Reports:

Topic 1: Scope of maternal and child health nursing based on existing laws.

GOALS, PHILOSOPHIES, AND STANDARDS OF MATERNAL AND CHILD

NURSING
A. The primary goal of maternal and child nursing deals with the promotion and
maintenance of optimal family health, to ensure cycles of optimal childbearing and child rearing.
The scope of practice in maternal and child health nursing care includes the following:
• Preconception health care
• Care of women during the three trimesters of pregnancy and the puerperium (6 weeks
after childbirth).
• Care of children during the perinatal period ( 67 weeks before conception and 6 weeks
after birth )
• Care of children from birth to adolescent
• Care in settings as varied as the birthing room, the pediatric
intensive care unit, and the home.
B. Philosophies of Maternal and Child Health Nursing:
• A family- centered approach enables the nurse to better understand individuals and in
turn to provide holistic care.
• Maternal and child health nursing is community-centered; the health of families depends
on and influences the health of communities.
• Maternal and child health nursing is research oriented, because research is the means
whereby critical knowledge increases.
• Both nursing theory and evidence-based practice provide a foundation for nursing care.
• A maternal and child health nurse serves as an advocate to protect the rights of all family
members, including the fetus.
• Maternal and child health nursing includes a high degree of independent nursing
functions, because teaching and counselling are so frequently required.
• Promoting health is an important nursing role, because this protects the health of the next
generation.
• Pregnancy or childhood illness can be stressful and can alter family life in both subtle and
extensive ways.
• Personal, cultural, and religious attitudes and beliefs influence the meaning of illness and
its impact on the family.
• Maternal and child health nursing is a challenging role for a nurse and is a major factor
in promoting high-level wellness in families.

C. Standards of Maternal and Child Nursing

To promote consistency and ensure quality nursing care and outcomes in these areas,
specialty organizations develop standards for care in their specific areas of nursing practice.
 The Association of Women’s Health, Obstetric, and Neonatal Nurses (AWHONN) has
developed similar standards for the nursing care of women and newborns.

C.1 Standards of Care

• Assessment- collection of patient data.
• Diagnosis- assessment of data to determine the diagnosis.
• Outcome identification- identifying expected outcomes individualized to the
child and family.
• Planning- developing a plan of care that prescribes interventions to obtain the
expected outcomes.
• Implementation – implementing interventions identified in the plan of care.
• Evaluation – nurse evaluates the child’s and family’s progress towards
attainment of outcomes.
C.2 Standards of Professional Performance
• Quality of Care – evaluating the quality and effectiveness of nursing practice.
• Performance Appraisal – evaluation of nursing practice in relation to
professional standards,
• Education – acquisition and maintenance of current knowledge in nursing
practice.
• Collegiality – contributing to the professional development of peers, colleagues
and others.
• Ethics - decisions and actions on behalf of the patient are determined in an
ethical manner.
• Collaboration – collaborating with the patient, significant others, and health care
providers.
• Research Utilization – considering factors related to safety, effectivity, and cost
in planning and delivering patient care.
• Practice Environment – contributing to the environment of care delivery within
the practice setting.
• Accountability – the nurse is professionally and legally accountable for her
practice.
FACTORS AFFECTING MATERNAL AND HEALTH
1. Systemic level
• Poverty
• Religious beliefs
• Cultural beliefs
• Traditional practices
• Societal stigma
2. Organizational level
• Availability of services
• Quality of healthcare providers
• Accessibility of health services
 3. Interpersonal level
• Family tradition
• Husband’s knowledge and perception
• Peer influence
• Influence of other members of the family
• Family support for home delivery
4. Individual level
• Age and education
• Knowledge and perceived need of maternal health care
• Afraid of disclosure of pregnancy
• Financial burden or income
• Low decision-making autonomy
ROLES AND RESPONSIBILITIES OF A MATERNAL AND CHILD HEALTH NURSE
The maternal and child nurse:
• Considers the family as a whole and a partner to achieve optimal care,
• Serves an advocate to protect the rights of the family including the fetus.
• Demonstrates a high degree of nursing functions.
• Promotes health and disease prevention
• Respects personal, cultural and spiritual attitudes and beliefs.
• Assesses family’s strengths as well as specific needs and challenges.
• Encourages family bonding through rooming-in and visits in MCN settings.
• Encourages early hospital discharge options to reunite family ASAP.
• Encourages families to reach out to their community.
Maternal and Child Nursing: From a Legal Standpoint
The basic law of the country provides for the duty of the State to protect and promote the right to
health of the people and instill health consciousness among them. It also recognizes the role of
women and the youth in nation building, The same is echoed in Article XIII, Section 14 of the
Constitution, which mandates the State to provide safe and healthful working conditions for
women, taking into account their maternal functions and to provide facilities and opportunities that
will enhance their welfare and enable them to realize their full potential in the service of the nation.
Hence the State by enacting laws and policy making ensures the health of the citizens who serves
as the foundation of its existence. The State to fulfill its duties to its people is mandated to adopt
and integrate a comprehensive approach to health development which shall endeavor to make
essential goods, health and other social services available to all the people at affordable cost. Under
Article XIII Section 13, priority is given for the needs of the underprivileged, sick, elderly disabled,
women and children.
The government to address the needs of the lower level of the society introduced the
principle of devolution. A process in which there is decentralization of powers from the national
government to local governments to ensure services are delivered to the people. Since health
services delivery was devolved to the Local Government Units (LGU) along with the new powers
and functions of the varying structures of the health sector are new responsibilities that each LGU
should assume. With the institutional restructuring the Department of Health (DOH) serves as the
main national agency responsible for overseeing health service delivery, financing, regulation and
governance of the health sector. The Local Government code of 1991 mandates the DOH to
“formulate policies, standards and regulations, as well as provide tertiary care in tertiary hospitals
and special hospitals, while the LGUs are responsible for the primary and secondary cases in
hospitals and some general tertiary hospitals, which are provided by the provincial hospitals.”
The Philippines being one of the countries who ratified the United Nations and World
Health Organization Charters adopted the Millennium Development Goals and Sustainable
Development Goals. In relation to Maternal and Child Health the former includes goals to reduce
child mortality and improve maternal health while the former aims to attain good health and well-
being for all.

Nursing Practice in the Philippines

The main legal leg of nursing practice in the Philippines is embodied in the Republic Act
9173 otherwise known as The Philippine Nursing Act of 2002. This law is a repeal of Republic
Act 7164 which was passed in 1992 that regulated nursing practice for two decades. Under Article
II, Section 2 of this statute as a policy the State assumes responsibility for the protection and
improvement of the nursing profession. This is done by instituting measures that result in relevant
nursing education, humane working conditions, better career prospects and dignified existence of
nurses. At the same time the declaration of policy provides a guarantee that the State will deliver
quality basic services through an adequate nursing personnel system throughout the country. The
scope of nursing practice is embodied in Article VI, Section 28 of the law which states:
“A person shall be deemed to be practicing nursing within the meaning of this Act
when he/she singly or in collaboration with another, initiates and performs
nursing services to individuals, families and communities in any health care
setting. It includes, but not limited to, nursing care during conception, labor,
delivery, infancy, childhood, toddler, pre-school, school age, adolescence,
adulthood and old age. As independent practitioners, nurses are primarily
responsible for the promotion of health and prevention of illness. As members
of the health team, nurses shall collaborate with other health care providers for the
curative, preventive, and rehabilitative aspects of care, restoration of health,
alleviation of suffering, and when recovery is not possible, towards a peaceful
death. It shall be the duty of the nurse to:
(a) Provide nursing care through the utilization of the nursing process.
Nursing care includes, but not limited to, traditional and innovative
approaches, therapeutic use of self, executing health care techniques and
procedures, essential primary health care, comfort measures, health
teachings, and administration of written prescription for treatment,
therapies, oral, topical and parenteral medications, internal examination
during labor in the absence of antenatal bleeding and delivery. In case of
suturing of perineal laceration, special training shall be provided according
to protocol established;
(b) Establish linkages with community resources and coordination with
the health team;
(c) Provide health education to individuals, families and communities;
(d) Teach, guide and supervise students in nursing education programs
including the administration of nursing services in varied settings such as
 hospitals and clinics; undertake consultation services; engage in such
activities that require the utilization of knowledge and decision-making
skills of a registered nurse; and
(e) Undertake nursing and health human resource development training
and research, which shall include, but not limited to, the development of
advanced nursing practice;
Provided, That this section shall not apply to nursing students who perform
nursing functions under the direct supervision of a qualified faculty: Provided,
further, That in the practice of nursing in all settings, the nurse is duty-bound
to observe the Code of Ethics for nurses and uphold the standards of safe
nursing practice. The nurse is required to maintain competence by continual
learning through continuing professional education to be provided by the
accredited professional organization or any recognized professional nursing
organization: Provided, finally, that the program and activity for the continuing
professional education shall be submitted to and approved by the Board.”
In this provision maternal and child care is one of the scopes of nursing practice. The
same scope is echoed in the Implementing Rules and Regulations of the law issued by the Board
of Nursing in 2003.
To ensure the quality of nursing care the Board of Nursing promulgated the Code of
Ethics for Registered Nurses. Aside from the requirements of finishing a Bachelor of Science in
Nursing Degree, passing the Philippine Nursing Licensure Exam and Registration as a
Professional Nurse, all Filipino nurses must comply with the continuing requirement of abiding
to existing laws and Code of Ethics that regulates the profession. The code comprises seven (7)
articles and eighteen (18) sections, which as a whole provide guidelines to nurses on how to
carry out the profession. Article I of the code provides for the primary responsibility of a nurse to
preserve health at all costs including the assistance to peaceful death. It also emphasizes the
responsibility to a nurse to gain knowledge to understand every aspect of a client to render
effective care and to always maintain the highest possible degree of ethical conduct.

Statutes and Issuances Related to Maternal and Child Health

1. Magna Carta of Women (R.A. No. 9710)
Signed in August 15, 2009, this enactment is a comprehensive women’s human
rights law that aims to eradicate discrimination against women by recognizing,
protecting, fulfilling and promoting the rights of Filipino women, especially those in
the marginalized sectors. This law provides for all rights of women under the
Philippine Constitution, rights recognized under international instruments duly signed
and ratified by the Philippines, in consonance with Philippine laws. It also stressed
that all rights shall be enjoyed without discrimination since discrimination is
prohibited by the law, whether done by or public entities or individuals.
Key features of the law are:
i.Comprehensive health services and health information and education covering all
stages of a woman’s life cycle, and which addresses the major causes of women’s
morbidity and mortality, including access to among others maternal care,
responsible, ethical, legal, safe and effective methods of family planning, and
encouraging healthy lifestyle activities to prevent diseases;
 ii.Gynecological leave—leave benefits of two (2) months with pay based on gross
monthly income/compensation, for women employees who undergo surgery
caused by gynecological disorders, provided that they have rendered continuous
aggregate employment service of at least six (6) months for the last twelve (12)
months;
iii.Equal rights in all matters relating to marriage and family relations. The State
shall ensure the same rights of women and men to: enter into and leave marriages,
freely choose a spouse, decide on the number and spacing of their children, enjoy
personal rights including the choice of a profession, own, acquire, and administer
their property, and acquire, change, or retain their nationality. It also states that
the betrothal and marriage of a child shall have no legal effect.
iv.Review amendment or repeal of laws that are discriminatory to women.
v.Mandate access to information and services pertaining to women’s health.

2. Newborn Screening Act of 2004 (RA No. 9288)

Passed in April 07, 2004 the law makes it a policy of the State to protect and
promote the right to health of people, including the rights of children to survival and
full and healthy development as normal individuals. To achieve this goal the State
shall institutionalize a national newborn screening system that is comprehensive ,
integrative and sustainable, and will facilitate collaboration among government and
non-government agencies at the national and local levels, the private sector, families
and communities, professional health organizations, academic institutions, and non-
governmental organizations. The National Newborn Screening System shall ensure
that every baby born in the Philippines is offered the opportunity to undergo
screening and thus be spared from heritable conditions that can lead to mental
retardation and death if undetected and untreated.

Section 3 of this act states the objectives of the government namely:

• To establish and integrate a sustainable newborn screening system with the

public health delivery system;

• To ensure that all health practitioners are aware of the advantages of

newborn screening and of their respective responsibilities in offering
newborns the opportunity to undergo newborn screening; and

• To ensure that parents recognize their responsibility in promoting their

child's right to health and full development, within the context of
responsible parenthood, by protecting their child from preventable causes of
disability and death through newborn screening.

It is the duty of the health practitioner who delivers or assists in the delivery,
to inform the parents or legal guardian of the newborn of the availability, nature and
benefits of newborn screening. The law also mandates that the screening shall be
performed after twenty-four (24) hours of life but not later than three (3) days
from complete delivery of the newborn. A newborn that must be placed in
 intensive care in order to ensure survival may be exempted from the 3-days
requirement but must be tested by seven (7) days of age. it shall be the joint
responsibility of the parent(s) and the practitioner or other person delivering
the newborn to ensure that newborn screening is performed. An appropriate
informational brochure for parents to assist in fulfilling this responsibility shall be
made available by the Department of Health and shall be distributed to all health
institutions and made available to any health practitioner requesting it for
appropriate distribution.

Although this procedure is mandatory, it is one that admits an exemption,

particularly when it comes to conscientious objectors. In this case the parent or legal
guardian may refuse testing on the grounds of religious beliefs but shall
acknowledge in writing their understanding that refusal for testing places their
newborn at risk for undiagnosed hereditable conditions. A copy of refusal
documentation shall be made part of the newborn’s medical record and refusal shall
be indicated in the national newborn screening database.

3. THE MAGNA CARTA OF PUBLIC HEALTH WORKERS (Republic Act No.

7305)
To ensure that the public health facilities are staffed, and delivery of quality
health care comes the advent of RA No. 7305 otherwise known as the Magna
Carta of Public Health Workers. This Act aims : (a) to promote and improve the
social and economic well-being of the health workers, their living and working
conditions and terms of employment; (b) to develop their skills and capabilities in
order that they will be more responsive and better equipped to deliver health
projects and programs; and (c) to encourage those with proper qualifications and
excellent abilities to join and remain in government service. This law also
provides that there shall be no understaffing or overloading of public health
workers and that health staff-patient ratio shall be such as to effect a sustained
delivery of quality health care at all times without overworking the public health
workers. It also provides for married couples both who are public health workers,
to be employed or assigned within the same municipality, but not of the same
office.

4. 105-Day Expanded Maternity Leave Law (R.A. No. 11210)

The 105-Day Expanded Maternity Leave Law was passed taking into account
the mandate of the 1978 Philippine Constitution regarding its duty to protect and
promote the rights of working women, and considering their maternal functions,
and to provide enabling environment in which their full potential can be achieved
and in consonance with the state principle that the State recognizes the sanctity of
family life and shall protect and strengthen the family as the basic autonomous
social institution and that it shall equally protect the life of the mother and the life
of the unborn from conception. Moreover, Sections 17 and 22 of R.A. No. 9710,
provides for women’s right to health and decent work.
To achieve this goal, and in recognition of women’s maternal function as a
social responsibility, the State institutionalized a mechanism to expand the
maternity leave period of working women. The purpose of this act is to provide
 ample transition time to regain health and overall wellness as well as to assume
maternal roles before returning to work.
In the new legislation, all working mothers—including those employed in the
informal sector—can take up to 105 days of paid maternity leave. Previously,
working mothers are only entitled to 60 days for normal delivery and 78 days for
cesarean delivery for each pregnancy. This benefit can be claimed only if the
claimant has made at least three (3) monthly contributions to the Social Security
System in the twelve (12) months preceding the semester of the birth and have
notified their employer. Previously, the women were entitled to this leave benefit
for up to four pregnancies but in the new law this cap have been removed, thus
claims can be filed regardless of the number of pregnancies or miscarriage.
Paid maternity leave is available to all working mothers, regardless of their
civil status and legitimacy of their child. Women who suffer a miscarriage or have
an emergency termination can take up to 60 days of paid maternity leave. Leave
can also be extended for additional 30 days, but it is without pay, subject to
notifying their employer 45 days before the end of the leave. While mothers who
are single parents can request for an additional 15 days’ leave with full pay.

5. Solo Parent Act (R.A. No. 8972)

The Solo Parent Act provides for benefits and privileges to solo parents who
are the parents of their children or relatives. According to Section 3(a), a “solo
parent” is a person who has been left with the child’s responsibility or care any of
the following categories:
1. A woman who gives birth as a result of rape and other crimes against
chastity even without final conviction of the offender, provided that the
mother keeps and raises the child.
2. Parent left solo or alone with the responsibility of parenthood due to the
following circumstances:
3. Due to the death of a spouse.
4. Spouse is detained or is serving sentence for a criminal conviction for at
least one (1) year.
5. Physical and/or mental incapacity of spouse as certified by a public
medical practitioner.
6. Legal separation or de facto separation from spouse for at least one (1)
year, as long as he/she is entrusted with the custody of the children.
7. Declaration of nullity or annulment of marriage as decreed by a court or by
a church as long as he/she is entrusted with the custody of the children.
8. Unmarried mother/father who has preferred to keep and rear her/his
child/children instead of having others care for them or give them up to a
welfare institution.
9. Any other person who solely provides parental care and support to a child
or children.
10. Any family member who assumes the responsibility of head of family as a
result of the death, abandonment, disappearance or prolonged absence of
the parents or solo parent.
 Under the law a comprehensive package of social development and welfare
services for solo parents and their families will be developed by the government
agencies and instrumentalities in coordination with the LGU and non-
governmental institutions with proven track record services for solo parents. It
also provides for a flexible work schedule if it will not affect individual or
company productivity. Parental leave shall be provided in addition to leave
privileges under existing laws, parental leave of not more than 7 working days
every year shall be granted to any solo parent employee who has rendered at least
1 year. Medical assistance shall be implemented by the DOH through their
retained hospitals and medical centers and the LGU’s through their provincial,
district, city, municipal hospitals and rural health units.

6. Responsible Parenthood and Reproductive Health Law (R.A. No. 10354)

This law guarantees universal access to medically-safe, non-abortifacient,
effective, legal, affordable, and quality reproductive health care services, methods,
devices, supplies which do not prevent the implantation of a fertilized ovum as
determined by the Food and Drug Administration (FDA) and relevant information
and education thereon according to the priority needs of women, children and
other underprivileged sectors, giving preferential access to those identified
through the National Household Targeting System for Poverty Reduction (NHTS-
PR) and other government measures of identifying marginalization, who shall be
voluntary beneficiaries of reproductive health care, services and supplies for free.
The State shall eradicate discriminatory practices, laws and policies that
infringe on a person’s exercise of reproductive health rights.
The State shall also promote openness to life; Provided, that parents bring
forth to the world only those children whom they can raise in a truly humane way.
It also provides reproductive health care which refers to the access to a full
range of methods, facilities, services and supplies that contribute to reproductive
health and well-being by addressing reproductive health-related problems. It also
includes sexual health, the purpose of which is the enhancement of life and
personal relations. The elements of reproductive health care include the following:
(1) Family planning information and services which shall include as a first
priority making women of reproductive age fully aware of their respective
cycles to make them aware of when fertilization is highly probable, as well as
highly improbable;
(2) Maternal, infant and child health and nutrition, including breastfeeding;
(3) Proscription of abortion and management of abortion complications;
(4) Adolescent and youth reproductive health guidance and counseling;
(5) Prevention, treatment and management of reproductive tract infections
(RTIs), HIV and AIDS and other sexually transmittable infections (STIs);
(6) Elimination of violence against women and children and other forms of
sexual and gender-based violence;
(7) Education and counseling on sexuality and reproductive health;
(8) Treatment of breast and reproductive tract cancers and other
gynecological conditions and disorders;
(9) Male responsibility and involvement and men’s reproductive health;
 (10) Prevention, treatment and management of infertility and sexual
dysfunction;
(11) Reproductive health education for the adolescents; and
(12) Mental health aspect of reproductive health care.

Department of Health Programs

1. National Safe Motherhood Programs
With the vision for Filipino women to have access to health services towards making their
pregnancy and delivery safer, the DOH is committed to provide rational and responsive
policy direction to its local partners in the delivery of quality maternal and newborn health
services with integrity and accountability using proven and innovative approaches. The
Program contributes to the national goal of improving women’s health and well-being by:
i.Collaborating with Local Government Units in establishing sustainable, cost-effective
approach of delivering health services that ensure access of disadvantaged women to
acceptable and high quality maternal and newborn health services and enable them to
safely give birth in health facilities near their homes
ii.Establishing core knowledge base and support systems that facilitate the delivery of
quality maternal and newborn health services in the country.
The program is composed of two components. Component A focuses on the local delivery
of maternal-newborn service packages. In each province and city, the following shall
continue to be undertaken:
i.Establishment of critical capacities to provide quality maternal-newborn services through
the organization and operation of a network of Service Delivery Teams consisting of:
1. Barangay Health Workers
2. BEmONC Teams composed of Doctors, Nurses and Midwives
ii.In collaboration with the Centers for health Development and relevant national offices:
Establishment of Reliable Sustainable Support Systems for Maternal-Newborn Service
Delivery through such initiatives as:
1. Establishment of Safe Blood Supply Network with support from the National
Voluntary Blood Program
2. Behavior Change Interventions in collaboration with the Health Promotion and
Communication Service
3. Sustainable financing of maternal - newborn services and commodities through
locally initiated revenue generation and retention activities including PhilHealth
accreditation and enrolment.
Component B on the other hand focuses on National Capacity to Sustain Maternal-Newborn
Services:
i.Operational and Regulatory Guidelines
1. Identification and profiling of current FP users and identification of potential FP
clients and those with unmet need for FP (permanent or temporary methods)
2. Mainstreaming FP in the regions with high unmet need for FP
3. Development and dissemination of Information, Education Communication
materials
4. Advocacy and social mobilization for FP
ii.Network of Training Providers
 iii.Monitoring, Evaluation, Research, and Dissemination with support from the Epidemiology
Bureau and Health Policy Development and Planning Bureau
1. Monitoring and Supervision of Private Midwife Clinics in cooperation with PRC
Board of Midwifery and Professional Midwifery Organizations
2. Maternal Death Reporting and Review System in collaboration with Provincial and
City Review Teams
3. Annual Program Implementation Reviews with Provincial Health Officers and
Regional Coordinators.

2. Integrated Management of Childhood Illnesses (IMCI)

IMCI is an integrated approach to child health that focuses on the well-being of the whole
child. Its aim is to reduce death and disability and to promote growth and development among
children under five (5) years of age. IMCI include curative and preventive elements that are
implemented by families and communities and by health facilities.

3. National Family Planning Program

A nationwide mandated priority public health program aiming for the country’s national
health development: a health intervention program and an important tool for the improvement
of the health and welfare of mothers, children, and among other members of the family. The
program also includes information dissemination and services for the couples of reproductive
ages to plan for their family according to their beliefs and circumstances through legally and
medically acceptable family planning methods.

4. Newborn Screening Program

5. Unang Yakap (Essential Newborn Care: Protocol for New Life)

One of the government's strategies towards the attainment of MDGs 4 and 5. Unang yakap
is best described as “simple cost-effective newborn care intervention” intended to enable
improved neonatal and maternal care.
UNANG YAKAP emphasizes a step-by-step sequence of actions, or Four Core Steps of
Essential Newborn Care:
i.Immediate and thorough drying provides warmth to the child and prevents
hypothermia from setting in;
ii.Early skin-to-skin contact establishes mother and child bonding and minimizes the risk
of sepsis and hypoglycemia;
iii.Properly timed cord clamping and cutting prevents anemia and hemorrhage;
iv.Non-separation of the newborn and mother for early initiation of breastfeeding.

6. National Immunization Program

Children who are not fully immunized are more susceptible to common childhood
diseases. To address this problem in 1976, the Expanded Program on Immunization (EPI) was
established. It included six vaccine-preventable diseases were initially included in the EPI:
tuberculosis, poliomyelitis, diphtheria, tetanus, pertussis and measles. Vaccines under the EPI
 are BCG, Hepatitis B, Oral Poliovirus Vaccine, Pentavalent Vaccine, Measles Containing
Vaccines (Anti-measles Vaccine, MMR) and Tetanus Toxoid.
Immunization is one of the DOH Programs that has already been institutionalized and
adopted by all LGUs in the region. The main objective is to reduce infant mortality and
morbidity through decreasing the prevalence of six immunizable diseases.
In 2014, Pneumococcal Conjugate Vaccine 13 was included in the routine immunization
of EPI. In 2016, the Expanded Program on Immunization transitioned to become the National
Immunization Program. It will include immunizations of other populations such as senior
citizen immunization, school-age immunization, and adolescent immunizations.

7. Food Fortification Program

The Philippine government’s response to the growing micronutrient malnutrition, which
has been prevalent in the country. Republic Act No. 8976 otherwise known as ““An Act
Establishing the Philippine Food Fortification Program and for other purposes” mandated
fortification of flour, oil, sugar with Vitamin A and flour and rice with iron by November 7,
2004 and promoting voluntary fortification through Sangkap Pinoy Program Seal.

Women and Children Protection Laws and Programs

1. Anti-Violence Against Women and Their Children Act of 2004 (R.A. No. 9262)
This legislation declares that the State the dignity of women and children and guarantees
full respect for human rights. The State also recognizes the need to protect the family and its
members, particularly women and children, from violence and threats to their personal safety and
security. Hence, the law provides for a remedy for abused women and children in the form of
medical assistance in coordination with the LGU. Section 31 of this Act lays the duties and
responsibilities of any healthcare worker when working with the victim. The said provision
states:
“Healthcare Provider Response to Abuse – Any healthcare provider, including, but not
limited to, an attending physician, nurse, clinician, barangay health worker, therapist or
counselor who suspects abuse or has been informed by the victim of violence shall:
(a) properly document any of the victim’s physical, emotional or psychological injuries;
(b) properly record any of victim’s suspicions, observations and circumstances of the
examination or visit;
(c) automatically provide the victim free of charge a medical certificate concerning the
examination or visit;
(d) safeguard the records and make them available to the victim upon request at actual cost;
and
(e) provide the victim immediate and adequate notice of rights and remedies provided under
this Act, and services available to them.”
To ensure protection of women and children Section 41 provides for the mandate for the
governmental agencies to provide services to the victim, it thus states:
“Mandatory Programs and Services for Victims. – The DSWD, and LGU’s shall provide
the victims temporary shelters, provide counseling, psycho-social services and /or,
recovery, rehabilitation programs and livelihood assistance. The DOH shall provide
medical assistance to victims.”
 2. Special Protection of Children Against Child Abuse, Exploitation and
Discrimination Act (R.A. No. 7610) Implementing Rules and Regulations (IRR) on
the Reporting and Investigation of Child Abuse Cases

Pursuant to Section 32 of R.A. No. 7610 the IRR of the law was made effective in 1993
after the publication requirement was complied. The objective of the IRR is to encourage
reporting of cases of physical or psychological injury, sexual abuse or exploitation, or negligent
treatment of children and to ensure early and effective investigation of cases of child abuse.
Under Section 4 of the IRR, the head of any public or private hospital, medical clinic and
similar institution, as well as the attending physician and nurse, shall report, either orally or in
writing, to the Department the examination and/or treatment of a child who appears to have
suffered abuse within forty-eight (48) hours from knowledge of the same. To facilitate reporting
the rules also provided for immunity for reporting clauses. In this provision a person who acted
in good faith, shall report a case of child abuse shall be free from any civil or administrative
liability arising therefrom and that there shall be a presumption of good faith.
In the same IRR also provides referral of the child who is placed under protective custody
to a government medical or health officer for a physical/ mental examination and/or medical
treatment.

3. Responsible Parenthood and Reproductive Health (RPRH Act of 2012) (RA 10354)

4. Philippine National Strategic Framework for Plan Development for Children, 2000-
2025 (Child 21)
The health sector's contribution to the Philippine National Development Plan for
Children defines the vision for children by 2025, formulates cost-effective interventions, and
outlines a budget that will reflect contributions of different national and local government
units, private sectors, NGOs, and international organizations. It serves as a framework for
LGUs in the formulation of their development plans.
Strategies and activities under this program are the following:
i.Enhance capacity and capability of health facilities in the early recognition, management
and prevention of common childhood illness
1. This will entail improvements in the flow of services in the implementing facilities
to ensure that every child receives the essential services for survival, growth and
development in an organized and efficient manner. Facilities should be equipped
with the essential instruments, equipment and supplies to provide the services.
Health providers shall have the knowledge and skills to be able to provide quality
services for children. Existing child health policies, guidelines and standards shall
be reviewed and updated, and new ones formulated and disseminated to guide
health providers in the standard of care.
ii.Strengthening community-based support systems and interventions for children's
health
1. Notable community-based projects and interventions, such as the health and
nutrition posts, mother support groups, community financing schemes shall be
replicated for nationwide implementation. Model building and dissemination of
best practices from pilot sites has proven effective in generating support and
 adoption in other sites. More of these shall be initiated particularly for developing
interventions to increase care-seeking and prevention of malnutrition in children.
iii. Fostering linkages with advocacy groups and professional organizations and to promote
children's health
1. Collaboration with the non government sector and professional groups shall:
1. Conduct national campaigns on children's health
2. Conduct and support national campaigns for children
3. Initiate and support legislations and researches on children's health and welfare
4. Development of a comprehensive monitoring and evaluation system for child
health programs and projects.

Topic 2: Prenatal / Signs of pregnancy

Categories of pregnancy symptoms

Indicators or early signs of pregnancy can be broken down as follows:

• Presumptive signs — possibility of pregnancy

• Probable signs — most likelihood of indicating pregnancy
• Positive signs — confirmation of pregnancy (1)

Occasionally a person with an immense desire for, or fear of, pregnancy can develop
presumptive, even probable, signs of pregnancy. This is known as a false pregnancy
(pseudocyesis) and truly shows how the brain can influence physiology.

Side note: sympathetic pregnancy (also known as couvade syndrome) is when a non-pregnant
partner experiences similar symptoms to the pregnant partner.

• PRESUMPTIVE SIGNS – these are changes felt by woman, these signs and
symptoms are not proof of pregnancy but they will make you suspect of pregnancy
because it may resemble pregnancy signs and symptoms, but may in fact be caused by
any number of other conditions.
o Morning sickness (Nausea and vomiting)
§ Nausea and vomiting occurs commonly in early morning as early as the
first month of pregnancy or may persist continually until delivery. The
severity of symptom can vary. This is associated with increased HCG
levels. But it is unreliable sign of pregnancy, since it may result from
other conditions such as gastrointestinal disorders, infection, emotional
stress and indigestion. Thus, it’s included in presumptive sign.
o Amenorrhea (absence of woman’s menstrual period)
§ Amenorrhea is one of the earliest clues of pregnancy but considered to
be a presumptive sign. It suggests pregnancy has occurred, but not
uncommon for a woman to miss her period. It maybe cause by stress
(tension, fear or strong desire for a pregnancy), excessive exercises,
chronic illnesses (endocrine disorders, central nervous system
abnormalities), hormonal imbalance (thyroid malfunction),
medications (allergy medications, blood pressure drugs) and
 contraceptives.
o Change in breast
§ In early pregnancy changes start with a light, temporary enlargement
of the breasts and continues to increased firmness or tenderness and
more visible veins due to increased blood supply but it could also be a
result of
hormonal factors, injury and breast disease.
o Fatigue (extreme tiredness resulting from mental or physical exertion)
§ This is a common complaint, many women feel constantly tired in
early pregnancy. Hormonal changes are likely the cause of fatigue
but other reason to feel exhausted are anemia, infection, emotional
stress and malignant disease.
• Lassitude (lethargy or lack of energy) Lassitude is interchangeable with
fatigue. However, lassitude is the feeling where you lack energy of doing
something. Most of the time a pregnant woman may experience. Lassitude
is a presumptive sign because it’s not uncommon for us, even the energetic
or productive men may experienced lethargy once in their lifetime.
o Urinary frequency (frequent urination)
§ You may have noticed more need to pee even before you realized you
were pregnant. Hormonal changes cause
blood to flow more quickly through your kidneys, filling your bladder
more often. If you feel pain or burning when urinating and feel the
urge to pee even you’re only able to produce a few drops, these could
be signs of urinary tract infection (UTI). It is not a definite sign since
other factors can be possible such as tension, diabetes, tumor, excess
drinking and also some medications (diuretics).
o Quickening (woman feel or recognize fetal movements in the uterus)
§ A primigravida (woman pregnant for the first time) usually cannot
feel quickening until after 18 weeks, but multigravida (pregnant more
than one time) can feel fetal movement as early as 16 weeks. It feels
like gas bubbles, flutters or butterflies in stomach. This “feeling of
life” is not considered positive indication of pregnancy because it
can’t be confirmed objectively by anyone aside from the woman
herself. The movement of gas within the intestine can also mimic this
feeling.

• PROBABLE SIGNS – these are signs observed by the examiner (Obstetrician or

Midwife). They are more reliable indicators of pregnancy than the presumptive
signs but are not definitive.
o Uterine changes – these signs in uterus are probable and cannot be consider as
true signs of pregnancy.
§ Uterine enlargement – at twelve weeks gestation it felt just above
symphysis pubis.
§ Hegar’s sign – this is softening of the lower uterine segment just
above the cervix. Physician examines your uterus by compressing it
between examining fingers, the wall feels tissue paper thin.
§ Ballottement – this is demonstrated during bimanual exam. It is the
sinking and rebound of fetus.
o Cervical changes
§ Goodell’s sign – softening of the cervix. Cervix is normally firm like the
 cartilage at the end of the nose.
§ Braxton-Hicks Contractions – this involves painless contractions
occurring throughout pregnancy. It usually be stopped by walking.
o Positive Pregnancy test
§ Maybe your shock, but positive pregnancy test may indicate either a
false positive or false negative, making it just a probable sign because
by doing it too early or too late can affect its result. Besides there are
many things
to consider in using and taking a home pregnancy test. First, timing is
very important. The advisable time to take the test is in the morning to
have a better result. This is because urine is more concentrated and the
hormones level is much measurable. Moreover, the kit itself is a factor
too, you must purchase home pregnancy test kit in a known and trusted
drug store. It’s not all about the price, what matters is whether or not a
test is damaged, expired or used inaccurately. Even if the test is
positive, it could be the result of ectopic pregnancy and hydatidiform
mole (abnormal growth of a mass of tissue inside your womb).
o Chadwicks’ sign – bluish discoloration of vaginal wall.
o Outlining of fetal body
§ Fetal outline can be palpated by the examiner through the abdomen
and identify fetal parts. It is not always accurate.
• POSITIVE SIGNS – these are definitive and unmistakable signs of pregnancy.
Objective signs that strongly indicate pregnancy. There are only three positive signs of
pregnancy that are documented by the obstetrician or health care professional.
o Fetal heart rate (heartbeat)
§ With the use of Doppler it can be heard by 10 weeks, fetoscope by 16
weeks and by auscultation (stethoscope) by 18-20 weeks. The normal
fetal heart rate usually ranges from 120-160 beats per minute (bpm).
Hearing the first “lub dub” of your baby’s heart will tickle your
excitement. No doubt, there is a life inside you. It’s undeniably a
positive sign.
o Fetal movement
§ This fetal movement is felt by health care provider usually after 20
weeks where pregnant woman feel their unborn baby’s kicks, flutter,
swish or roll and sometimes their hiccup. At first, the kicks you
observe will be
few and far at intervals, but later in your second trimester the flutters
will be much stronger and regular that may bother your sleep. It’s
really amazing to feel the movements your baby is doing inside you.
A proof that there is a life developing in you and a confirmation of
positive sign of pregnancy.
o Fetal outline on Ultrasound
§ Ultrasound shows image of the fetal outline the head, body and
spine. It is a noninvasive diagnostic test that uses sound waves.
Ultrasound confirms positive pregnancy and allows health care
practitioner to check the
progress of your pregnancy and your baby’s health. Likewise,
ultrasound is important in detecting abnormalities in pregnancy such
 as hydrocephalus, distention of fetal abdomen, polyhydramnios,
oligohydramnios and masses in pregnancy.

Danger signs of pregnancy

It is important to instruct the pregnant woman about the danger signs of pregnancy. Assure her
you have no reason to think she is going to experience any of these things, that you have every
reason to believe she is going to have a normal, uncomplicated pregnancy; but that if any of these
things should occur, she should inform or consult a doctor immediately.

1. Vaginal bleeding no matter how slight. This may mean abortion.

2. Persistent vomiting. This may lead to severe dehydration and fetal distress.

3. Chills and fever. This may be evidence of an intrauterine infection.

4. Sudden escape of fluid from the vagina. It is evident that the membrane has ruptured and so
mother and fetus are now both threatened.
5. Abdominal or chest pain. This may mean ectopic pregnancy: a separation of the placenta;
preterm labor; appendicitis; ulcer or pancreatitis.
6. Danger signs of pregnancy - induced hypertension, like swelling of the face or fingers, flashes
of light or dots before the eyes, dimness or blurring of vision, and severe continuous headache,
decreased urine output, and rapid weight gain.
7. Increase or decrease fetal movement.

1st trimester pregnancy: What to expect

The first trimester of pregnancy can be overwhelming. Understand the changes you might
experience and how to take care of yourself during this exciting time.
The first trimester of pregnancy is marked by an invisible — yet amazing — transformation. And
it happens quickly. Knowing what physical and emotional changes to expect during the first
trimester can help you face the months ahead with confidence.

Your body
While your first sign of pregnancy might have been a missed period, you can expect several
other physical changes in the coming weeks, including:

• Tender, swollen breasts. Soon after conception, hormonal changes might make your
breasts sensitive or sore. The discomfort will likely decrease after a few weeks as
your body adjusts to hormonal changes.
• Nausea with or without vomiting. Morning sickness, which can strike at any time of
the day or night, often begins one month after you become pregnant. This might be
due to rising hormone levels. To help relieve nausea, avoid having an empty stomach.
Eat slowly and in small amounts every one to two hours. Choose foods that are low in
fat. Avoid foods or smells that make your nausea worse. Drink plenty of fluids. Foods
containing ginger might help. Contact your health care provider if your nausea and
vomiting is severe.
 - Take dry carbohydrates (e.g. crackers, toast) 30 minutes before getting up in the
morning.
- Refrain from taking fatty foods
- Take small frequent meals
- Increase fluids, but best tolerated between meals
• Increased urination. You might find yourself urinating more often than usual. The
amount of blood in your body increases during pregnancy, causing your kidneys to
process extra fluid that ends up in your bladder.
• Fatigue. During early pregnancy, levels of the hormone progesterone soar — which
can put you to sleep. Rest as much as you can. A healthy diet and exercise might
increase your energy.
- Have enough rest and sleep in modified Sim's position
- Wear comfortable dress and shoes
• Food cravings and aversions. When you're pregnant, you might become more
sensitive to certain odors and your sense of taste might change. Like most other
symptoms of pregnancy, food preferences can be chalked up to hormonal changes.
• Heartburn. Pregnancy hormones relaxing the valve between your stomach and
esophagus can allow stomach acid to leak into your esophagus, causing heartburn. To
prevent heartburn, eat small, frequent meals and avoid fried foods, citrus fruits,
chocolate, and spicy or fried foods.
- Take small frequent meals
- Refrain from taking indigestible gas forming fatty and spicy foods
- Maintain an upright position to prevent regurgitation of gastric contents in the
esophagus.
• Constipation. High levels of the hormone progesterone can slow the movement of
food through your digestive system, causing constipation. Iron supplements can add to
the problem. - Increase fluid intake at least 6-8 glasses a day
- Increase roughage or bulk in the diet. Take 3-4 servings of fruits and vegetables a
day
- Have a regular exercise like walking
- Encourage regular bowel movement
• Your emotions. Pregnancy might leave you feeling delighted, anxious, exhilarated
and exhausted — sometimes all at once. Even if you're thrilled about being pregnant,
a new baby adds emotional stress to your life. It's natural to worry about your baby's
health, your adjustment to parenthood and the financial demands of raising a child. If
you're working, you might worry about how to balance the demands of family and
career. You might also experience mood swings. What you're feeling is normal. Take
care of yourself, and look to loved ones for understanding and encourageement. If
your mood changes become severe or intense, consult your health care provider.
Prenatal care
If you haven't yet received a COVID-19 vaccine, get vaccinated. COVID-19 vaccines don't cause
infection with the COVID-19 virus. Studies have shown COVID-19 vaccines don't pose any
serious risks for pregnant women or their babies. Vaccination can help pregnant women build
antibodies that protect their babies. If possible, people who live with you should also be
vaccinated against COVID-19.
Whether you choose a family doctor, obstetrician, nurse-midwife or other pregnancy specialist,
your health care provider will treat, educate and reassure you throughout your pregnancy.
Your first visit will focus on assessing your overall health, identifying any risk factors and
determining your baby's gestational age. Your health care provider will ask detailed questions
about your health history. Be honest. If you're uncomfortable discussing your health history in
front of your partner, schedule a private consultation. Also expect to learn about first trimester
screening for chromosomal abnormalities.
After the first visit, you'll probably be asked to schedule checkups every four weeks for the first
32 weeks of pregnancy. However, you may require more or less frequent appointments,
depending on your health and medical history. In some cases, virtual prenatal care may be an
option if you don't have certain high-risk conditions. If you and your health care provider opt for
virtual prenatal visits, ask if there are any tools that might be helpful to have at home, such as a
blood pressure monitor. To make the most of any virtual visits, prepare a list of questions ahead
of time and take detailed notes.
During these appointments, discuss any concerns or fears you might have about pregnancy,
childbirth or life with a newborn. Remember, no question is silly or unimportant — and the
answers can help you take care of yourself and your baby.
Initial Prenatal Visit
Ø Initial interview/History-taking. This has several purposes: to gain information about the
woman's physical and psychosocial health, to establish rapport, and to obtain a basis for
anticipatory guidance at the conclusion of the visit.
1. Information regarding this pregnancy, including date and character of last menstrual
period, and normal frequency of menstruation and early signs of pregnancy such as
nausea, vomiting, heartburn and fatigue.
a. Previous obstetric history, including weight, condition, spacing and type of
previous deliveries. Any previous miscarriages or abortion, and complications if
any.
b. Medical history (past and present). Diseases which are threats to pregnancy
especially diabetes, hypertension, cardiovascular disease, tuberculosis, venereal
disease, mumps, rubella, poliomyelitis, allergies, kidney diseases, and
gynecological interventions
c. Surgical history, especially abdominal or uterine surgery.
d. Medications used before and during this pregnancy include alcohol, tobacco, and
marijuana.
e. Any problem encountered during this or previous pregnancy. Has she experienced
any of the danger signals of pregnancy such as bleeding, continuous headache,
blurring of vision, or swelling of the hands or face.
2. Information about a woman's nutrition, elimination, sleep, recreation, lifestyle and
interpersonal interactions.
3. Review of systems. This method causes her to recall diseases she forgot to mention earlier,
diseases that are important for your history-taking.
4. Computation of the Expected Date of Delivery (EDD) and determining Obstetrical
assessment of the mother.
 The lunar month pregnancy actually begins on the first day of a woman's last
menstrual period. Although she likely does not become pregnant for another two weeks, four
weeks from that day she is said to be four weeks into the forty week pregnancy process. By
this method, a pregnancy is 280 days long. In many places, this method is the traditional one
for tracking pregnancy Lunar Months.
Prenatal development is often measured in lunar months. Each lunar month consists
of 28 days, organized into four weeks of seven days each. That means a pregnancy is 10
lunar months long! 40 weeks from the start of your LNMP. Gestation is 38 weeks from
conception to birth.

TERMS TO REMEMBER:
• Para - The number of pregnancies that reached viability, regardless of whether the infants
were born alive or not or those who weighs 500-600 gms
• Gravida - A woman who is or has been pregnant
• Primigravida - A woman who is pregnant for the first time
• Primipara - A woman who has given birth to one child past age of viability
• Multigravida - A woman who has been pregnant previously
• Multipara - A woman who has carried two or more pregnancies to viability
• Nulligravida - A woman who has never been and is not currently pregnant
• Gravida (G) – number of pregnancy/ies/a woman who is or has been pregnant
• Para (P) -the number of pregnancies that reached viability (24 weeks), regardless of
whether the infants were born alive or not or those who weighs 500-600 gms
• Term (T) – number of full-term infants born (born at 37 weeks or after)
• Preterm (P) – number of preterm infants born (born before 37 weeks) = 25 to 36 weeks
• Abortion (A) – number of spontaneous or induced abortions (pregnancy terminated before
the age of viability). Age of viability is 24 weeks.
• Living children (L) – number of living children
• Multiple Gestation
Naegele’s Rule:
Jan – Mar:: +9 +7 +1
April Dec: -3 +7 same year

Topic 3: Prenatal Assessment for pregnant

2nd-trimester pregnancy: What to expect

The second trimester of pregnancy is often the most enjoyable. Find out how to relieve
common symptoms — and consider ways to prepare for what's ahead.
The second trimester of pregnancy often brings a renewed sense of well-being. The worst of the
nausea has usually passed, and your baby isn't big enough to make you too uncomfortable. Yet
more pregnancy symptoms are on the horizon. Here's what to expect.
1. Growing belly and breasts. As your uterus expands to make room for the baby, your belly
grows. Your breasts will also gradually continue to increase in size. A supportive bra
with wide straps or a sports bra is a must. Your breasts may not be as tender as they were
in the first trimester, but they will continue to grow. Enlarging milk glands and deposits
of fat cause the growth. These changes prepare you for breastfeeding. You may notice
 that the skin on and around your nipples darkens. You may also have small bumps around
your nipples. The bumps are glands that make an oily substance to keep your nipples
from drying out. A yellowish fluid, called colostrum, might begin to leak from your
nipples.
2. Braxton Hicks contractions. Also called “false labor,” Braxton Hicks contractions are a
tightening of your uterine muscles. It’s one of the ways your uterus prepares for labor and
delivery. Braxton Hicks make your belly feel very tight and hard and may cause
discomfort. The contractions are irregular in timing and should go away within a few
minutes. You might feel these mild, irregular contractions as a slight tightness in your
abdomen. They're more likely to occur in the afternoon or evening, after physical activity
or after sex. Contact your health care provider if the contractions become regular and
steadily increase in strength. This could be a sign of preterm labor.
3. Skin changes. Hormonal changes during pregnancy stimulate an increase in pigment-
bearing cells (melanin) in your skin. As a result, you might notice brown patches on your
face (melasma). You might also see a dark line down your abdomen (linea nigra). These
skin changes are common and usually fade after delivery. Sun exposure, however, can
aggravate the issue. When you're outdoors, use sunscreen. You might also notice reddish-
brown, black, silver or purple lines along your abdomen, breasts, buttocks or thighs
(stretch marks). Although stretch marks can't be prevented, most eventually fade in
intensity. As your body grows, some areas of skin may become stretched tight. Elastic
fibers right beneath the skin may tear. This creates streaks of indented skin called stretch
marks. Stretch marks are likely to occur on your belly and breasts. Not every pregnant
woman gets stretch marks, but they’re common. Unfortunately, there is no way to prevent
them completely. Try to manage your weight and not gain more than what your doctor
recommends. There are some lotions and oils that claim to prevent stretch marks. The
effects of these products are not proven. However, keeping your skin well moisturized
can help cut down on itchiness that comes with stretch marks. The marks should fade and
become less noticeable after pregnancy.Other skin changes are possible, too, although not
all women get them. Common skin changes include:
• Dry, itchy skin, especially on the belly
• Increased sensitivity to the sun. This means you might burn more easily. Make sure
you wear a strong sunscreen when spending time outside.
• A dark line (“linea nigra”) down the middle of your belly from your navel to your
pubic hair
• Patches of darkened skin on the face (sometimes called the “mask of pregnancy”)
4. Nasal Congestion. During pregnancy, your hormone levels increase and your body makes
more blood. These result from increased blood flow to the mucous membranes in your
nose and mouth. This can cause your mucous membranes to swell and bleed easily,
resulting in stuffiness and nosebleeds. Saline drops or a saline rinse can help relieve
congestion. Also, drink plenty of fluids, use a humidifier, and dab petroleum jelly around
the edges of your nostrils to help moisten skin.
5 Dental issues. Pregnancy can cause your gums to become more sensitive to flossing and
brushing, resulting in minor bleeding. Pregnancy hormones also affect the ligaments and
bones in your mouth, so teeth may loosen. They return to normal after pregnancy. Contact
your dentist if you have bleeding or swelling of your gums. These symptoms can be signs
of periodontal disease. This condition has been linked to preterm (early) birth and low birth
 weight. The second trimester is the best time to have dental work done. Rinsing with salt
water and switching to a softer toothbrush can decrease irritation. Frequent vomiting could
also affect your tooth enamel and make you more susceptible to cavities. Be sure to keep
up your dental care during pregnancy.
6 Dizziness. Pregnancy causes changes in circulation that might leave you dizzy. If you're
having trouble with dizziness, drink plenty of fluids, avoid standing for long periods, and
move slowly when you stand up or change position. When you feel dizzy, lie down on
your side.
7 Heartburn may begin or worsen in the second trimester. Your growing uterus presses on
your stomach, which can force food and acid up into your esophagus, causing the burn.
Leg cramps. Leg cramps are common as pregnancy progresses, often striking at night.
These may be related to the pressure your growing baby puts on the nerves and blood vessels
that go to your legs. Make sure you sleep on your side instead of your back. Another leg
condition, deep vein thrombosis (DVT), can be serious. DVT is a blood clot that forms in a
vein and causes pain and swelling in one leg. Contact your doctor right away if you have
these symptoms. Your ankles, hands, and face may swell during the second trimester. This
happens because your body retains more fluid for the baby. You also have slower blood
circulation.
- Avoid fatigue of muscles, change position frequently
- Don't wear constricting garters
- Hyperextension of involved muscles
- Soaking in warm water or using heating pads.
8 Vaginal discharge. You might notice a sticky, clear or white vaginal discharge. This is
normal. Contact your health care provider if the discharge becomes strong smelling,
unusual in color, or if it's accompanied by pain, soreness or itching in your vaginal area.
This could indicate a vaginal infection.
9 Urinary tract infections. Hormonal changes slow the flow of urine and your
bladder doesn’t empty completely because your enlarged uterus pushes on it. Untreated
UTIs can lead to preterm labor, so tell your doctor if you think you have one. Symptoms
include needing to urinate more often, a burning sensation when you urinate, or the
presence of blood or a strong odor in your urine. These infections are common during
pregnancy. Contact your health care provider if you have a strong urge to urinate that can't
be delayed, sharp pain when you urinate, urine that is cloudy or has a strong smell or you
have a fever or backache. Left untreated, urinary tract infections can become severe and
result in a kidney infection.
10 Aching back, pelvis, and hips. The job of supporting your growing belly puts stress
on your back. Your hips and pelvis may begin to ache as pregnancy hormones relax the
ligaments that hold your bones together. Your bones move to prepare for childbirth.
11 Stomach pain. The muscles and ligaments supporting your uterus stretch as your uterus
grows. These can cause mild pain or cramping.
12 Your emotions. During the second trimester, you might feel less tired and more up to the
challenge of preparing for your baby. Check into childbirth classes. Some childbirth
classes may be available online. Find a doctor for your baby. Read about breastfeeding. If
you will work after the baby is born, get familiar with your employer's maternity leave
policy and investigate child care options. You might worry about labor, delivery or
 impending parenthood. To ease your anxiety, learn as much as you can. Focus on making
healthy lifestyle choices that will give your baby the best start.
Prenatal care
If you haven't yet received a COVID-19 vaccine, get vaccinated. COVID-19 vaccines don't cause
infection with the COVID-19 virus. Studies have shown COVID-19 vaccines don't pose any
serious risks for pregnant women or their babies. Vaccination can help pregnant women build
antibodies that protect their babies. If possible, people who live with you should also be
vaccinated against COVID-19.
Your prenatal appointments will focus on your baby's growth and detecting any health problems
during the second trimester of pregnancy. Your health care provider will begin by checking your
weight and blood pressure. Your provider might measure the size of your uterus by checking
your fundal height — the distance from your pubic bone to the top of your uterus (fundus).
At this stage, the highlight of your prenatal visits might be listening to your baby's heartbeat.
Your health care provider might suggest an ultrasound or other screening tests this trimester.
You might also find out your baby's sex — if you choose.
In some cases, virtual prenatal care may be an option if you don't have certain high-risk
conditions. If you and your health care provider opt for virtual prenatal visits, ask if there are any
tools that might be helpful to have at home, such as a blood pressure monitor. To make the most
of any virtual visits, prepare a list of questions ahead of time and take detailed notes.

3rd-trimester pregnancy: What to expect

The third trimester of pregnancy can be physically and emotionally challenging. Your baby's size
and position might make it hard for you to get comfortable. You might be tired of pregnancy and
eager to move on to the next stage. If you've been gearing up for your due date, you might be
disappointed if it comes and goes uneventfully.
Try to remain positive as you look forward to the end of your pregnancy. Soon you'll hold your
baby in your arms! Here's what to expect in the meantime.
1. Braxton Hicks contractions. You might feel these mild, irregular contractions as a slight
tightness in your abdomen. They're more likely to occur in the afternoon or evening, after
physical activity or after sex. These contractions also tend to occur more often and become
stronger as you approach your due date. Contact your health care provider if the
contractions become regular and steadily increase in strengths.
2. Swelling/Puffiness. Fluid retention and slowed blood circulation are to blame for swelling
in your legs, ankles, feet, hands, and face. If swelling in your hands and face becomes
extreme, call your doctor. Call your doctor right away if you also have a headache, blurred
vision, dizziness, and belly pain. These may be signs of a dangerous condition called
preeclampsia.
3. Tingling and numbness. The swelling in your body may press on nerves, causing tingling
and numbness. This can happen in your legs, arms, and hands. The skin on your belly may
feel numb because it is so stretched out. Tingling and numbness in the hands usually
 occurs because of carpal tunnel syndrome. That is caused by pressure on a nerve in the
wrist. You may be able to get rid of these symptoms by wearing wrist splints overnight.
The problem often improves after pregnancy.
4. Heartburn. A burning feeling in the lower chest, along with a sour taste in the throat and
mouth. Pregnancy hormones relax the valve between your stomach and esophagus. This
can allow stomach acid to reflux into your esophagus and cause heartburn. To prevent
heartburn, eat small, frequent meals. Also, avoid fried foods, citrus fruits, chocolate, and
spicy or fried foods.
5. Varicose veins. These are bluish, swollen, sometimes painful veins beneath the surface of
the skin. They often show up on the backs of the calves or the inside of the legs. Varicose
veins are caused by:
• Pressure your growing uterus puts on the large veins behind it, which slows blood
circulation.
• Pregnancy hormones, which cause the walls of veins to relax and possibly swell.
• Constipation, which makes you strain to pass hard bowel movements.
• Increased fluid retention.
• Increased blood circulation might cause tiny red-purplish veins (spider veins) to appear
on your face, neck and arms. Redness typically fades after delivery.
- Wear support or elastic stockings
- Elevate legs and hips at intervals for 15-20 minutes twice a day
- Avoid prolonged sitting and standing
- Avoid wearing round garters

6. Hemorrhoids. These are varicose veins in the rectum. They may stick out of the anus and
cause itching, pain, and sometimes bleeding. Ask your doctor about taking a stool softener
(not a laxative).
- Avoid straining at stools. Prevent constipation
- Avoid spicy foods
- Ice packs or warm water sitz bath to promote comfort
- Prolapsed hemorrhoids are lubricated and may be replaced gently

7. Aching back, pelvis, and hips. This may have started in the second trimester. The stress
on your back will increase as your belly grows larger. Your hips and pelvic area may hurt
as pregnancy hormones relax the joints between the pelvic bones in preparation for
childbirth.

8. Backaches. Pregnancy hormones relax the connective tissue that holds your bones in
place, especially in the pelvic area. These changes can be tough on your back, and often
result in discomfort during the third trimester of pregnancy. When you sit, choose chairs
with good back support. Get regular exercise. Wear low-heeled — but not flat — shoes
with good arch support. If you have severe or persistent pain, contact your health care
provider Sleeping with a pillow behind your back may help with the pain.

9. Abdominal pain - Muscles and ligaments (tough, ropelike bands of tissue) in your belly
that support the uterus will continue to stretch as your baby grows. They may be painful.
 10. Shortness of breath - As your uterus continues to grow, your lungs will have less room to
expand for breathing. Practice good posture to give your lungs more room to expand.

11. More breast growth. Your nipples may be tender and leak a yellowish liquid, called
colostrum. If you breastfeed, this fluid will be your baby’s first food.

12. Weight gain. You’ll likely add pounds at the beginning of your third trimester. Your
weight should even out as you get closer to delivery. During your first 12 weeks—the first
trimester—you may gain only 1 to 5 pounds or no weight at all. In your second and third
trimesters, if you were a healthy weight before pregnancy, you should gain between half a
pound and 1 pound per week.

13. Vaginal discharge. Discharge may increase. If you have fluid leaking or see any blood,
call your doctor right away.

14. Stretch marks. As the baby grows, your skin will get stretched more and more. This may
lead to stretch marks. These can look like small lines on your skin. They often appear on
your stomach, breasts, and thighs.

15. Less fetal movement. As your baby continues to grow, he or she will start to run out of
room to move around in your uterus. That might make you notice fewer movements during
the day. If you’re concerned about lack of movement, call your doctor.

16. Frequent urination. As your baby moves deeper into your pelvis, you'll feel more
pressure on your bladder. You might find yourself urinating more often. This extra
pressure might also cause you to leak urine — especially when you laugh, cough, sneeze,
bend or lift. If this is a problem, consider using panty liners. If you think you might be
leaking amniotic fluid, contact your health care provider.
- Increase fluids to replace losses except before bedtime
- Use perineal pad to absorb leakage
- Flush perineum every after voiding
- Explain that voiding frequently is a normal phenomenon.

17. Your emotions. As anticipation grows, fears about childbirth might become more
persistent. How much will it hurt? How long will it last? How will I cope? If you haven't
done so already, consider taking childbirth classes. You'll learn what to expect — and meet
others who share your excitement and concerns. Talk with others who've had positive birth
experiences, and ask your health care provider about options for pain relief.. The reality of
parenthood might begin to sink in as well. You might feel anxious, especially if this is your
first baby. To stay calm, write your thoughts in a journal. It's also helpful to plan ahead. If
you'll be breastfeeding, you might get a nursing bra or a breast pump. If you're expecting a
boy — or you don't know your baby's sex — think about what's right for your family
regarding circumcision.
Prenatal care
During the third trimester, your health care provider might ask you to come in for more frequent
checkups — perhaps every two weeks beginning at week 32 and every week beginning at week
36.
Like previous visits, your health care provider will check your weight and blood pressure and ask
about any signs or symptoms you're experiencing. In some cases, virtual prenatal care may be an
option if you don't have certain high-risk conditions. If you and your health care provider opt for
virtual prenatal visits, ask if there are any tools that might be helpful to have at home, such as a
blood pressure monitor. To make the most of any virtual visits, prepare a list of questions ahead
of time and take detailed notes.
If you haven't yet received a COVID-19 vaccine, get vaccinated. COVID-19 vaccines don't cause
infection with the COVID-19 virus. Studies have shown COVID-19 vaccines don't pose any
serious risks for pregnant women or their babies. Vaccination can help pregnant women build
antibodies that protect their babies. If possible, people who live with you should also be
vaccinated against COVID-19.
Also, one dose of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis (Tdap)
vaccine is recommended during each pregnancy — ideally during the third trimester, between
weeks 27 and 36 of pregnancy. This can help protect your baby from whooping cough before he
or she can be vaccinated.
You will also need screening tests for various conditions, including:

• Gestational diabetes. This is a type of diabetes that sometimes develops during

pregnancy. Prompt treatment and healthy lifestyle choices can help you manage your
blood sugar level and deliver a healthy baby.
• Iron deficiency anemia. Iron deficiency anemia occurs when you don't have enough
healthy red blood cells to carry adequate oxygen to your body's tissues. Anemia
might cause you to feel very tired. To treat anemia, you might need to take iron
supplements.
• Group B strep. Group B strep is a type of bacteria that can live in your vagina or
rectum. It can cause a serious infection for your baby if there is exposure during birth.
If you test positive for group B strep, your health care provider will recommend
antibiotics while you're in labor.
Your health care provider will also check your baby's size and heart rate. Near the end of your
pregnancy, your health care provider will also check your baby's position and ask about your
baby's movements. He or she might also ask about your preferences regarding labor and pain
management as you get ready for delivery. If you have specific preferences for labor and birth —
such as laboring in water or avoiding medication — define your wishes in a birth plan. Review
the plan with your health care provider but keep in mind that pregnancy problems might cause
plans to change.
Things to consider
Sleeping
As you get bigger, you might have difficulty finding a comfortable sleeping position. You may
also find it harder to change positions while sleeping. Side sleeping will be best. Try to fall
asleep on your left side. This will help circulation, which is important for the baby. If you wake
up, return to that position before going back to sleep. Putting a pillow between your knees or
behind your back may make you comfortable.
Sleeping on your back will be uncomfortable because the weight of your baby presses on the
veins in your lower back. Also, this can slow the blood flow from the lower body to the heart.
Other things that disrupt sleep may include:
• Nasal congestion, caused by increased blood flow to the mucous membranes in the nose
and mouth.
• Heartburn may get worse as your uterus grows, pushing your stomach out of its usual
position. Ask your doctor if you can take an antacid, if needed.
• The need to urinate. This is partly due to hormones. And partly due the fact your growing
baby is pushing on your bladder.
• Leg cramps, which may be related to the pressure your uterus puts on the nerves and
blood vessels that go to your legs.
• Restless leg syndrome, in which you feel a need to move your legs often because of an
unpleasant feeling in them.
• Strange dreams, which some women have in the last weeks of pregnancy.
• Your baby’s movements.

Sex
You may lose the desire for sex. That may be because of your size and because you are focused
on getting ready for labor, delivery, and parenthood. Sometimes intercourse can lead to
uncomfortable contractions in your uterus. It’s still fine to have sex, unless your doctor has told
you not to.

Labor
Talk to your doctor about the signs of labor. He or she will tell you what to expect and when to
call or go to the hospital. But here are some common changes you may notice.
• Your baby may change position, with his or her head moving down in your pelvis. People
may notice your belly is lower and say that you have “dropped.”
• Your cervix (the lower end of your uterus) will begin to thin (effacement) and open
(dilate).
• Braxton Hicks contractions (tightening of your uterine muscles) may happen more often
and become stronger. This type of contractions can happen throughout the third trimester
but get stronger as labor gets closer. They are often a sign labor will be starting soon.
• You may have a constant backache and cramping, diarrhea, and gas before labor begins.
• You will probably be in labor if your contractions seem to happen in a pattern. Also, the
time between each contraction will get shorter. Labor contractions are usually more
painful than Braxton Hicks contractions. If your contractions are so painful you can’t
talk, call your doctor.
• Your “water” may break. This is caused when a tear in the sac that encloses your baby
causes fluid to be released. Call your doctor or go to the hospital if you think this has
happened. However, for many women, the water doesn’t break until contractions start.

Promotion of Nutritional Health during Pregnancy

 A woman's nutritional status at conception and during pregnancy have direct bearing on
her health as well as fetal growth and development. Ensuring optimum nutrition for all
childbearing women might not eliminate all the problems of pregnancy, but it certainly makes an
important contribution.

A fetus who is deprived of adequate nutrition early in pregnancy, then, will be small for
gestational age because of too few cells in the fetus's body; later on, retarded growth is due to a
normal number but smaller than usual size cells. To be certain that early pregnancy deficiencies
do not occur, women of childbearing age should be especially encouraged to follow a balanced
diet.
Ø Increase protein intake - Protein is necessary for growth and repair of maternal and fetal
tissues for increased maternal blood volume and for fetal growth and development. During
pregnancy, the intake of protein should be increased to 60 g per day.
Ø Decrease fat intake - Fats are difficult to digest and can contribute to gastrointestinal
discomfort in early pregnancy. A daily quota of 90 g fat coming mainly from animal
sources would be a reasonable amount. (Myles, 1981)
Ø Decrease carbohydrates intake - The human placental lactogen (HPL), the major insulin
antagonist in pregnancy, spares maternal glucose for fetal use. To prevent excessive fetal
growth, the woman's carbohydrates should be decreased during the second and third
trimesters during which time there is an increase in HPL secretion.
Ø Increase major minerals and vitamins intake
1. Iron - is the most important mineral that must be taken in supplementary amounts. The
total iron needed for pregnancy is about 800 to 1000 mg. Of this total amount, 50%
(500 mg) is needed for hemoglobin formation, the result of increased maternal blood
volume in pregnancy; 30% (300 mg) is transferred to the placenta and the fetus to
provide for iron store in the liver to last for 3 to 6 months; and 20% (200 mg) is to
replace natural loses in skin, sweat and hair. Liver is an excellent source of iron. Other
red meats; beef; heart and kidneys; green leafy vegetables; cereals; whole or enriched
grain, nuts, and legumes; dried fruits and eggs are appropriate. To enhance iron
utilization and absorption, ascorbic acid (Vit. C) in the form of fruit juices is essential.
2. Calcium and phosphorus - To supply adequate minerals for bone formation, the daily
requirement of calcium and phosphorus is 1,200 – 1,500 mg/day. Tooth formation
begins as early as 8 weeks and bones begin to calcify at 12 weeks in utero. Milk and
milk products such as cheese are the best sources of calcium and phosphorus. Almost
the entire calcium requirement in pregnancy is utilized by the fetus. The expectant
mother retains about 30 g of calcium during pregnancy and most of which is deposited
in the fetus late in pregnancy (Pitkin, 1985).
3. Iodine. This is essential for the formation of thyroxine and therefore for the proper
functioning of the thyroid gland. The daily need for iodine is 175 ug. Pharaoh and
associates (1971,in their study of New Guinean pregnant women demonstrated that
intramuscular injection of iodized oil early in pregnancy could prevent cretinism in
infants.
4. Vitamin C - The recommended Vit. C per day is 80-100 mg. A reasonable diet rich in
citrus fruits, tomatoes, green leafy vegetables and green peppers may be enough to
provide this amount. Excess Vitamin C supplementation (1 g/day) may prove harmful in
 pregnancy as shown by Cochrane (1965) who identified withdrawal scurvy in normally
fed infants whose mothers received large doses of Vit. C during pregnancy. Likewise,
excess Vitamin C can result in a functional deficiency in Vitamin B12 by interfering
with its absorption and metabolism and which cannot be overcome by Vitamin B12
supplementation (Herbert and Jacob,1974).
5. Vitamin B12. To help in red blood cell formation and to provide a coenzyme in protein
metabolism, 4 ug Vitamin B12 daily is recommended.
Ø Encourage pregnant women to increase fluid intake for good kidney function and eat foods
rich in fiber to prevent constipation. Fiber also has the advantage of lowering cholesterol
levels and may remove carcinogenic contaminants from the intestine.
Ø Educate the pregnant woman regarding foods to be avoided during pregnancy, such as:
• Foods with caffeine. Caffeine is a central nervous system stimulant capable of increasing
heart rate, urine production in the kidney, and secretion of acid in the stomach. A daily
intake of caffeine of more than 300 mg has been associated with low birth weight (Caan
et. al., 1989). For this reason the Food and Drug Administration has issued a formal
warning to women to limit their caffeine intake during pregnancy.
• Alcoholic beverages should not be ingested by the pregnant woman because of their
potentially teratogenic effects on the fetus.
• Foods with artificial sweeteners. The use of saccharine is not recommended during
pregnancy because it is eliminated slowly from the fetus (London, 1988).
• Weight loss diets

Ø Advise the pregnant woman not to smoke. Smoking results to small-for-gestational age
(SGA) infants which is the effect of:
• vasoconstricting nicotine
• decreased plasma volume
• increased carbon monoxide level in the blood functionally inactivates oxygen
• decrease caloric intake

DIAGNOSTIC PROCEDURES

1. URINALYSIS: This test is done to check the presence of Proteinuria, Glycosuria, Nitrites and
Pyuria.
2. Complete Blood Count (CBC): Check blood components like RBC, HGB, WBC and Platelet
count.
3. Genetic Screen: for common inherited diseases
4. Rapid Plasma Reagin Test: to detect for presence of Syphilis
5. Blood Typing and Rh factor: To detect for ABO and RH incompatibility
6. Culture Test: to check for presence of Chlamydia or Gonorrhea
7. Alpha-Fetoprotein Level:
• Done by drawing maternal blood sample at 16-18 weeks AOG
• To determine presence of neural tube defects and Down’s syndrome
• Elevated: neural tube defects (Spina bifida) abdominal defect
• Decreased: Down’s Syndrome
8. Antibody Titers:
• Rubella
 • Hep B (HBsAg)
• Hep C
• Varicella (Chicken pox)
9. HIV Screening
10. Glucose Challenge Test
11. PPD Tuberculin Test
• 0.1 ml of tuberculin units
• ID route
• 48-72 hours reading
• Reddened, raised, hardened area (induration)
• (+) more than 10cm
• (+) more than 5 cm
• X-ray (lead apron to cover abdomen)
12. Ultrasound: to confirm the pregnancy length and document healthy fetal growth.
• 7-11 weeks of pregnancy with unknown LMP
• 16-20 weeks to verify healthy fetal structures
• Useful early in pregnancy to identify gestational sac(s).

Health Maintenance during Pregnancy

1. Prenatal visits. Ideally a pregnant mother should follow this schedule of clinic visits.
• First 7 months - once a month
• 7th & 8th months - every other week
• 9th month until delivery - every week
Subsequent visits to the prenatal clinic need not be as lengthy or as detailed as the initial
prenatal visit. The patient's Weight and Blood Pressure are to be taken each time. Likewise the
following are to be done.

2. General hygiene. Daily bathing is recommended not only because of leukorrhea but also
because of increased sweating during pregnancy.
3. Exercise. Women need exercise during pregnancy to prevent circulatory stasis, to promote
comfort, to facilitate labor and delivery and to strengthen muscles.
• Kegel’s Exercise
• Tailor Sitting
• Squatting
• Abdominal Muscle Contraction
• Pelvic Rocking
• Yoga
• Sexual Activity. Women who have a history of repeated abortion may be advised to avoid
coitus during the time of the pregnancy when the previous abortions occurred. Women whose
membranes have ruptured or who have vaginal spotting should be advised against coitus until
they are examined in order to prevent infection. Otherwise, there are no sexual restrictions
during pregnancy.
• Travel. Early in pregnancy, there are literally no restrictions except those who are susceptible
to motion sickness. Late in pregnancy, travel plans should take into consideration the
possibility of early labor.
• Work. Unless the woman's job involves exposure to toxic substance, lifting heavy objects,
other kinds of excessive physical strain, or long periods of standing or having to maintain
body balance, the pregnant woman may continue to work.
• Importance of a well-balanced diet as previously discussed.
• Dental care. It is important that women continue good tooth brushing habit throughout
pregnancy. Gingival tissue tends to hypertrophy during pregnancy.
• Breast care. All women should observe a few precautions during pregnancy to prevent loss
of breast tone, which can result in pendulous breasts later in life that can be painful. When
colostrum secretion begins in the breast (16th week of pregnancy), wash breasts with clear
water to minimize the risk of infection from organisms growing in this medium.
• Preparation of baby's layette and things to bring in the hospital. Baby's clothes must be ready
2-4 weeks before the expected date of confinement. They should have been previously
washed, ironed, and kept separately before use.
• Father's and other sibling's role during pregnancy. It must be recognized that they have
important roles to undertake like being supportive to the pregnant woman.

Topic 4: Post partum Assessment

Postpartum physiological changes

The postpartum physiological changes are those expected changes that occur to the
woman's body after childbirth. These changes mark the beginning of the return of pre-
pregnancy physiology in women’s body and of breastfeeding. Most of the time these
postnatal changes are normal and can be managed with medication and comfort
measures, but in a few situations discomforts may develop.

ASSESSMENT: An assessment of any patient is always considered to be from head to toe. In

the postpartum patient, the assessment EXPANDS to also include the following (starting from
top to bottom): BUBBLESHE is an acronym used to denote the components of the postpartum
maternal nursing assessment. This method enhances the standard physical assessment process
typically performed on hospitalized patients. While performing the BUBBLESHE assessment,
the nurse must also use this assessment time to provide patient education.
The BUBBLESHE Acronym stands for:
Breast
Uterus
Bowel
Bladder
Lochia
Episiorrhaphy and the perineum
Skin/Sex
Homan’s sign
EMOTIONS and Presence of Edema
BREASTS:
1. The first step is to determine if the mother is breastfeeding or bottle-feeding.
2. Inspect the breast for size, shape, redness, symmetry, presence of milk down reflex. Inspect
the nipples if erect, flat or inverted. Assess the nipples for signs of bruising, crackling,
chapping, or blisters.
3. Palpate each breast for firmness, fullness, tenderness, shininess, and contour . Palpate both
breasts for engorgement/filling. Minimize palpation for bottle-feeding mother to avoid
stimulation.
4. Ask the mother for complaint of breast engorgement.
HEALTH TEACHING:
All mothers should wear a supportive bra 24 hours a day for the first few days
postpartum.
Engorgement-- usually occurs 2-3 days post-partum.
o Teach mom to apply warm packs 15-20 minutes pre-nursing
o try a warm shower before nursing
o ice bags and/or binders for non-nursing moms
o proper techniques of emptying the breast

Encourage breastfeeding and impart to them its importance both to mother and to the
baby.

To enable mothers to establish and sustain exclusive breastfeeding for six months, WHO and
UNICEF recommend:
● Initiation of breastfeeding within the first hour of life;
● Exclusive breastfeeding - that is, the infant only receives breast milk without any
additional food or drink, not even water;
● Breastfeeding on demand - that is, as often as the child wants, day and night;
● No use of bottles, teats or pacifiers.

RA 7600 OR THE ROOMING-IN AND BREASTFEEDING ACT OF 1992:

> Normal Spontaneous Deliveries. — The following newborn infants shall be put to the breast of
the mother immediately after birth and forthwith roomed-in within thirty (30) minutes.
a) well infants regardless of the age of gestation; and
b) infants with low birth weights but who can suck.
> Deliveries by Caesarian. — Infants delivered by caesarian section shall be roomed-in and
breast-fed within three (3) to four (4) hours after birth.

Nursing Management:
A. Advise using firm-fitting brassiere to reduce discomfort and prevent contamination the of
the nipples and areola
B. Cold compression application on the breasts desires not to breastfed and warm who desires.
C. Breast massage or the use of breast pump if the woman will breastfeed.
Lactation
A. Early pregnancy, increased estrogen level produced by the placenta
B. Stimulates growth of milk glands breast increase in size, accumulation of fluid and adipose
tissue
 C. Midway of pregnancy, she has been secreting colostrum (thin watery prelactation secretion)
until 2 days postpartum
D. 3rd day postpartum, breast becomes full, tender, as milk forms within the breast ducts
E. Milk forms in response to decreasing estrogen/progesterone levels follow after delivery of
the placenta (stimulates prolactin production – milk production)
F. Breast ducts are distended Nipple secretion changes from clear colostrum to bluish-white
(typical color of breast milk) Breast becomes fuller, larger, and firmer
G. Infant suck -Releases oxytocin to contract milk ducts and push milk forward
H. Let down reflex

UTERUS:
The fundus is palpated for the following:
1. Height-- Record finger-widths above or below the umbilicus. e.g. Fundus 2/U (2
fingerbreadths above the umbilicus) Fundus U/2 (2 fingerbreadths below the umbilicus Fundus
descends 1 fingerbreadth each day
2. Position-- Fundus should be midline near the umbilicus --A full bladder may push the fundus
to the R or L of the umbilicus and cause the pt’s flow to be heavier.
3. Tone- Fundus should remain firm --If uterus becomes boggy gently massage the uterus to help
the muscles to contract --Adjust the IV flow rate to control bleeding if Pitocin is in the IV
solution --If no IV, administer p.o. or IM Methergine per Dr.’s order
• Uterine involution – refers to the return of the uterus to its pre-pregnant size, shape and
function. A sub- involuted uterus implied the presence of blood clots, which are good
culture media for bacteria, it is , therefore, a sign of puerperal sepsis.
Weight of the uterus:
Right after delivery: 1000 gms
One week after delivery: 500 gms
Two weeks after delivery: 300 gms
Six weeks after delivery: 50-60 gms
• The uterus reduces in size immediately following birth, due to myometrial contractions,
and then continues to reduce in size over the next few days and weeks, until it returns to
being a pelvic organ.
Fundus:
• Assessed frequently for firmness, position, and height. It should be checked after the
bladder is emptied.
• Palpate the fundus: Place the woman in a supine position with a small pillow
under her head and knees flexed to relaxed abdominal muscles. Palpate
by placing a hand at the umbilicus and pressing it downward while the
other hand is placed just above the symphysis to support the lower
uterine segment.
If boggy:
a. Massage gently in a circular motion, the first action
b. Place the infant on the mother’s breast to stimulate uterine
contraction (released of oxytocin)
c Administer oxytocin or increase infusion if BP is not above
140/90 mmHg
 • Location of the fundus post partum
o After the delivery of the placenta, the uterus can be palpated halfway between the
umbilicus and symphysis pubis
o One hour after it will rise to the umbilical area
o Per day it will go down 1 fingerbreadth
o By the 9th and 10th day the uterus is fully contracted so it can no be longer palpated in
the pelvis
• Afterpains
o Contraction of the uterine muscles is felt as ‘afterpains’ for 4–7 days and is strongest
12–24 hours postpartum, especially in multiparous women,these contractions facilitate
the process of involution.
o Afterpains may occur in association with breastfeeding, due to the release of oxytocin
and uterine contractions, or they may occur independently of breastfeeding.
• Nursing interventions
1. Instruct to assume prone position to lessen discomfort
2. Massage uterus gently
3. Never apply heat on the abdomen
4. Administer analgesics

BLADDER:
Assess the following
1. Accompany mother and record first 2 voidings. (More if voiding less than 150cc each time)
2. Palpate for distention above the symphysis pubis
3. If the patient has not voided in 6-8 hours post-delivery --straight cath per Doctor’s order --
notify Doctor for any voiding difficulties
4. Be alert for signs and symptoms of UTI: --infrequent voiding --painful urination (dysuria) --
burning --frequency --urinary retention --foul-smelling urine
5. Postpartum voiding difficulties related: --fatigue --perineal swelling --long, difficult Labor
and Delivery eg. use of Forceps, Vacuum Extractor
Urinary System
• Transient loss of bladder tone such as edema on the surrounding urethra that results in
difficult voiding
• A full bladder puts pressure on the uterus causes ineffective uterine contractions
• Epidural, spinal or general anesthesia for delivery can feel no sensation in the bladder area
until the anesthesia wears off
• In poor bladder tone, retains a large amount of residual urine which may result in bladder
infection
• The urinary volume rises from the normal level of 1,500cc to about 3,000cc during the 2nd
to 5th day after delivery
• Diaphoresis to get rid of fluid, generally, bladder tone is regained after one week and
normal kidney function after one month
Assess Distended abdomen:
1. Palpating hard or firm area above the symphysis pubis
2. Uterine position is a good gauge to determine if the bladder is full or empty
3. On percussion, a full bladder sounds resonant; non-filled dull thudding sound
Effects of distended abdomen:
• Hemorrhage
• Infection
• Increased discomfort
• Atony of the bladder wall
• Overflow incontinence
Signs of a full bladder
• Suprapubic swelling
• High fundus or deviation of the fundus from the midline
• Increased lochia
Nursing Management
• Measures to Induce Voiding (expected to void within 6 – 8 hrs after delivery.
o Provide privacy)
o Open the faucet let the woman listen to running water
o Pour warm & cold water alternately over the perineum
o Offer bedpan
o Place woman’s hand on warm water
o Practice kegel’s exercises
o Liberal fluid intake
o Straight Catheterization as per doctor’s order
Measures to Prevent Infection:
A. Flush perineum with warm water after each voiding
B. Apply perineal pad from front to back
C. Liberal fluid intake
D. Decoction of guava leaves for perineal flushing promotes wound healing
E. Instruct signs and symptoms of UTI

BOWEL:
1. Assess for presence of BS q shift in all 4 quadrants: palpate the abdomen for distension
2. Check for the presence of Flatus
3. Assess for presence of bowel movement. First BM usually occurs on or after 2nd
Postpartum.
Gastrointestinal System
A. Digestion and absorption begins to be active as soon after delivery
B. Feels hungry and thirsty from glucose used during labor
C. Delayed bowel elimination because:
1. Decreased abdominal and intestinal muscle tone
2. Lack of food during labor and delivery
3. Dehydrating effects of labor and delivery
4. Fear of pain on the episiotomy/presence of hemorrhoids
5. Enema during the first stage of labor
6. Hormone relaxin is still present
Nursing Management:
A. Provide a meal if she is not nauseated. 2,500-2,600 cal/day, high protein, vitamins, and
minerals
B. Encourage fluid intake and roughage in her diet
C. Administer mild laxatives or cathartic if no bowel on the 3rd postpartum
D. Provide relief from hemorrhoid discomfort:
1. Hot sitz bath/anesthetic sprays with hazel
2. Gentle manual replacing of hemorrhoidal tissue
3. Assume sim’s position to provide a good venous return on the rectal area and to reduce
discomfort

LOCHIA:
- is a uterine discharge after delivery consisting of blood, mucus, epithelial cells,
leukocytes, and bacteria
• When examining the fundus, check the lochia for color, amount, odor, and the number
of pads used.
• For the first two to three days, lochia is bright red, similar to menses, and is known as
RUBRA.
• The next few days lochia becomes serous, pinkish, and more watery and is known as
SEROSA.
• By 10 to 14 days the lochia is thin and colorless and is known as ALBA.
• If the lochia has a foul odor, then be suspicious of infection. The doctor should be notified
of any unusual odor, excessive bleeding, or clotting.
• Estimation of blood loss:
1-inch stain after one hour: scant amount
2-4 inch stain after one hour: light amount
4-6 inch stain after one hour: moderate amount
Fully saturated after one hour: heavy amount

Nursing Management
o Assess fundic height every 15 minutes for the first hour postpartum. Be certain the bed is
flat for uterine assessment so the height of the uterus is not influenced by an elevated
position.
o Assess fundus for consistency (firm, soft, boggy). Massage gently with examining and
rotating motion. Never palpate the uterus without supporting the lower segment, as the
uterus potentially can invert if not supported this way, and may lead to massive
hemorrhage.
o Palpate fundus gently so as not to cause pain
o Evaluate the uterus height and consistency frequently ff the first hour after delivery, every
hour next 8 hours then once every shift
 o Assess lochia every 15 mins for the first hour, once every hour for the first 8 hours, then
every 8 hours. Observe for the character
o Instruct mother how to perform uterine assessment upon discharge

EPISIOTOMY:
• Also, check for a hematoma. The patient may need to be medicated for discomfort. Also,
check the rectum at this time for hemorrhoids and initiate appropriate measures if
uncomfortable to the patient.
• 5 signs of Assess Perineum (REEDA)
o Redness-excessive tenderness is probably normal inflammation associated with healing,
but pain with the redness is more likely to be an infection.
o Edema-mild is common, but severe interferes with healing
o Ecchymosis-a few small superficials are common, larger interferes healing
o Discharge-no discharges
o Approximation-(intact of the suture line) – should not be separated, intact
• Perineum
o Swollen, discolored, painful after delivery, often with lacerations and episiotomy
o Observed for signs of infection and trauma
o Ecchymosis may appear due to rupture of the surface of capillaries
o Perineal muscle tone regained by 6 weeks
o Perineal care, Ice packs, sitting on a doughnut pillow
o Labia minora/Majora typically remained atrophic and softened after birth never
returning to a prepregnant state.
Nursing Management
• Perineal care
o Lochia, perineal care should done after each voiding or bowel movement and as part
of daily bath, to prevent for bacterial growth and cause infection and also results
discomforts and emit a foul odor.
o Perineum great deal of pressure, this resulted in edema and generalized tenderness
and some portion may even show ecchymosis because of rupture fo surface
capillaries.
o Perineal stitches at the episiotomy site, cause much discomfort since perineal stitches
are involved in many activities such as sitting, walking, standing, squatting, bending,
voiding & defecating
Care of episiorrhaphy
• Application of ice bag for the first 12-24 hours to reduce edema, bruising, by
vasoconstriction and thus decrease tension on the suture line.
• Exposing perineum to a heat lamp (gooseneck lamp) reduce edema by vasodilation,
promoting healing and providing comfort. A 25-40 watt bulb after the first postpartum
day. Woman in supine (dorsal recumbent) with knees flexed, properly draped, heat lamp
is placed between her legs about 12-16 inches away from the perineum, and left in place
for 20 mins. Done 3-4 x a day
• Sitz bath: after 24 hours promotes circulation by vasodilation thereby promoting wound
healing. The perineal area is immersed in 4-6 inches of water temperature of 102 to
105°F. For 3-4x a day for no more than 20 minutes
 o Placed patient in sim’s position, to minimize perineal discomfort because it reduces
tension on the suture line.
o Instruct to contract perineal floor muscles (KEGEL’S EXERCISE),
o Instruct to use foam rubber rings, to relieve perineal discomfort.

SKIN:
• Assess for signs of pallor, turgor, capillary refill
• Assess also for the presence of EDEMA, (location, Pitting or Non-Pitting)
• Striae gravidarum may fade and becomes striae albicans
• Chloasma and linea nigra will be barely detectable in 6 weeks
• The abdominal wall and uterine ligaments are stretched and pouched forward.
Nursing Management:
• Provide abdominal binder or girdle on the first few weeks for comfort
• Encourage exercises such as sit-ups, abdominal breathing, chin to chest or head raising,
kegel’s, legs and arms raising to give support to the abdominal muscles and aids in
involution, return of abdominal tone, and strengthen abdominal and pelvis muscle.
• Encourage good posture, body mechanics, and rest

HOMAN’S SIGN:
• Assess for Signs of DVT by the Homan’s Sign
• Performing the Homan’s Test
o Most commonly performed with the mom in a supine position while laying in bed
o The calf is flexed at a 90° angle
o The nurse manipulates the foot in a dorsiflexion movement
o If pain is felt in the calf, the Homan’s Sign is said to be positive Signs of DVT
o A sudden and unexplainable pain, usually in the back of the leg or calf
o Tachycardia and shortness of breath or dyspnea (from decreased oxygenation status)
o Edema, redness, and warmth localized over the area of the DVT (from the vascular build-
up around the clot)
HEALTH TEACHING:
• Preventing a DVT
o Dangle at the side of the bed within 6 hours
o Stand up within 8 hours
• Encourage ambulation at first and independent walking when ready Potential Complications
of a DVT
Nursing Management:
A. Monitor VS every hour during the first 4 hours then every 4 hours when stable
B. Assess peripheral circulation:
• Assess the thigh for skin turgor
• Assess the presence of ankle edema and over the tibia of the lower leg and observe pitting
edema
• Assess Homan’s sign, it is done by dorsiflexing the foot and assess for the presence of
pain in the calf, if there is a pain in the calf of her leg, it indicates thrombophlebitis is
beginning. DO NOT MASSAGE THE AREA, it may cause circulatory emboli. This test
is done every shift or every 8 hours.
C. Encourage early ambulation, to prevent bowel, bladder, or circulatory complications.
D. Encourage postpartum exercises, like abdominal breathing and arm raising to help strengthen
the abdominal muscles.

E: Emotional Status Emotional Status and Bonding Patterns

• Caregiving of self and baby is an indicator of emotional status Common Postpartum
Assessment Findings.
• Assess and observe for mother and child bonding. Signs that will indicate mother is on
what Phase of the Psychological changes postpartum. Taking-In, Taking-Hold, Letting
Goal.
• Assess also for early signs of Postpartum Depression and Psychosis

Other Assessment
Cervix
• soft, edematous, relaxed right after delivery
• After one week firm but external os does not return to its original prepregnant condition as it
is lacerated during delivery, the external os assumes a slit like appearance or stellate (star
shape)
• End of first week – the external os is closed and will not admit a finger (7 days external OS
is narrowed)

Vagina
• After childbirth, soft and swollen, with few rugae, with a greater diameter than normal, the
hymen is permanently torn. Thickening of the walls due to renewed estrogen production
from the ovaries.
• Lacerations and episiotomy healed after 2 weeks
• Returns to its prepregnant condition after 6-8 weeks but does not regain its original virginal
state.
• Kegel’s helps increase the strength and tone of the vagina
• If a woman is breastfeeding may have delayed ovulation, she may have continued thin-
walled or fragile vaginal cells that causes slight vaginal bleeding during sexual intercourse
until about 6 weeks

Sexual activity – resumed when lochia stops and healing of the perineum & episiotomy has
occurred usually 4– 6 weeks

NSD mothers are allowed to ambulate 4-8 hrs after childbirth

Reasons for early ambulation:
• prevent constipation
• Prevent circulatory problems e.g. thrombophlebitis
• Prevent urinary problems
• promote rapid recovery
• hastens drainage of lochia
• improves GI and urinary function
• provide a sense of well being
Exercise:
Purpose:
1. Promotes psychological well being
2. Rapid return of woman’s figure
3. Strengthen muscle of the back, pelvic floor, abdomen
• Abdominal breathing: tighten abdominal muscles
• Kegel: tighten the perineal muscle
• Chin to chest: strengthen abdominal muscles
• Arm raising: return breast and abdominal muscle tone
• Leg raising: tighten abdominal muscles
• Sit-ups: tighten abdominal muscles
• Kegel’s exercise

Nutrition:
1. High CHON, CHO, iron, Fiber, Calcium, and vitamins to promote wound healing
2. For lactating additional 500 calories
3. Daily intake of vitamins and iron supplements for 4-6 weeks postpartum is recommended
for breastfeeding mothers to ensure nutritious milk supply to the infant

Hormonal Changes
• Pregnancy hormones begin to decrease as soon as the placenta is no longer present
• hCG,hPL are negligible by 24 hours
• Progestin, estrone, estradiol are at the pre-pregnancy level by one week, FSH remains
low for about 12 days then rise as a new menstrual cycle is initiate

Menstrual flow
• After placental delivery, estrogen/progesterone level ends decreased hormone
concentrations causing a rise in production of FSH slight delay to return of ovulation
• NON breastfeeding mothers: menstrual flow returns 6 – 10 weeks after birth
• Breastfeeding: returns 3 or 4 months (lactation amenorrhea) LAM

Topic 5: Post partum hemorrhage

Ø Postpartum hemorrhage (also called PPH) is when a woman has heavy bleeding after
giving birth. It’s a serious but rare condition. It usually happens within 1 day of giving
birth, but it can happen up to 12 weeks after having a baby. About 1 to 5 in 100 women
who have a baby (1 to 5 percent) have PPH.
Ø It’s normal to lose some blood after giving birth. Women usually lose about half a quart
(500 milliliters) during vaginal birth or about 1 quart (1,000 milliliters) after a cesarean
birth (also called c-section). A c-section is surgery in which your baby is born through a
cut that your doctor makes in your belly and uterus (womb). With PPH, you can lose much
more blood, which is what makes it a dangerous condition. PPH can cause a severe drop in
blood pressure. If not treated quickly, this can lead to shock and death. Shock is when your
body organs don’t get enough blood flow.
When does PPH happen?
After your baby is delivered, the uterus normally contracts to push out the placenta. The
contractions then help put pressure on bleeding vessels where the placenta was attached in your
uterus. The placenta grows in your uterus and supplies the baby with food and oxygen through
the umbilical cord. If the contractions are not strong enough, the vessels bleed more. It can also
happen if small pieces of the placenta stay attached.

How do you know if you have PPH?

You may have PPH if you have any of these signs or symptoms. If you do, call your health care
provider or 911 right away:
• Heavy bleeding from the vagina that doesn’t slow or stop
• Drop in blood pressure or signs of shock. Signs of low blood pressure and shock include
blurry vision; having chills, clammy skin or a really fast heartbeat; feeling
confused, dizzy, sleepy or weak; or feeling like you’re going to faint.
• Nausea (feeling sick to your stomach) or throwing up
• Pale skin
• Swelling and pain around the vagina or perineum. The perineum is the area between the
vagina and rectum.

Are some women more likely than others to have PPH?

Yes. Things that make you more likely than others to have PPH are called risk factors. Having a
risk factor doesn’t mean for sure that you will have PPH, but it may increase your chances. PPH
usually happens without warning. But talk to your health care provider about what you can do to
help reduce your risk for having PPH.
You’re more likely than other women to have PPH if you’ve had it before. This is called having
a history of PPH. Asian and Hispanic women also are more likely than others to have PPH.
Several medical conditions are risk factors for PPH. You may be more likely than other women
to have PPH if you have any of these conditions:

Conditions that affect the uterus

• Uterine atony. This is the most common cause of PPH. It happens when the muscles in
your uterus don’t contract (tighten) well after birth. Uterine contractions after birth help
stop bleeding from the place in the uterus where the placenta breaks away. You may have
uterine atony if your uterus is stretched or enlarged (also called distended) from giving
birth to twins or a large baby (more than 8 pounds, 13 ounces). It also can happen if
you’ve already had several children, you’re in labor for a long time or you have too
much amniotic fluid. Amniotic fluid is the fluid that surrounds your baby in the womb.
• Uterine inversion. This is a rare condition when the uterus turns inside out after birth.
• Uterine rupture. This is when the uterus tears during labor. It happens rarely. It may
happen if you have a scar in the uterus from having a c-section in the past or if you’ve
had other kinds of surgery on the uterus.
• Retained placental tissue: This is when the entire placenta doesn't separate from your
uterine wall. It’s usually caused by conditions of the placenta that affect your uterus’s
ability to contract after delivery.
 • Blood clotting condition (thrombin): If you have a coagulation disorder or pregnancy
condition like eclampsia, it can interfere with your body’s clotting ability. This can make
even a tiny bleed uncontrollable.

Conditions that affect the placenta

• Placental abruption. This is when the placenta separates early from the wall of the
uterus before birth. It can separate partially or completely.
• Placenta accreta, placenta increta or placenta percreta. These conditions happen
when the placenta grows into the wall of the uterus too deeply and cannot separate.
• Placenta previa. This is when the placenta lies very low in the uterus and covers all or
part of the cervix. The cervix is the opening to the uterus that sits at the top of the vagina.
• Retained placenta. This happens if you don’t pass the placenta within 30 to 60 minutes
after you give birth. Even if you pass the placenta soon after birth, your provider checks
the placenta to make sure it’s not missing any tissue. If tissue is missing and is not
removed from the uterus right away, it may cause bleeding.

Conditions during labor and birth

• Having a c-section
• Getting general anesthesia. This is medicine that puts you to sleep so you don’t feel
pain during surgery. If you have an emergency c-section, you may need general
anesthesia.
• Taking medicines to induce labor. Providers often use a medicine called Pitocin to
induce labor. Pitocin is the man-made form of oxytocin, a hormone your body makes to
start contractions.
• Taking medicines to stop contractions during preterm labor. If you have preterm
labor, your provider may give you medicines called tocolytics to slow or stop
contractions.
• Tearing (also called lacerations). This may happen if the tissues in your vagina or
cervix are cut or torn during birth. The cervix is the opening to the uterus that sits at the
top of the vagina. You may have tearing if you give birth to a large baby, your baby is
born through the birth canal too quickly or you have an episiotomy that tears. An
episiotomy is a cut made at the opening of the vagina to help let the baby out. Tearing
also can happen if your provider uses tools, like forceps or a vacuum, to help move your
baby through the birth canal during birth. Forceps look like big tongs. A vacuum is a soft
plastic cup that attaches to your baby’s head. It uses suction to gently pull your baby as
you push during birth.
• Having quick labor or being in labor a long time. Labor is different for every woman.
If you’re giving birth for the first time, labor usually takes about 14 hours. If you’ve
given birth before, it usually takes about 6 hours. Augmented labor may also increase risk
of PPH. Augmentation of labor means medications or other means are used to make more
contractions of the uterus during labor.

Other conditions
• Blood conditions, like von Willebrand disease or disseminated intravascular
coagulation (also called DIC). These conditions can increase your risk of forming a
 hematoma. A hematoma happens when a blood vessel breaks causing a blood clot to
form in tissue, an organ or another part of the body. After giving birth, some women
develop a hematoma in the vaginal area or the vulva (the female genitalia outside of the
body). Von Willebrand’s disease is a bleeding disorder that makes it hard for a person to
stop bleeding. DIC causes blood clots to form in small blood vessels and can lead to
serious bleeding. Certain pregnancy and childbirth complications (like placenta accreta),
surgery, sepsis (blood infection) and cancer can cause DIC.
• Infection, like chorioamnionitis. This is an infection of the placenta and amniotic fluid.
• Intrahepatic cholestasis of pregnancy (also called ICP). This is the most common liver
condition that happens during pregnancy.
• Obesity. Being obese means you have an excess amount of body fat. If you’re obese,
your body mass index (also called BMI) is 30 or higher. BMI is a measure of body fat
based on your height and weight. To find out your BMI, go to www.cdc.gov/bmi.
• Preeclampsia or gestational hypertension. These are types of high blood pressure that
only pregnant women can get. Preeclampsia is a condition that can happen after the 20th
week of pregnancy or right after pregnancy. It’s when a pregnant woman has high blood
pressure and signs that some of her organs, like her kidneys and liver, may not be
working properly. Signs of preeclampsia include having protein in the urine, changes in
vision and severe headache. Gestational hypertension is high blood pressure that starts
after 20 weeks of pregnancy and goes away after you give birth. Some women with
gestational hypertension have preeclampsia later in pregnancy.

How is PPH tested for and treated?

Your provider may use these tests to see if you have PPH or try to find the cause for PPH:
• Blood tests called clotting factors tests or factor assays
• Hematocrit. This is a blood test that checks the percent of your blood (called whole
blood) that’s made up of red blood cells. Bleeding can cause a low hematocrit.
• Blood loss measurement. To see how much blood you’ve lost, your provider may weigh
or count the number of pads and sponges used to soak up the blood.
• Pelvic exam. Your provider checks your vagina, uterus and cervix.
• Physical exam. Your provider checks your pulse and blood pressure.
• Ultrasound. Your provider can use ultrasound to check for problems with the placenta or
uterus. Ultrasound is a test that uses sound waves and a computer screen to make a
picture of your baby inside the womb or your pelvic organs.
Treatment depends on what’s causing your bleeding. It may include:
• Getting fluids, medicine (like Pitocin) or having a blood transfusion (having new
blood put into your body). You get these treatments through a needle into your vein
(also called intravenous or IV), or you may get some directly in the uterus.
• Having surgery, like a hysterectomy or a laparotomy. A hysterectomy is when your
provider removes your uterus. You usually only need a hysterectomy if other treatments
don’t work. A laparotomy is when your provider opens your belly to check for the source
of bleeding and stops the bleeding.
• Massaging the uterus by hand. Your provider can massage the uterus to help it contract,
lessen bleeding and help the body pass blood clots. Your provider may also give you
medications like oxytocin to make the uterus contract and lessen bleeding.
• Getting oxygen by wearing an oxygen mask
 • Removing any remaining pieces of the placenta from the uterus, packing the uterus
with gauze, a special balloon or sponges, or using medical tools or stitches to help stop
bleeding from blood vessels.
• Embolization of the blood vessels that supply the uterus. In this procedure, a provider
uses special tests to find the bleeding blood vessel and injects material into the vessel to
stop the bleeding. It’s used in special cases and may prevent you from needing a
hysterectomy.
• Taking extra iron supplements along with a prenatal vitamin may also help. Your
provider may recommend this depending on how much blood was lost.

Topic 6: Post partum infection

Ø Postpartum infections can be observed in various parts of the body - boggy uterus, breast -
and you must watch for them.
Ø Whenever you observe any discomfort or an unbearable pain in your body, your first line of
action is getting to your doctor.
Ø Common types of postpartum infections
• Endometritis
Endometritis is defined as an infection of the upper genital tract including endometrium,
myometrium, and surrounding tissue.
Endometritis risk factors include:
• Prolonged rupture of membranes (>18 h)
• Colonization with group A or B streptococcus
• Chorioamnionitis
• Prolonged operative time
• Bacterial vaginosis
• Internal monitoring
• Multiple vaginal exams.
Endometritis is a potentially severe postpartum infection that most likely will
require hospitalization.

• Puerperal mastitis
Puerperal mastitis is a regional infection of the breast, commonly caused by the patient’s skin
flora or the oral flora of breastfeeding infants. The organisms enter an erosion or cracked nipple
and proliferate, leading to infection. Lactating women will often have bilaterally warm, diffusely
tender, and firm breasts, particularly at the time of engorgement or milk letdown.
Mastitis can be treated with oral antibiotics (e.g. dicloxacillin).
In addition, patients should be encouraged to breastfeed, which prevents intraductal
accumulation of infected material. Those who are not breastfeeding should breast pump in the
acute phase of the infection.
Women who are unresponsive to oral antibiotics are admitted for IV(intravenous) antibiotics
until afebrile for 48 hours. If there is no response to IV antibiotics, a breast abscess should be
suspected and an imaging study obtained.
• Urinary tract infection
This is a puerperal infection that affects women that undergo delivery through both the cesarean
section and vagina.
This type of infection is associated with a series of discomfort, and having a long term
hospitalization.
This type of infection has been found to lead to a stoppage in breastfeeding.
The women that are affected by this type of infection must have had "asymptomatic antepartum
bacteriuria" which follows the trauma of delivery. This type of infection is usually not different
from the uterus infection (endometritis) when observed in the body clinically.
This infection can be treated using postpartum infection antibiotics. When you feel disturbed,
you should visit your physician to prevent continuous pain and discomfort.

• Wound infection
This is an infection that occurs after a C-section.
The incision area in the woman's body can be infected by the presence of bacteria around these
areas. This infection can be recognized by various symptoms such as redness(erythema) of the
incision site, fever, lower abdominal pain after giving birth, etc.
Oral antibiotics with coverage against streptococci, staphylococci, enteric, and anaerobic
organisms are first line in treating perineal infections.

• Perineal infection
This type of infection affects the perineum and ranges from mild to complicated in women with
health-related issues.
Perineal infection should be properly taken care of especially in women with health issues such
as diabetes, hypertension, etc. Women should go for postnatal treatments when they observe any
form of discomfort in the perineum region. A timely visit to your healthcare provider will help
with checkup and diagnosis.

Other forms of postpartum infections are as follows:

• Pudendal and paracervical block infection
• Abdominal wound infection
• Intravenous infection
• Soft tissue infection, etc.

Causes of postpartum infections

After delivery, the woman body is prone to postnatal infections which are caused by bacteria and
other microorganisms. Infections can be caused by staphylococcus, a bacterial usually present in
the oral cavity of the baby or within the abdominal and uterus lining of the mother.

Signs of postpartum infections

• Too much bleeding or hemorrhage discharge from the vagina.
• Foul smell coming out from the vagina.
• Little or no bleeding after delivery is a potential problem as well
• Increment or swelling of the uterus
• Pain in one or both of your breasts.
• Frequent nausea and/or vomiting.
• Hot or tender legs.
• Having breathing problems
• Having flu-like symptoms.
 • High fever
• Problem when urinating, extremely dark urine.
• Severe headaches.
• Abdominal or pelvic pain that doesn’t get better. The pain could be intense and it might
hurt or burn when you pee.
• Redness, discharge or swelling around your C-section incision, perineal tear or
episiotomy. The discomfort will get worse instead of better with an infection.

How are postpartum infections treated?

Postpartum infections can quickly become serious or even life-threatening, so they almost always
require treatment with antibiotics. The drugs might be given orally or through an IV, depending on the
infection and its severity.
Most of the antibiotics used to treat postpartum infections are safe to take while breastfeeding. But if
you’re nursing, you should still confirm with your doctor that the recommended treatment is
breastfeeding-compatible and find out about any possible risks.
For instance, antibiotics like ciprofloxacin and ofloxacin, while safe for nursing moms to take, aren’t
usually recommended as a front-line treatment since women are encouraged to pump and dump for at
least two hours after dosing.
Your practitioner will work with you to find the best treatment option that allows you to keep feeding
your baby safely.

Can you prevent a postpartum infection?

It’s not always possible to avoid a postpartum infection, but there are steps you can take to reduce
your risk as much as possible. If you do get sick, seek help sooner rather than later, when the infection
is easier to treat.
• Be vigilant about wound care and cleanliness after delivery. Wash your hands before
touching the perineal area, wipe from front to back after going to the bathroom and only use
maxi pads — not tampons — for postpartum bleeding.
• Know the symptoms — and your risk factors. Keep in mind that you’re more prone to
infection if you’ve undergone a C-section, especially an unplanned one. And no matter how
you gave birth, pay attention to any warning signs or unusual discomfort. Pain that gets worse
instead of better is generally a red flag, so don’t ignore it.
• Contact your doctor ASAP if something seems wrong. The sooner your infection can be
diagnosed and treated, the sooner you’ll get better.
• Take preventive antibiotics, if they’re prescribed to you. Your doctor may prescribe
antibiotics if you’ve delivered via C-section as extra insurance against infection. Take each
dose exactly as instructed.

When to call the doctor

You should let your doctor know right away if you notice any signs of a possible infection. In rare
cases, infections can trigger a life-threatening reaction called sepsis.
You should seek emergency medical attention right away if you have any possible symptoms,
including fever, chills, clamminess, rapid breathing, rapid heart rate, feelings of confusion or extreme
pain.
Even though postpartum infections are rare, the thought of getting one can be nerve-wracking. Be
proactive by keeping wounds clean and talking to your doctor about concerning symptoms instead of
trying to tough it out. Seeking help quickly is the best way to feel better — so you can get back to
enjoying your new bundle.

Topic 7: Thromboembolic disorders

Postpartum hemorrhage or excessive bleeding after birth can occur for a variety of reasons.
Continued bleeding can lead to severe, life-threatening blood loss.
Postpartum hemorrhage is a significant complication for women giving birth worldwide,
though mortality is decreasing over time.
1. Thrombophlebitis is an inflammation of the vascular endothelium with clot
formation on the vessel wall.
2. A thrombus forms when blood components (platelets and fibrin) combine to form an
aggregate body (clot).
3. Pulmonary embolism occurs when a clot travelling through the venous system
lodges within the pulmonary circulatory system, causing occlusion or infarction.
4. The incidence of postpartum thrombophlebitis is 0.1% to 1%, when not treated, 24%
of these develop pulmonary embolism, with a fatality rate of 15%.
Pathophysiology
1. The three major causes of thrombus formation and inflammation are venous stasis,
hypercoagulable blood, and injury to the innermost layer of the blood vessel.
2. Both venous stasis (in pelvis and lower extremities) and hypercoagulable blood are present
during pregnancy.
3. The level of most coagulation factors (especially fibrinogen, and factors III, VII, and X) are
increased during pregnancy. This increase is accompanied by a decrease in plasminogen and
antithrombin III, which cause clots to disintegrate.
4. Injury to the innermost layer of the vessel is probably not contributory, in general, during
pregnancy. However, the possibility exists if the birth is by cesarean section.
Assessment Findings
1. Common clinical manifestations
§ Superficial thrombophlebitis within the saphenous vein system manifests as midcalf pain,
tenderness, redness, and warmth along the vein.
§ DVT symptoms include muscle pain, the presence of humans sign (ie, pain in the calf on
passive dorsiflexion of the foot, possibly caused by DVT). However, the presence of
Homans sign is no longer believed to be conclusive because the pain may result from
other causes such as strained muscles or contusions.
§ Pelvic thrombophlebitis, typically occurring 2 weeks after delivery, is marked by chills,
fever, malaise, and pain.
§ Femoral thrombophlebitis, generally occurring 10 to 14 days after delivery, produces
chills, fever, malaise, stiffness, and pain.
§ Pulmonary embolism is heralded by sudden intense chest pain with severe dyspnea
followed by tachypnea, pleuritic pain, apprehension, cough, tachycardia, hemoptysis, and
temperature above 38°C (100.4°F).
2. Laboratory and diagnostic study findings
§ Venography accurately diagnoses DVT. There are risks associated with the radiopaque dye
that is used.
§ Real-time and color Doppler ultrasound will diagnose deep venous thrombosis.
§ Impedance plethysmography measures changes in venous blood volume and flow.
 Nursing Management
1. Promote resolution of symptoms and prevent the development of embolus.
§ Assess vital signs.
§ Assess extremities for signs of inflammation, swelling, and the presence of Homans sign.
§ Administer anticoagulant therapy as prescribed, and observe for signs of bleeding and
allergic reactions, Note: Keep the antidote protamine sulfate available in case of a severe
heparin overdose. Usually, protamine sulfate solution is administered intravenously at a
rate no greater than 50 mg every 10 minutes (see Drug Chart)
§ Caution: Do not administer estrogens for lactation suppression, because estrogens may
encourage clot formation.
§ Prepare the client for diagnostic studies (ie, venography and Doppler ultrasound), as
indicated.
§ Implement measures to prevent complications of bed rest (e.g., bed placed in
Trendelenburg position, use of footboard, passive or active range of motion exercises,
frequent shifts in position, and adequate fluid intake and output).
Drug Chart Medications Used for Postpartum Complications
Classifications Used for Selected Interventions

§ Heparin IV should be
§ Blocks the administered as a “piggy
conversion of back” infusion.
prothrombin to § Heparin SQ is given deep into the
thrombin and site (abdomen), sites are rotated,
Anticoagulants fibrinogen to fibrin do not aspirate, apply pressure
Heparin sodium thus decreasing (do not massage).
injection clotting ability § Used to prevent and treat
(Hepalean) § Inhibits thrombus and pulmonary embolism and
Lovenox clot formation thrombosis.

§ Women on
anticoagulopathy therapy
should no be given
estrogen or aspirin.
§ Obtain baseline
coagulation studies.
§ Obtain serial coagulation
studies while the client is
§ Interferes on therapy.
with hepatic § Keep protamine sulfate
synthesis of readily available in case of
vitamin K – heparin overdose.
dependent § Assess client for bleeding
Warfarin sodium clotting from nose, gums,
(Coumadin, factors hematuria, and blood in
Warfilone) (II,VII, IX, X) stool.
 § Observe color and amount
of lochia. Institute pad
count.
§ Avoid IM injections to
avoid formation of
hematomas.
§ Inform the client that this
drug does not pass into
breast milk.
§ Monitor for the following
side effects; hemorrhage,
bruising urticaria, and
thrombocytopenia.
§ Women on anticoagulant
therapy should not be
given estrogen or aspirin.
§ Obtain baseline
coagulation studies while
on therapy.
§ Keep AquaMEPHYTON
(vitamin K) on hand in
case of Coumadin
overdose.
§ Assess client for bleeding
from nose, gums,
hematuria, and blood in
stool.
§ Observe color and amount
of lochia. Institute a pad
count.
§ Avoid IM injections to
avoid formation of
hematomas.
§ Inform the client that this
drug passes into breast
milk and its use is
contraindicated during
pregnancy. Monitor the
following side effects:
hemorrhage, fever, nausea,
and cramps.

§ Directly
Oxytoxic stimulates
methylergonovine uterine and § Obtain a baseline calcium
maleate vascular level.
(methergine) smooth § Advise the client that this
(PO, IM, IV) muscle medication will cause
§ Promotes menstrual-like cramps.
uterine § Assess for numb fingers
contraction and toes, cold, chest pain,
§ Used for nausea, vomiting, muscle
prevention pain, and weakness.
and treatment § May cause decreased
of postpartum serum prolactin.
or § IV administration is used
postabortion for emergency dosage only.
hemorrhage Administer at a rate of 0.2
caused by mg over at least 1 minute.
uterine atony § DO NOT MIX THIS
or DRUG WITH ANY
subinvolution. OTHER DRUG.
§ Use solution only if it is
clear and colorless, with no
precipitate. May store at
room temperature for 60
days. The drug deteriorates
with age.
§ Monitor for the following
side effects: dyspnea,
palpitations, diaphoresis,
chest pain, hypotension,
and headache.

The reasons typically include:

• the uterus not contracting and clamping down as it should (this is the most common)
• injury to the birth canal, cervix, or other structures
• clotting problems
• part of the placenta remaining attached to the uterus
After a woman gives birth, her uterus may be checked regularly by her doctors and nurses to
ensure it is contracting and becoming smaller. If the uterus feels soft and floppy, or the woman is
bleeding excessively, emergency medical care is needed.
Treatment for postpartum hemorrhage can include:
• Undergoing a procedure in which the doctor puts pressure on the uterus with their hands
to help it contract.
• Inserting a small balloon inside the uterus to stop bleeding.
• Taking oxytocin or a similar medication that causes uterine contractions.
• A specialized procedure to block blood flow to arteries of the uterus.
• A blood transfusion to replace lost blood.
• In severe, life-threatening cases, surgery to remove the uterus (hysterectomy).
When to see a doctor
With so many changes happening to a woman’s body after giving birth, it can be hard to know
what is normal. Pregnant women should speak with a healthcare professional about what kind of
bleeding to expect. They can also discuss any risk factors they might have for developing
dangerous internal clots.
In general, any unusual symptoms, excessive or large clots, heavy bleeding, signs of a clot in a
vein, and feeling unwell are reasons to speak to a doctor or midwife.

Topic 8: Post partal psych disorders

PSYCHOLOGICAL CHANGES
1. Taking-In Phase
Usually sets 1 to 3 days after delivery.
This is the time of reflection for the woman because within the 2 to 3 day period, the woman
is passive.
The woman becomes dependent on her healthcare provider or support person with some of
the daily tasks and decision-making
dependence is mainly due to her physical discomfort from hemorrhoids or the after pains,
from the uncertainty of how she could care for the newborn, and also from the extreme tiredness
she feels that follows childbirth
The woman prefers to talk about her experiences during labor and birth and also her
pregnancy.
The taking-in phase provides time for the woman to regain her physical strength and organize
her rambling thoughts about her new role.
Encouraging the woman to talk about her experiences during labor and birth would greatly
help her adjust and let her incorporate it into her new life.

2. Taking Hold Phase

The taking hold phase starts 3 to 4 days after delivery.
The woman starts to initiate actions on her own and making decisions without relying on
others.
Women who underwent anesthesia reach this phase only hours after her delivery.
She starts to focus on the newborn instead of herself and begins to actively participate in
newborn care.
Demonstrate newborn care to the mother and watch her do a return demonstration of every
procedure.
The woman still needs positive reinforcements despite the independence that she is already
showing because she might still feel insecure about the care of her child.
Allow the woman to settle in gradually into her new role

3. Letting Go Phase
During the letting go phase, the woman finally accepts her new role and gives up her old
roles like being a childless woman or just a mother of one child.
This is the phase where postpartum depression may set in.
Readjustment of relationships is needed for an easy transition to this phase.
 Postpartum or maternity "blues“
- In the days following childbirth, up to 70% of women experience the “baby blues.” The
woman may have abrupt mood fluctuations, such as feeling extremely pleased and then
extremely depressed, may cry for no apparent cause, and experience feelings of
impatience, irritability, restlessness, anxiety, loneliness, and sadness. The baby blues can
persist anywhere from a few hours up to two weeks following delivery. The baby blues
usually do not require medical attention.
- Are frequent the normal experiences of mother after the birth of the newborn.
- They are characterized by labile mood and affect, crying spells, sadness, insomnia (unable
to sleep), and anxiety.
- Symptoms begin approximately 1 day after delivery, usually, its peak is 3-7 days, and
subside rapidly with no medical treatments.

Postpartum Depression
- Meets all the criteria for a major depressive episode, with onset within 4weeks or 1month
of delivery.
- Symptoms are anxiety, appetite changes, difficulty concentrating or making decisions,
fatigue, unable to sleep, feeling of guilt, irritability and agitation, lack of energy, less
responsiveness to the need of the infant, loss of pleasure in normal activities, and suicidal
thoughts.
- The woman can experience sensations comparable to the baby blues, such as grief,
despair, anxiety, and loneliness, but they are much stronger. PPD frequently prevents the
woman from doing the things needed to do on a daily basis. Consultation with a health
care practitioner, such as your OB/GYN or primary care doctor if the capacity to function
is impaired. The doctor can assess depression symptoms and devise a treatment plan. If
the patient does not receive treatment for PPD, the symptoms may worsen. While PPD is
a serious illness, it is treatable with medication and treatment.

Postpartum Psychosis
- Is a psychotic episode developing within 3 weeks of delivery and beginning with fatigue,
sadness, emotional lability, poor memory, and confusion and progressing to delusion(false
belief with stimuli), hallucination(false perception occurring without any true sensory
stimuli), poor insight and judgment, and loss of contact with reality. This requires an
immediate treatment
- This illness can strike swiftly, usually within the first three months following delivery.
Women can experience auditory hallucinations (hearing things that aren’t actually
happening, such as a person talking) and delusions, losing touch with reality (strongly
believing things that are clearly irrational). Visual hallucinations (seeing things that aren’t
there) are less prevalent than auditory hallucinations. Insomnia (inability to sleep),
agitation and anger, pacing, restlessness, and unusual feelings and actions are some of the
other symptoms. Women with postpartum psychosis require immediate care and almost
invariably require medication. Women are sometimes admitted to hospitals because of the
danger of harming themselves or others.
Postpartum Obsessive-Compulsive Condition (OCD).
- An anxiety-related mood disorder affects about 3% to 5% of new mothers. Intrusive and
persistent thoughts are common symptoms of postpartum OCD. The majority of these
thoughts involve injuring or even murdering the baby. Because moms with postpartum
OCD are aware of and appalled by these thoughts, they are rarely acted upon.
Compulsive routines, such as cleaning and changing the infant repeatedly, are other
behavioral markers of postpartum OCD. Postpartum OCD frequently stays undiagnosed
and untreated because moms feel embarrassed and ashamed of their thoughts and
behaviors.

Signs and Symptoms of PPD

The signs and symptoms of postpartum depression must be evaluated carefully to aid towards an
accurate diagnosis.
• Overall feeling of sadness. This is very evident in postpartum depression, especially if it
already affects the daily tasks of the woman.
• Extreme fatigue. The woman would only want to lie in bed all day because she is feeling
very tired at all times.
• Inability to stop crying. Due to the intense sadness that the woman feels, she may only
feel like crying all the time just to express her feelings.
• Increased anxiety. The woman is always overly anxious about her own and her baby’s
health.
• The woman may feel insecure because of the lack of support system and she has no one
to assist her in taking care of the infant.

Causes of postpartum depression

Postpartum depression has no single cause, but physical and emotional factors may play a role
such as,
• Physical transformations. A substantial decline in hormones (estrogen and progesterone)
in the body after childbirth may lead to postpartum depression. Other hormones generated
by the thyroid gland may also decline dramatically, leaving anxiety and sadness.
• Emotional problems. When sleep-deprived and overloaded, even simple issues can be
difficult to handle. It might be difficult to care for a newborn. It may feel like there is a loss
of control.

Risk Factors to Postpartum Depression

• History of depression. If the woman was diagnosed with depression prior to the
pregnancy, there is a probability that it will resurface after birth.
• Low self-confidence. A woman with poor self-esteem may have insecurity when making
decisions and may be reluctant to leave the baby alone.
• Workplace and home stress. If the woman’s stress is not addressed, it will most likely
lead to depression.
• Lack of support system. Emotional support is crucial in a woman’s recovery from
postpartum depression. The woman may sink deeper into depression when there’s no one
to talk to or support her.
Treatment for Postpartum Depression
1. Management of “baby blues”. The baby blues normally dissipate within a few days to
one to two weeks on their own. While waiting, the mother should do the following:
• Get as much sleep as possible.
• Accept the assistance of family and friends.
• Make friends with other new mothers.
• Avoid drinking and using recreational drugs, which can exacerbate mood fluctuations.
• Get health counseling
2. Psychotherapy. It may be beneficial to speak with a psychiatrist, psychologist, or another
mental health expert about the anxiety. The patient can learn better ways to cope with
emotions, solve problems, make realistic objectives, and respond to situations positively
through therapy. Family or relationship counseling might also be beneficial.
3. Antidepressants. An antidepressant may be prescribed by the healthcare provider. Any
drugs taken while breastfeeding will pass via breast milk. Most antidepressants, on the
other hand, can be taken during breastfeeding with little danger of negative effects for the
infant. Consult with the healthcare provider to consider the dangers and advantages of
various antidepressants.
4. Management of postpartum psychosis. It necessitates rapid medical attention, which is
generally in the hospital.To regulate the signs and symptoms, It may be advised to combine
the medications, such as antipsychotics, mood stabilizers, and benzodiazepines.
5. Electroconvulsive Therapy (ECT). If the postpartum depression is severe and there is
trouble sleeping, ECT may be considered if the symptoms aren’t responding to medicine.
ECT is a technique that involves passing tiny electrical currents through the brain to cause
a short seizure. ECT appears to create changes in brain chemistry that can help with
psychosis and depression symptoms, especially when other therapies have failed.

Nursing Management
Nurses must be alert in sensing the current psychological state of the patient too. They must
provide a precise data of the patient’s well-being to give way to a more accurate care plan for a
woman with postpartum depression.

Nursing Interventions
• Assist the woman in planning for her daily activities, such as her nutrition program,
exercise, and sleep.
• Recommend support groups to the woman so she can have a system where she can share her
feelings.
• Advise the woman to take some time for herself every day so she can have a break from her
regular baby care.
• Encourage the woman to keep in touch with her social circle as they can also serve as her
support system.
Topic 9: Breastfeeding

Breastfeeding refers to the act of providing breast milk as the primary source of nutrition and
nourishment to an infant directly from the mother’s breast. This natural process involves the
baby latching onto the mother’s nipple and suckling, allowing the baby to receive essential
nutrients, antibodies, and immune factors present in breast milk.

Physiology of breastfeeding
• Acinar cells or alveolar cells are responsible for the formation of breast milk.
• Progesterone levels fall after the placenta is delivered, leading to the stimulation of
prolactin.
• Prolactin stimulates the production of milk.
• On the fourth month of pregnancy, the acinar cells start producing colostrums, which is full
of nutrients for the newborn.
• Colostrum production continues for the first 3 to 4 days after birth.
• Transitional breast milk replaces colostrums on the 2nd to 4th
• True or mature breast milk is produced on the 10th
• Milk flows through its reservoirs, the lactiferous sinuses, which are located behind the
nipple.
• Foremilk is the constantly forming milk.
• When the infant sucks at the breast, oxytocin is released and the collecting sinuses of the
mammary glands contract.
• Milk is forced forward through the nipples, and this action is called the letdown reflex.
• Let down reflex can be triggered by thinking about the baby or whenever the mother hears a
baby crying.
• After the letdown reflex, new milk or hind milk is formed, and it has higher fat than
foremilk.
• Hind milk makes the infant grow more rapidly than foremilk.
• Oxytocin also helps in the contraction of the uterus so that the woman will feel a small
tugging or cramping in the lower pelvis on the first few days of breastfeeding.

Advantages for the Infant

• Breast milk contains immunoglobulin A which binds viruses and bacteria so they will not
be absorbed from the gastrointestinal tract into the infant.
• Lactoferrin, which is from the breast milk, also interferes with the growth of pathogens.
• An enzyme from the breast milk, the lysozyme, destroys bacteria by lysing their cell
membranes.
• Leukocytes in the breast milk provide protection against common respiratory infections.
• Macrophages that produce interferons protects against common viruses.
• Lactobacillus bifidus in breast milk prevents colonization of pathogenic bacteria in the
gastrointestinal tract, reducing the incidence of diarrhea.
• Breast milk contains the ideal composition of electrolytes and minerals for infant growth.
• Rapid brain growth in the infants is achieved because breast milk is high in lactose which
provides ready glucose.
• Breast milk also contains linoleic acid which is an essential fatty acid for skin integrity.
• The levels of nutrients are enough to supply the infant’s needs and also spare the infant’s
kidneys from processing a high renal solute load of unused nutrients.
• Breast milk is free from allergens, unlike cow’s milk.
• Calcium is regulated better in newborns that are breastfed.
• Breastfeeding prevents excessive weight gain in infants.

Advantages for the Mother

• Breastfeeding helps prevents breast cancer.
• Oxytocin aids in uterine involution as it helps the uterus contract.
• Breastfeeding empowers women because only women can master it.
• Feeding and preparation time is greatly reduced.
• The bond between the mother and the baby is strengthened.

Babies give signs that they are hungry. Initially, the baby may display the following to signal that
they are ready to be fed:
• Rooting
• Sticking out their tongue
• Licking their lips
• Placing hands in their mouth
• Sucking on things
• Fussiness
• Crying (late sign)

Different breastfeeding positions can help the mother and baby feel more comfortable and
relaxed while feeding. These positions include:

Common Concerns in Breastfeeding

Some mothers may love breastfeeding their babies, but there are others who are quite hesitant to
do so. These are mainly due to some of their concerns during breastfeeding, and examples of
these concerns are as follows.
 Issue Intervention

The nurse should assure the mother that to be certain

The mother worries about the amount of
that an adequate amount is taken by the baby; she
milk taken by the baby because she cannot
must observe whether the baby appears content
see it.
between feedings and is wetting the diapers.

The infant does not suck well because of the

possible effect of analgesia during birth.
The nurse should guide the mother in adjusting
the feeding pattern of the infant to meet its needs,
and assure her that the effect of analgesia is
The infant also cannot suck well when it is temporary.
not hungry or was exhausted by crying from
hunger.

The mother is worried because the infant’s

stools are loose and thin, but these are Explain the normal stool pattern and transitions to
normal because stools are normally lighter the mother and also examine the infant’s stools.
and looser for breastfed babies.

The father feels shut out of the mother-baby

Advise the father to look for other ways to bond with
relationship, so he does not participate in
the infant aside from feeding.
infant feeding.

Assist the mother by helping the infant grasp the

The mother has sore nipples because the
nipples were kept wet, so the infant cannot
grip the entire areola properly.
nipple correctly and advise the mother to expose the
nipple to air between feedings.
Advise the mother that she can apply aloe vera or
vitamin E to help heal the tissue.

Encourage the infant to suck and advise the mother

to apply warm packs to breasts.
 The engorgement of the mother’s breasts
Instruct the mother to take a warm shower before
causes a lymphatic filling as milk
breastfeeding the infant to soften the breast tissue.
production begins.

The mother does not want to breastfeed in

Encourage the woman to use discretion to avoid
public because some people make them
confrontation.
uncomfortable.

Breastfeeding is one of the most natural things that a mother could give to her children. As
breastfeeding provides so many benefits, nurses should promote this action to ensure that every
newborn is given the care that it deserves.

Topic 10: Family Planning

NATURAL AND ARTIFICIAL FAMILY PLANNING METHODS

Family Planning is the voluntary and mutual or shared act of both couples to plan , decide and
take action on:
1. What their aspirations are for their family and how to achieve them;
2. How many children to have;
3. When to have the next baby;
4. What methods to use to achieve their desired number of children.

It is important to note that family planning is not only talking about contraceptives or limiting or
spacing the number of children for its own sake. It is all about the effort of the couple to ensure
that their family will have the quality of life they desire. Ensuring that the family will achieve a
desired quality of life can be achieved by the use of planning methods which can be categorized as
natural or artificial.

Natural Family Planning Methods

Natural family planning primarily involves a woman who monitors and records different
fertility signals during her menstrual cycle to work out when she is likely to get pregnant. Methods
that are within this category include the following:
1. Abstinence. This involves refraining from sexual relations. It is the most effective way in
preventing sexually-transmitted infections (STIs).
2. Periodic Abstinence. This is characterized by avoiding sexual intercourse on days the
woman may conceive.
3. Lactation Amenorrhea Method(LAM). Women can achieve a method of contraception
by way of breastfeeding. Guidelines on breastfeeding as a method of contraception include
the following:
a. Breastfeeding is a natural suppressor of both ovulation and menstruation
b. It is safe if the infant is under 6 months of age.
c. The woman must totally breastfeed at least every 4 hours during the day;and every
6 hours at night
 d. There should be no infant’s supplemental feeding.
e. Menses have not returned.
4. Coitus Interruptus. This is also known as the withdrawal method.
5. Post-coital Douching. This involves the use of douching following intercourse.
6. Calendar Method. This is characterized by the use of a diary of six (6) menstrual cycles.
Guidelines include the following:
a. Calculate safe days
b. Subtract 18 on the shortest cycle
c. Subtract 11 on the longest cycle
7. Basal Body Temperature Method (BBM). Just before ovulation, the basal body
temperature(BBT) at rest falls about 0.5 F. At time of ovulation, BBT rises 0.2F.
8. Cervical Mucus Method (Billing’s Method). This involves monitoring of cervical mucus.
Before ovulation, cervical mucus is thick and viscous. Just before ovulation, cervical mucus
increases, becomes thin, and watery.
9. Two-Day Method. It is characterized by monitoring of secretions for two (2) days.
10. Symptothermal Method. This is a combination of cervical mucus method and basal body
temperature monitoring.
11. Standard Days Method. This involves the use of cycle beads whose menstrual cycle
ranges between 26 and 32 days.

Modern Artificial Family Planning Methods

The modern artificial family planning methods can be categorized according to duration of effect
of contraception. Some methods can provide instant contraception while the others can give either
a long-duration or a permanent method of contraception.
1. Short Acting Methods
a. Barrier Method: Condoms. A condom is worn over the penis during sexual intercourse
thus preventing the sperm from entering the vagina.
b. Hormonal Methods
• Pills. They prevent ovulation and thicken the cervical mucus, which prevents the sperm
from entering the uterus.
• Injectables. They thicken the cervical mucus, which prevents sperm from entering the
uterus, stops ovulation and causes changes in the uterus and fallopian tubes, which
prevents fertilization.

2. Long- Acting Methods

a. Intrauterine device (IUD). It is a tiny device that is positioned into the uterus to prevent
pregnancy. It is long-term, reversible, and one of the most effective birth control methods.
b. Subdermal Implants. They are progestin only implants that are inserted under the skin of
the inner upper arm of women . They suppress ovulation and thicken cervical mucus, thus
hindering sperms from passing through the cervical canal.

3. Permanent Methods. These are more appropriate for couples that have decided to complete
their number of children and cease further pregnancies of the wife.
a. Bilateral Tubal Ligation (BTL). It is a surgical procedure that involves blocking
the fallopian tubes to prevent the ovum (egg) from being fertilized. Cutting, burning or
 removing sections of the fallopian tubes or by placing clips on each tube, can do the
procedure.
b. Vasectomy. It is a surgical procedure for male sterilization or permanent contraception.
During the procedure, the male’s vas deferens are cut and tied or sealed so as to prevent
sperm from entering into the urethra and thereby prevent fertilization of a female through
sexual intercourse.