. Observe the newborn for the feeding cues (e.g., opening of mouth, ‘tonguing’,
licking, rooting) and when these cues are present, suggest to the mother to ▪ Povidone-iodine 2.5% drops: one drop on each conjunctival sac after
encourage the baby to move toward the breast (e.g., nudging). the newborn has located the breast.
c. Counsel the mother on positioning and attachment and when the baby is b. Do not wash away the eye antimicrobial agent.
ready. If the attachment or suckling is not good, advise the mother to try again.
Then, reassess for signs of good attachment and suckling: F. Essential newborn care from 90 minutes to 6 hours
- Mouth wide open o The nursing interventions carried out from 90 minutes to 6hours are
considered non-immediate interventions and should never be made to
- Lower lip turned outwards compete with the time-bound interventions (DOH A.O. 25, 2009; WHO, 2009).
- Baby’s chin touching breas 1. Give vitamin K prophylaxis: 1 mg IM.
- Slow, deep suckling with some pauses a. Wash hand.
→ Proper Positioning for Breastfeeding b. Offer oral vitamin K if parents decline intramuscular injection.
o The newborn’s neck is not flexed nor twisted. 2. Inject Hepatitis B and BCG vaccinations.
o The newborn is facing the breast with his/her nose opposite the nipple of the a. Wash hands.
mother and chin touching her breast.
b. Give Hepatitis B vaccine IM and BCG intradermally.
o The newborn’s body is held close to the mother’s body.
c. Record
o The newborn’s whole body, not just the neck and shoulders, is supported by
the mother. 3. Examine the newborn, thoroughly checking for any birth injuries,
malformations, or defects.
o The mother moves her newborn onto her breast, aiming the baby’s lower lip
well below the nipple. a. Weigh the newborn and record.
d. Advise the mother to express a small amount of breast milk before starting b. Look for possible birth injuries, malformations or defects, and when
breastfeeding to soften the nipple area; thus, favoring easier newborn identified, refer newborn for special treatment and/or evaluation.
attachment (DOH A.O. 25, 2009; WHO, 2009).
c. Help the mother to breastfeed newborn found to have feeding
2. Provide eye care to prevent opthalmia neonatorum. difficulties because of an injury/malformation (e.g., Bell’s palsy, cleft
lip, cleft palate); teach mother on alternative feeding methods
a. Administer ophthalmic ointment or ophthalmic drops (DOH A.O25, 2009;
WHO, 2009):
40
NEWBORN’S WEIGHT AND OTHER ANTHROPOMETRIC MEASUREMENTS o To measure the head circumference, the measuring tape is wrapped around
WEIGHT the head above the eyebrows and over the most prominent part or the largest
part of the occiput in the back, in a “hat band” position.
→ Weight. The normal weight of the newborns commonly ranges from 3,000 g to 4,000 g
with the lowest limit normal of 2,500 g and normal upper limit of 4,000 g. o To get the most accurate measure:
o AGA. Appropriate for gestational age; weight between 10th and 90th ▪ HC is taken three times, and the largest of three attempts is
percentile recorded by the nurse/midwife
o Lowest limit normal weight: 2,500 g (5 ½ lb); less than 2,500 g is small for → Abnormalities:
gestational age (SGA) and over 4,000 to 4,100 g (9 lb) is large for gestational
age (LGA) (Kain & Hall, 2000). o Microcephaly: when the head is smaller than the chest (under 31.7 cm or 12
½ in.) or FOC less than the 10thpercentile; usually because of a small brain
o SGA: small (or inadequate weight or growth) for gestational age; weight below termed microencephaly.
the 10th percentile. The SGA is an infant who has not achieved his genetic
growth potential (Goldenberg & Cliver, 1997) o Macrocephaly: when the FOC is greater than the 90thpercentile.
▪ Synonyms: dysmaturity, intrauterine growth restriction (IUGR) o Anencephaly: when the cranial bones are absent or incomplete.
▪ Strictly speaking, intrauterine growth restriction generally is reserved → Chest Circumference. (CC) is routinely measured only in the newborn.
for infants who are at less than the 10th percentile at birth on
standardized graphs not only in weight, but also in LENGTH and o To measure the CC, the measuring tape is wrapped around the chest at the
HEAD CIRCUMFERENCE (Littleton & Engerbretson,2006). nipple line, taken between inspiration and expiration.
▪ LGA: large for gestational age; weight above the 90thpercentile o The CC is almost equal to the abdomen in measurement: 31 to 33 cm (12-
13in.), and is approximately 2 cm smaller than the head circumference.
▪ LBW: low birth weight; birth weight less than 2,500 g independent of
gestational age assessments o CC is almost equal to the HC after the first year of life.
→ Height. The heel-to-crown measurement is to be taken. The newborn height ranges → Abdominal Circumference. The AC is almost equal to the CC.
from 18to 22 in. or 19 to 21 in. Since height (like weight) is related to hereditary factors,
this will vary from child to child, but the average height/length of the newborn is 50 cm o To measure the AC, the measuring tape is wrapped around the abdomen just
(19.68 in., or rounded off at 20 in.). Length of under 45. 7 cm (18 in.) is considered small below the umbilicus level/navel.
for gestational age (SGA), and over 55.9 (22 in.) is considered large-for-gestational age
(LGA).
o The AC is almost equal to the CC: 31 to 33 cm (12-13 in.); like the CC, it is 2
cm less than the HC.
→ Head Circumference. The head, the biggest part of the body, is about ¼ of the body
length. It measures 33 to 35 cm (13 to 14 in). The head circumference (HC) or frontal-
occipital circumference (FOC) of the newborn is measured and plotted on a standard
growth chart.
41
o Refer to the hospital urgently if pus drainage or

redness worsens or does not improve.
Summary of “Don’ts” in the Immediate Care of the Newborn
1. Within first 30 seconds of life:
• Do not suction unless the mouth/nose is blocked with secretions or other

material.
• Do not ventilate unless the baby is floppy/limp and not breathing.
4. Provide cord care • Do not place the newborn on a cold or wet surface.
a. Wash hands. 2. After 30 seconds of thorough drying, newborn is breathing/crying:
b. Put nothing on the cord stump. • Do not separate newborn from the mother as long as the newborn does not exhibit
danger signs of respiratory distress such as severe chest in-drawing or apnea, and
c. Fold diaper below the stump. Keep cord stump loosely covered with the mother does not need urgent medical stabilization (e.g., emergent
clean clothes. hysterectomy). If newborn must be separated from the mother, put him/her on a
warm and safe surface close to the mother.
d. Provide maternal teaching:
• Do not do foot printing to identify the newborn; ankle band is sufficient.
• If stump is soiled, wash it with clean water and soap. Dry
thoroughly with clean cloth. • Do not wipe off vernix caseosa if present as it prevents heat loss.
• If the umbilicus is red or if pus is draining, seek medical • Do not manipulate (e.g., routine suctioning) if the newborn is crying and breathing
care as these are signs of omphalitis. normally to prevent undue trauma which can precipitate newborn infection
• If there is local umbilical infection, treat three times a day: 3. From 1 to 3 minutes:
o Wash hands with clean water and soap. • Do not milk the cord towards the newborn.
o Gently wash off pus and crusts with cooled boiled

water and soap.
o Dry area with clean cloth.
o Paint with gentian violet.
o Wash hands.
42
2. before 30 seconds of drying if newborn is completely floppy and not

breathing.
• Oxygenation is not routine in the immediate care of the newborn. Just ensure
a patent airway and good supply of atmospheric air, and a normal newborn is
likely to breathe spontaneously. Injudicious use of oxygen can result to
damage to the retina causing neonatal blindness. This condition is called
retrolental fibroplasia.
• When there is a need to resuscitate the newborn, observe the following simple
4. Within 90 minutes: steps(DOH A.O 25, 2009; WHO, 2009):
• Do not touch the newborn while on maternal abdomen unless there is a 1. Call for help.
medical indication.
2. Clamp and cut the cord immediately.
• Do not give glucose water, formula, or other prelacteal feedings.
3. Transfer the newborn to a dry, warm, and firm surface. Dry the newborn;
• Do not give bottle or pacifiers. keep wrapped or placed under a radiant warmer, if available.
• Do not throw away colostrum. 4. Inform the mother that the newborn has difficulty breathing and that the
newborn needs help to breathe.
• Do not wash away the eye antimicrobial.
5. Position; clear airway (only when needed).
5. From 90 minutes to 6 hours:
6. Do bag/mask ventilation. While ventilating, explain to the mother what
• Do not touch the stump unnecessarily. happened, what you are doing and why.
• Do not apply any substances or medicine on the stump. 7. Check breathing; continue keeping baby warm.
a. If baby is breathing strongly for 30 to 60 per minute or is crying

• Do not bandage the stump or abdomen.
vigorously, stop ventilation. Return baby to mother’s chest, do
routine care, and monitor for breathing difficulties.
• Do not bathe the newborn at least 6 hours after birth.
b. If breathing is 0 to 30 per minute, or is gasping, or with severe chest-
G. Newborn resuscitation in drawing, do bag/mask ventilation ensuring that it is properly
sealed and there is effective chest rise, with continued monitoring at
• Newborn suctioning, oxygenation, or resuscitation is not done if the newborn 30seconds interval while transporting; or proceed to intubation per
is breathing well or is crying vigorously. However, one should start advanced resuscitation guidelines if the personnel is skilled and if
resuscitation: equipment are available.
1. after 30 seconds of thorough drying, the newborn is not breathing or is c. If after 20 minutes of effective ventilation, the newborn does not start
gasping, or to breathe or gasp at all:
43
• Stop ventilating. issue the corresponding certificate of death, and order its registration in the
officer of the local civil registrar within thirty (30) days after death.
• Explain to the mother that the baby is dead.
• Who shall register deaths?
• Give supportive care.
o Attending physician, nurse, midwife, hilot, or hospital or clinic administrator; or
• Record the event on the referral form and labor record. All
births or deaths should be properly registered as provided o Nearest responsible relative; or
for by P.D. No. 651.
o Any person who has knowledge of the death
P.D. No. 651, Registration of Births and Deaths
• In case the deceased was attended to by a physician, the latter must issue the
• When is the registration of births? necessary certificate of death within 48 hours after death and submit the same to the
local health officer of the place of death, who shall or derits registration in the office of
the local civil registrar within the said period of thirty (30) days after death.
o Babies born after the effectivity of this decree (January 1, 1974) must be
registered in the office of the local civil registrar of the place of birth within
thirty (30) days after birth. H. Provide additional care for a small baby or twin [if more than one month early or weighs
1,500 to2,599 g (or visibly small where a scale is not available)].
• Who shall register births?
1. Encourage the mother to keep the small newborn warm in SSC using the
Kangaroo hold.
o Attending physician, nurse, midwife, hilot, or hospital or clinic administrator; or
in default of the same, by:
2. Provide extra blankets for the mother and the newborn, plus bonnet/cap, mittens
and socks for the newborn.
1. Either parent or a responsible member of the family; or
3. 3. If the mother cannot keep the newborn in SSC because of complications, wrap
2. Any person who has knowledge of the birth.
the newborn in a clean, dry, and warm cloth. Place the newborn in a cot. Cover
with blanket. Use a radiant warmer if the room is not warm or if the baby is small.
The parents or the responsible member of the family and the attendant at birth or the hospital or
clinic administration referred to above shall be jointly liable in case they fail to register the
4. Give special support for breastfeeding; encourage breastfeeding every 2 to 3 hours.
newborn child.
5. Do not bathe the small baby. Ensure hygiene by wiping baby with a damp cloth
• Who shall register the birth if there was no attendant at birth, or if the child was not born only after six hours post delivery.
in a hospital or maternity clinic?
6. Weigh the newborn daily.
o The parents or the responsible member of the family alone shall be primarily
liable in case of failure to register the newborn child.
7. When the mother and the newborn are separated, or if the newborn is not sucking
effectively, use alternative feeding methods.
• When is the registration of deaths?
8. Refer a very small baby (less than 1.5 kg) or a baby born more than 2 two months
o Deaths occurring after the effectivity (January1, 1974) must be reported within early.
48 hours after death to the local health officer of the place, who shall then
44
UNNECESSARY PROCEDURES IN THE IMMEDIATE CARE OF THE NEWBORN → Devised by Dr. Virginia Apgar in 1952, the Apgar score has since then provided a quick
method of assessing the state of the newborn at birth.(Apgar, 1953; Apgar & co-workers,
→ These procedures are found to be routinely observed in Philippine hospitals but are not 1958). The score has been a useful tool to help identify neonates who might require
recommended for all neonates (DOH A.O. 25, 2009;WHO, 2009): resuscitation.
o Routine suctioning. Suctioning is not beneficial to newborns with clear o The first score should be decided at 60 seconds, even if resuscitation is in
amniotic fluid, or those who cry or breathe immediately after birth. Suctioning progress.
is indicated only if the mouth/nose is blocked with secretions/other materials.
o The second score may be computed 5 minutes later to measure how well the
o Early bathing/washing. Bathing the newborn soon after birth causes infant is adjusting to extrauterine life. The 5-minute score is a useful index of
hypothermia, increasing the risk for infections, coagulation defects, and the the effectiveness of the resuscitation efforts and thus, determines prognosis.
brain hemorrhage. Bathe the newborn atleast six hours after birth (WHO,
2009). o REMEMBER: 1 – 5 – 10
o Foot printing. DNA genotyping and human leucocyte antigen tests can better → The five adaptations scored in Apgar scoring are:
serve the purpose of identification according to the American Academy of
Pediatrics (AAP) and the American College of Obstetricians and o A- ppearance: color
Gynecologists (ACOG).
o P- ulse: apical beat for heart rate
o Giving sugar/glucose water, formula, or other prelacteals and the use of
bottles or pacifiers. Giving prelacteals using a bottle causes a learned
o G- rimace: reflex irritability
preference for the bottle and nipple, confusion, and inefficient suckling leading
to the cycle of poor attachment, sore nipples, and lactational insufficiency.
These are factors to unsuccessful breastfeeding. o A- ctivity: muscle tone
o Application of alcohol, medicine, and other substances in the cord o R- espiratory effort: cry
stump and bandaging the cord stump or abdomen. The use of alcohol
keeps the stump moist, while the use of cord bandage prevents adequate
aeration delaying the drying and healing.
ASSESSMENT OF NEWBORN AT BIRTH
Evaluating the Newborn: APGAR Scoring
→ Assessment of the newborn is a continuous process used to evaluate the newborn’s

growth and development and adjustment to extrauterine life. For the newborn to
proceed successfully in its transition from the intrauterine to the extrauterine
environment and prevent morbidity and mortality, careful assessment and observation
are essential.
→ The heart rate is the most important score. If it is absent, all the rest of the
adaptations are absent. So a total score of 0 means no heart rate. (But just because the
→ Assessment of the newborn begins at birth. Rapid initial evaluation of the newborn is
heart rate is above 100 does not mean the newborn is absolutely all right).
made possible with the use of Apgar scoring.
45
→ The least important Apgar score is color. The newborn is not expected to be pink all → Factors Predisposing to Heat Loss
over in the first minutes of life because of sluggish peripheral perfusion. Because of this,
the newborn’s skin exhibits mottling and underlying gray cyanosis. This should be a. Large body surface area for cooling compared to body weight/volume.
differentiated from “pink-on-blue” or “blue-on-pink”.
b. Increased cooling from evaporation of moisture from the skin.
Interpretation of Apgar Score
c. Immature thermogenesis/temperature-regulating mechanism.
• 0-3: Poor:
d. Cool temperature in the delivery room and nursery(68-72°F or 21°C), resulting in heat
o Needs resuscitation loss by convection and radiation.
• 4-6: Fair: e. Limited ability or inability to shiver.
o May need suctioning and oxygenation: → Major Effects of Cold Stress
o Condition guarded a. If a newborn is exposed to cold, four major complications may result:
• 8-10: Good: i. Hypoxia, which can lead to respiratory distress;
o No signs of immediate distress: ii. Hypoglycemia, when blood glucose is less than30mg/dl (Normal
serum glucose in newborn: 30-50mg/dl);
o Needs only admission care, no special care
iii. Metabolic acidosis; and
iv. Infection: hypoxia, hypoglycemia, and metabolic acidosis are

→ A normal, mature newborn in good condition at birth will achieve an Apgar score of 7 to 10. predisposing factors to infection.
Newborns whose Apgar score is less than 7 should be referred to the pediatrician.
→ Mechanisms of heat loss in the newborn
→ After Apgar scores, the second assessment is done in the first one to four hours after birth.
Depending on institutional policies, this assessment forms part of routine admission o Evaporation
procedures. Any maternal condition or problem that places a newborn at risk is assessed
further during this time. ▪ Loss of heat as liquid leaves the newborn’s body as a vapour
→ This is a brief assessment done mainly to: o Conduction
1. Evaluate the newborn adjustment and adaptation to extrauterine life. ▪ Loss of body heat to a cooler surface by direct skin contact
2. Estimate gestational age. o Convection
KEEPING THE NEWBORN WARM ▪ Loss of heat from the warm newborn’s body to the cooler air currents
46
o Radiation → Every health care provider dealing with newborns MUST consider keeping them warm a
serious task more if they are low-birthweight infants. Thermoregulation is a critical
▪ Loss of heat from warm newborn’s body to cooler surfaces and objects physiological function that is closely related to the survival of the infant (Bain, 1999). In these
NOT in direct contact with the baby. infants, heat loss from radiation and evaporation is three to five times greater than in larger
infants, and as previously stated, there is increased risk of mortality in infants with a decrease
FACTORS TO HEAT LOSS in body temperature.
Wet newborn skin surface: Cooler air currents in the presence
- After delivery when the of: Maintaining a Neutral Thermal Environment
newborn is wet with - Air conditioned rooms;
amniotic fluid, during bath; delivery room, nursing or
→ There are major methods of maintaining a neutral thermal environment.
or after urine/stools private room of mother
passage when diapers are
left unchanged for a long A. Using a radiant warmer. Whenever time-consuming procedures (e.g., circumcision,
period exchange transfusion) are to be done to the newborn outside of his warm environment, a
- Touching the newborn - Oxygen by mask radiant warmer should be used.
with chilled hands
- Use of cool and unlined - Removal from incubator B. Placing infant inside an incubator. Preterm infants and other low-birthweight infants at
scales, examination table, for procedures done high risk for hypothermia (low body temperature less than 36.5°C) should be placed inside
and crib without a source of added an incubator. When taken out of the incubator for procedures, measures should be
heat (i.e., overhead maintained to keep these newborns warm. The infant is clothed and warmly wrapped in
radiant warmer, drop light) blanket when taken out of the incubator.
- Use of stethoscopes or - Cooler walls of an
blood pressure cuffs incubator → It used to be that an infant in an incubator should be undressed, except for a diaper, notonly
- Most of the newborn’s heat for a maximum observation of the newborn, especially his respiration, but also toallow the
is lost through radiation flow of warm air to contact his body surface. Now, we can add one piece of covering: bonnet.
Inside or outside of incubators, head coverings are effective in preventing heat loss from the
Thermoneutral Environment head (Greer, 1988)
→ The newborn needs a neutral thermal environment. This environment is one that permits the C. Placing a dressed infant in an open bassinet with cotton blankets. This is favorable for the
infant to maintain anormal core temperature (deep body temperature stays within range of home environment, where more sophisticated means to keep a newborn warm are not
36.5 to 37.5 °C) with minimum oxygen consumption and calorie expenditure. available. Keeping the newborn covered does not favor close observation of high-risk
newborns especially the characteristics of respiration. This is why a high-risk newborn
requiring more frequent observation of his/her respiration should be placed in an incubator
o Merenstein, Gardener, and Blake (1989) described a neutral thermal environment and not in a bassinet.
for newborns as follows:
D. Practicing Kangaroo Mother Care (KMC). KMC has been found to stabilize premature
▪ For larger infants: 32.5 °C, plus or minus 1.4°C (90.5°F,plus or minus babies more effectively than incubators (Bergmen et al., 2004).
2.5°F)
o Kangaroo Mother Care (KMC)
▪ For smaller infants: 35.4 °C, plus or minus 0.5°C (95.7°Fplus or minus
1°F)
▪ is a method of care, which involves infants being carried by the mother,
with skin-to-skin contact (SSC),and intended for health professionals
→ Within this neutral thermal environment, the healthy newborn’s axillary temperature stays responsible for the care of low-birthweight and preterm infants (WHO,
within a normal range of36.5°C to 37.5°C (Blake and Murray, 2006). Department of Reproductive Health, 2003).
47
▪ KMC can begin after birth, after initial assessment and basic resuscitation ▪ Privacy. An integral part of a supportive
under the following conditions: environment is privacy since KMC requires
some maternal exposure which can make her
• Mother and baby are stable. nervous and de-motivated to continue.
• Baby is able to breathe on its own with no apneic episodes. C. A carrying cloth. A stretchy baby wrap or a ‘kanga carrier’
or a locally made stretchy tube blouse as what is used in
Dr. Fabella Memorial Hospital, the pioneering hospital in
• Baby is free of any life-threatening diseases or malformations the Philippines with a KMC unit ward.
▪ KMC supports the Department of Health’s Unang Yakap, Yakap ng Ina, D. A blanket is used if the mother is reclining on a chair or on
Yakap ng Buhay campaign which employs Essential Newborn Care (ENC) a bed.
protocol. ENC protocol provides evidence-based interventions meant to
improve newborn care and help reduce neonatal morbidity and mortality.
▪ Procedures of KMCA.
▪ Components of KMC
A. The baby is held in continuous SSC with his mother as
close as 24 hours a day as possible.
A. Continuous skin-to-skin contact (SSC) between mother
and baby
o If the mother needs to interrupt KMC for a short period,
the father or a relative should take over.
B. Exclusive breastfeeding on demand
B. Place the baby in the kangaroo position (WHO, 2009).
C. No (or minimal) separation of mother and baby. If the nurse
has to provide care to the mother or the infant, she would
render such care while the baby and mother remain in 1. Place the baby in an upright position on the mother’s
contact. bare chest, between the two breasts, chest to chest,
and with the baby’s abdomen at the level of the
mother’s upper abdomen.
D. Maternal support. This includes measures / methods of
providing medical, physical, emotional, psychological, and
physical well-being of the mother and the baby without 2. Position the baby’s hips in a ‘frog-leg’ position with the
separating them in order to enable the mother to continue arms also flexed or folded
providing for her baby’s needs
3. Secure the baby in this position with the support
▪ Requirements for KMCA. binder, sling or a ‘kanga carrier’.
A. mother. KMC works also with fathers, or substitute 4. Turn the baby’s head to one side, slightly extended or
caregiver, if the mother is not available (e.g., in cases of in a slightly upturned position to help ease his
maternal morbidity or mortality). breathing and to allow eye-to-eye contact between the
mother and the baby.
B. Supportive atmosphere. This includes physical,
emotional, and psychological environment. 5. Tie the cloth firmly.
48
▪ The greatest benefit of KMC to the baby is that it saves lives. The latest 3. helps contract the uterus resulting in less blood loss at delivery,
studies show a 51%reduction in newborn mortality when babies (stable and
and less than 2kg) were kangarooed within the first week after birth and
breastfed by their mothers (Lawn et al., 2010). 4. hastens uterine involution
▪ KMC Benefits for the Baby D. Reduces stress and builds parent confidence and competence
(zfeldman et al., 2002)
A. Provides the baby with safe, womb-like environment
1. Mother feels she is giving her baby the best possible care.
B. Keeps baby warm
2. Maternal feelings of guilt and anxiety over the birth of a
C. Makes breast milk readily available; supports exclusive breastfeeding, premature baby are replaced by confidence as she feels that
thus enhances immunologic system and prevents infection of the she is completing her baby’s gestation with continuous KMC.
baby
E. Helps parents play an active role in their baby’s recovery, improving
D. Builds an infant-mother attachment self-esteem.
E. Relieves stress reactions and lessens crying F. Increases duration of maternal rest and sleep periods as the SSC
helps the mother and her baby to settle in “sleep synchrony” rhythm
F. Provides longer periods of restful sleep of sleeping and waking up together.
G. Improves nutrition, hastens growth, and improves weight gain G. Enhances maternal mobility and early return to daily life.
H. Provides a buffer against over-stimulation H. Leads to shorter hospital stay; economical
I. Improves neurobehavior PERFORMING CREDE’S PROPHYLAXIS
▪ KMC Benefits for the Mother → The passage of the newborn through the vagina during the birthing process predisposes him
to an infection of the eyes called ophthalmia neonatorum. Vaginal infections like gonorrhea
A. Provides continuous SSC which helps the mother bond with her baby and chlamydia can result in ophthalmia neonatorum called gonorrheal and chlamydial
conjunctivitis. Since both eye infections may result in blindness, itis mandatory in the
immediate care of the newborn to administer Crede’s prophylaxis to protect him against
B. Supports and enhances prevalence and duration of breastfeeding
ophthalmia neonatorum.
C. Releases oxytocin which
→ Carl Siegmund Franz Crede (1884) introduced the practice of instilling into each eye
immediately after birth one drop of 1% solution of silver nitrate, later washed out with saline.
1. makes the mother calmer, This method was used systematically from 1884to protect the newborn from possible
inflammation of the eye during delivery by a mother with a venereal disease and is referred to
2. helps in the production of breast milk and early initiation of as Crede’s prophylaxis.
breastfeeding,
→ Crede’s Prophylaxis
49
A. Purpose: To prevent bacterial infection of the newborn’s eyes → Hepatitis B (Hep B) vaccine is given to protect the infant against hepatitis B viral
infection. Globally, HBV infections are a major cause of cirrhosis and liver cancer and
B. Recipient of care: It is mandatory and given to all result in an estimated 620,000deaths annually (Goldstein, Zhou, Hadler, Bell, Mast, &
Margolis, 2005). WHO recommends administering the first Hep B vaccine or dose less
C. Time of administration: After immediate initial bonding between the mother and the than 24 hours after birth to prevent perinatal HBV transmission (WHO, 2004).
infant
→ Hepatitis Band BCG vaccinations for newborns
D. Drugs used: 1% silver nitrate, 1 drop (gtt) into each conjunctival sac
HEPATITIS B BCG VACCINATION

VACCINATION
PREVENTION OF NEWBORN HEMORRHAGE Protection offered Gives active immunity Gives active immunity
against hepatitis B against pulmonary
Vitamin K Injection viral infection tuberculosis
→ The newborn is at risk of developing various haemorrhages. Route Intramuscular (IM) Intradermal (ID)
→ Vitamin K is poorly transferred across the placenta and the fetus has low stores, and Site of injection Thigh muscle: Right deltoid region of
any store is rapidly depleted after birth (Greig,1999). The newborn’s GIT is initially anterolateral aspect the arm for newborns
sterile, i.e., it has no bowel flora to assist in the activation of clotting factors. Until and infants
colonization has occurred, the production of vitamin K is restricted (Greig, 1999). Best site: vastus
lateralis or Left deltoid region of
→ Without adequate vitamin K, the newborn is at risk ofhemorrhagic conditions. Clotting anterolateral aspect of the arm for school
factors II(prothrombin), VII (proconvertin), IX (plasmathromboplastin component), and X the thigh for infants (or entrants
(thrombokinase)are proteins which need vitamin K to convert them intoactive clotting deltoid muscle for
factors (Greig, 1999), thus they arecalled vitamin K-dependent coagulation factors. older children)
→ The intramuscular injection of 1 mg vitamin K isamong the non-immediate interventions Dosage For newborns and For newborns and
in theimmediate newborn care which is carried out from 90minutes to 6 hours (DOH A.O. infants: 0.5 mL infants: 0.05 mL
25; WHO, 2009).
For school entrants:
Prophylactic Vitamin K Injection 0.10 mL
→ To prevent neonatal hemorrhage, vitamin K is prophylactically given to newborns,

especially those who are at greater risk of hemorrhage ,those with cephalhematoma,
those born preterm, and those delivered precipitately or instrumentally with forceps, or
through vacuum extraction (Mitchie, 1999; Nishiguchi et al.,1996).
IMMUNIZING THE NEWBORN
50
a. Signs of omphalitis
Syringe and needles Syringe/device Administered in a
used (WHO/V&B/99.25): 1.0mL syringe with a 1. Periumbilical redness, swelling, and tenderness
First choice is 0.5 mL 26-mm gauge needle
auto-disable 2. Ring of redness around the cord insertion area. If the redness is confined to one
(AD)injection device. side, say the superior area, or inferior area only and not entirely around the cord.
In immunization 3. Foul-smelling cord

services where
sterilizable syringes 4. Presence of foul discharge or pus on the cord. A normal umbilical cord may ooze a
are still used, 0.5 mL little amount of fluid, which may smell a bit at the point where the cord meets the
sterilized syringes abdominal wall of the newborn, but there should be no redness around the cord.
should be employed.
5. Fever
TAKING AND MAINTAINING NB TEMPERATURE
6. Lethargy
→ The newborn needs a neutral thermal environment. This environment is one that
permits the infant to maintain a normal core temperature (deep body temperature stays 7. Poor feeding or failure to suck
within range of 36.5 to 37.5 °C) with minimum oxygen consumption and calorie
expenditure.
b. Complications of omphalitis
Safe temperature-taking in the newborn
1. Septicemia. The neonate’s immune system is immature and cannot yet localize
infection. Local omphalitis can become systematic, causing sepsis neonatorum.
→ Axillary Temperature-taking
2. Peritonitis or infection of the lining surrounding the abdominal organs.
o The best route for taking a newborn’s temperature is per axilla and not per
rectum. It is the best indication (second only to skin) of an infant’score
3. Infection of adjacent abdominal organs.
temperature. It is safer, too, with no risk of membrane perforation.
c. Prevention of omphalitis
→ Rectal Temperature-taking
o To prevent omphalitis, avoid touching the cord stump unnecessarily and keep
o Rectal temperature-taking for newborn is a widely-used practice in the past, the cord clean and dry to enhance its early fall off within 2 to 3 days after
primarily to detect the presence of the so-called congenital defect “imperforate delivery. The cord may fall off as late as 2 to 3weeks. The earlier the cord falls
anus”. Anal patency is no longer confirmed by insertion of a thermometer but off, the less than chances there are for it to be infected.
by visual confirmation of meconium passage and by examination of the anus.
→ The mechanism of cord separation includes necrosis, granulocyte invasion, infarction,
SAFE CARE OF THE UMBILICAL CORD drying, and collegenase activity. When the umbilical cord falls off, it may leave a pink
stump behind, which may bleed a little but there should be no redness around the area
→ Omphalitis is commonly caused by bacteria that colonize the skin of the newborn, the where it meets the abdominal wall. To prevent omphalitis, the caregiver should:
mother’s vagina and the caregivers’ hands. The most commonly isolated microorganism 1. Observe meticulous handwashing before and after handling the cord. Since
is Staphylococcus aureus. Other causative microorganisms include E.coli and omphalitis commonly occurs outside of the hospital, mothers and other caregivers
Streptococcus pyogenes. must be instructed on proper handwashing technique.
51
2. Provide the newborn an initial bath using an antibacterial soap. The initial bath is 3. Dry area with clean cloth.
given six hours after birth. (DOH, 2009, WHO,2009).
3. Keep the cord stump clean and dry. Daily cord care varies. So is the frequency of treatment. 4. Paint with gentian violet.
Routine cord care usually includes cleaning the stump with alcohol at least daily or at every
diaper change when it gets wet with urine and until the cord heals. However, DOH (2009) 5. Wash hands.
recommends that nothing should be placed on the cord stump.
4. Avoid the use of umbilical binders if the home environment is clean. Umbilical binders 6. Refer to the hospital immediately if pus or redness worsens or if
hinder early cord healing and have been found to frequently harbour bacteria, precipitating conditions do not improve.
infection. If the home environment is unsafe for an open dressing, then umbilical binders
may be used BALLARD ESTIMATION OF GESTATIONAL AGE AND MATURITY RATING
→ Instruct the caregivers to observe the following simple rules: → The New Ballard Scale evaluates the newborn’s physical and neuromuscular tone
components, but in a simplified way, omitting some of the neuromuscular tone
a. Wash umbilical binders separately from soiled diapers and from other house assessment, such as head lag and ventral suspension, and leg recoil.
laundry.
→ Ballard’s Estimation of Gestational Age by Maturity Testing
b. Use soap and hot water.
a. Neuromuscular maturity
c. Dry under the sun.
1. Resting posture. This is a neuromuscular component that is assessed as the
d. Iron well and neatly fold individually, then pack. baby lies undisturbed on a flat surface.
e. Frequently change cord binder at least every cord care and each time it gets wet
with the infant’s urine.
5. Check the cord frequently for danger signs of infection.
6. Promptly report redness, swelling, tenderness, foul discharge or pus for evaluation
and prompt treatment. The primary treatment of omphalitis is antibiotic, which is 2. Square window (wrist). This is elicited by flexing the baby’s hand toward the
administered intramuscularly or intravenously until the infection is completely ventral forearm.
resolved
d. Management of omphalitis
o If there is local umbilical infection, treat three times a day with the following
(DOH, 2009; WHO, 2009):
1. Wash hands with clean water and soap. 3. Arm recoil. Test of flexion development. Arm recoil is tested by flexion at the
flexion at the elbow and extension of the arms at the newborn’s side.
2. Gently wash off pus and crusts with cooled boiled water and soap.
52
2. Lanugo
4. Popliteal angle. This is the degree of knee flexion.
3. Plantar (sole) creases
5. Scarf sign
4. Breast (areola)
6. Heel-to-ear maneuver
5. Ear
b. Physical maturity
1. Skin
53
6. Genitals (male & female)
VITAL SIGNS
TEMPERATURE – AXILLA
HEART RATE - Auscultating a newborn heart with a stethoscope is the best way to determine
heart rate, can do on an uncut cord. If cord is cut, you may palpate the pulsation on the base of
the cord with the use of your index finger and thumb.
RESPIRATIONS - Respirations are counted by watching respiratory movements. A mature

newborn usually cries and aerates the lungs spontaneously at about 30 seconds after birth.
Decreased RR due to analgesia given to mother on birth.
54
NEWBORN SCREENING o An endocrine disorder also referred to as “cretinism” or “dwarfism,” CH results

from the absence or lack of development of the thyroid gland, causing the
Newborn Screening (NBS) absence or lack of production of the thyroid hormone thyroxine, which is
needed for metabolism and growth of the body and the brain.
→ is a simple procedure to determine if the newborn infant has a heritable congenital
metabolic disorder that may lead to serious physical health complications, mental 2. Congenital adrenal hyperplasia (CAH)
retardation, and even death if left undetected and untreated
o CAH is an endocrine disorder caused by an inborn defect in the biosynthesis
Newborn Screening Act of 2004 (R.A 9288) of adrenal cortisol that causes severe salt or sodium losses, dehydration, and
abnormally high levels of male sex hormones in both boys and girls.
→ was enacted to provide for a ‘comprehensive, integrative, and sustainable national
3. Phenylketonuria (PKU)
newborn screening system to ensure that every baby born in the Philippines is provided
the opportunity to undergo newborn screening and be spared from heritable conditions
that can lead to mental retardation and even death if undetected and untreated’. Under o PKU is an inborn error of metabolism characterized by the lack of the liver
the Newborn Screening Act, the newborn is ‘a child from the time of complete delivery enzyme phenylalanine hydroxylase, which is needed to break down the amino
to 30 years old.’ acid phenylalanine to tyrosine and finally to the pigment melanin.
A. Components of the comprehensive NBS system 4. Galactosemia (GAL)
1. Education of relevant stakeholders o Galactosemia is an inborn error of metabolism caused by the deficiency in
galactokinase, resulting in the inability to convert galactose, derived from
lactose in milk, to glucose. As a consequence, galactose levels rise in the
2. Collection and biochemical screening of blood samples taken from newborns
blood (galactosemia) and there is an increased galactose in the urine
(galactosuria). If untreated, mental retardation, cataracts, and even death may
3. Tracking and confirmatory testing to ensure the accuracy of screening results result.
4. Clinical evaluation and biochemical/medical confirmation of test results 5. Glucose-6-Phosphate-Dehydrogenase Deficiency (G6PD)
5. Drugs and medical/surgical management and dietary supplementation to address o If a baby does not have enough G6PD, his red blood cells lack protection from
the heritable conditions the harmful effects of oxidative substances. Severe anemia and kernicterus or
jaundice of the brain can result.
6. Evaluation activities to assess long-term outcomes, patient compliance, and quality
assurance C. NBS Program Objectives
B. Heritable Conditions 1. To ensure that every newborn has access to newborn screening for
certain heritable conditions that can result in mental retardation, serious
A heritable condition is any condition that can result in mental retardation, health complications, or death if left undetected and untreated;
physical deformity, or death if left undetected or untreated, and which is usually
inherited from the genes of either or both biological parents (R.A9288). 2. To establish and integrate a sustainable newborn screening system
within the public health delivery system;
1. Congenital hypothyroidism (CH)
55
3. To ensure that all health practitioners are aware of the advantages of A. KANGAROO HOLD
newborn screening and of their respective responsibilities in offering
newborns the opportunity to undergo newborn screening; and o This hold provides warmth and closeness and is also called skin-to-skin
holding. In the kangaroo hold, the mother wears a tube blouse or a shirt that
4. To ensure that parents recognize their responsibility in promoting their opens in front and she holds upright on her chest her unclothed baby wearing
child’s right to health and full development, within the context of only a diaper.
responsible parenthood, by protecting their child from preventable causes
of disability and death through newborn screening. B. CRADLE HOLD
D. Obligation of the healthcare provider (R.A. 9288) o This hold is the traditional and the most commonly used type of hold. It is the
one often used when feeding and cuddling an infant.
The NBS ACT provides that it is every health practitioner’s obligation to inform
the parents or legal guardians of the newborn, prior to delivery, of the nature and C. SHOULDER HOLD
benefits of NBS.
o This is the hold commonly used for burping or bubbling an infant. In the
E. Role of healthcare professionals shoulder hold, the infant is held up against one side of the chest and shoulder,
using two hands to support the back correctly and adequately; one hand
o Motivator supports the head and the back.
o Educator D. FOOTBALL HOLD
o Collaborator o This is a secure hold for newborn and young infants, leaving the caregiver
with a free hand. It is the one used in giving hair shampoo to newborn and
o Implementor young infants. It may also be employed in breastfeeding twins simultaneously.
o Organizer E. TRANSFER HOLD
o Change agent o This is the type utilized whenever the infant is to be transferred from one place
to another, such as from the crib to the examination table and back, or from
the examination table to the weighing scale and back to the crib
o Model
o Advocate Criteria for holding the baby:
o Researcher → Safety
→ Support
→ Comfort
WAYS OF HOLDING THE INFANT
TYPES OF INFANT HOLD HOW NOT TO HOLD A NEWBORN INFANT
56
A. Holding the newborn upside down by the ankles. This is used to be the first hold
given a newborn right after birth and was meant to drain secretions and stimulate crying.
This hold should totally be eliminated from the care normal newborns. It has 3
potential dangers:
1. increased intracranial pressure
2. compromised breathing as the diaphragm gets pressed by the abdominal

contents
3. ankle pain as the entire weight of the infant is borne by the ankles
B. Acute Trendelenburg. The number one reason for the proper positioning of the
newborn at birth is drainage.
Slight trendelenburg with the infant’s head placed about10 to 15 degrees

angle head down is sufficient enough to drain secretions. This way, the naso-
pharyngeal secretions, liquid as they are, drains by gravity from the lungs to
the nose and mouth, from where they can be easily be suctioned. There is
really no need for an acute head-down position. Placing the newborn on prone
or the mother’s abdomen or chest can help drain secretions

Class Notes - Term 2 - MCN Lec

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TERM

6. From the pulmonary artery, a small amount of blood

5. Urogenital system, except the bladder

→ the inner layer; develops into:

1. Linings of gastrointestinal tract from pharynx to rectum

C. THE FETUS 2. Liver, pancreas, thyroid, parathyroid

4. Bladder, thyroid, thymus (for immunity building)

EMBRYONIC GERM LAYERS

→ the outer layer; develops into:

B. MESODERM AGE DEVELOPMENT

1. Dermis → Beginning formation of eyes, nose, GIT; Heart

16 WEEKS → More human appearance

→ Quickening stronger, felt by primigravida; FHT audible 1. SCHULTZE MECHANISM

1. Decidua Basalis: portion of decidua directly beneath the site of implantation,

3. Decidua Vera / Decidua Parietalis: lines the remainder of the uterus

1. Discoid: 15 to 20 cm in diameter and 2 to 4 cm in thickness

2. Location: in the uterus, anteriorly or posteriorly near the fundus

▪ Leakage allows fetal and maternal blood to mix slightly because

2. Excretory with the amniotic fluid as the medium of excretion

3. Respiratory organ of the fetus

4. The placenta acts as a protective barrier to some substance and

C. PLACENTAL MATURITY a. Estrogen and progesterone’s major source of production after

• The hormone found elevated in excessive vomiting

c. Human chorionic somatomammotropin (HCS) orHuman 5. Battledore placenta

• Influences somatic cellular growth of fetus; resembles

• The principal diabetogenic factor as it is the major

2. Placental infarcts 9. Cord knots

3. Placental bipartita THE UMBILICAL CORD / FUNIS

4. Placental tripartite B. PARTS:

COMMON TERATOGENS AND THEIR EFFECTS

Psychoactive Drugs Neonatal withdrawal syndrome when given in late

Category Fetal risk shown in humans; use only if benefits outweigh

SPECIAL CONCERN: TERATOGENIC EFFECTS OF DRUGS

DRUGS POSSIBLE EFFECTS ON FETUS

Progestins Virilization of female fetus Streptomycin Deafness

Stilboestrrol Vaginal carcinoma Penicillin Skin Disorders

Tetracycline Tooth deformities

Phenytoin Cleft lip/ palate, microcephaly, hypoplastic

TERATOGENS AND THEIR POSSIBLE EFFECTS ON FETUS INTRAPARTAL PERIOD

B. LOW PROGESTERONE THEORY / PROGESTERONE DEPRIVATION THEORY - Relief of abdominal tightness

Cervix Dilated; MOST IMPORTANT No Dilation

Walking Intensifies contractions No effect on contraction

Enema Intensifies Contractions No effect on contraction

Show Present and increasing Absent

4. position of the mother; and

5. psychologic response of the mother.

→ Primary Power: Uterine Contractions

o involuntary, rhythmical, regular activity of uterine musculature

o occurs intermittent by allowing for a period of uterine relaxation between

o Increased maternal BP due to increased peripheral arteriole pressure →

o Myometrial contractions constrict blood vessels decreasing uteroplacental

o Prolonged uterine contractions can cause fetal hypoxia.

o Cervical dilation during the first stage

o propel presenting part downward/forward → Phases of uterine contractions

▪ When fundus is difficult to indent, the intensity is MODERATE.

o Maternal bearing down / pushing – readiness for pushing:

o Intra-abdominal pressure: This is another secondary power. As the

→ Structure of the Fetal Skull: → Diameters of the Fetal Skull

▪ Sagittal suture joins the two parietal bones of the skull

→ Fetal Presentation and Position

Complete Longitudinal Good (full The fetus has

FACE PRESENTATION (MENTUM)