EENC ( EARLY ESSENTIAL NEWBORN CARE) this phase are mild and every 2 to 3 minutes with a the perineum
every 2 to 3 minutes with a the perineum begins to bulge and
• evidenced-based standards for safe and
quality care of birthing mothers and their
newborns, within the 48 hours of
Intrapartum period (labor and delivery)
and a week of life for the newborn.
The EINC practices during Intrapartum period
1. Continuous maternal support, by a
companion of her choice, during labor
and delivery
2. Mobility during labor – the mother is still
mobile, within reason, during this stage
3. Position of choice during labor and
delivery
4. Non-drug pain relief, before offering labor
anesthesia
5. Spontaneous pushing in a semi-upright
position
6. Episiotomy will not be done, unless
necessary
7. Active management of third stage of
labor (AMTSL)
8. Monitoring the progress of labor with the
use of pantograph
Recommended EINC practices for newborn care
are time-bound interventions at the time of birth
1. Immediate and thorough drying of the
newborn
2. Early skin-to-skin contact between
mother and the newborn
3. Properly-timed cord clamping and cutting
4. Unang Yakap (First Embrace) of the
mother and her newborn for early
breastfeeding initiation
STAGES OF LABOR
First Stage
• Three separate divisions mark the first
stage of labor
1. Latent Period/ Preparatory
Phase
- begins at the onset of
regularly perceived uterine
contractions and ends when
rapid cervical dilatation
begins. Contractions during
short, lasting 20 to 40
seconds. Cervical
effacement occurs, and the
cervix dilates from 0 to 3 cm.
- lasts approximately 6 hours
in a nullipara and 4.5 hours
in a multipara.
- Measuring the length of the
latent phase is important
because a reason for a
prolonged latent phase is
cephalopelvic disproportion
(a disproportion between the
fetal head and pelvis) that
could require a cesarean
birth.
2. Active Phase
- cervical dilatation occurs
more rapidly, increasing
from 4 to 7 cm. Contractions
grow stronger, lasting 40 to
60 seconds, and occur
approximately every 3 to 5
minutes. This phase lasts
approximately 3 hours in a
nullipara and 2 hours in a
multipara.
- This phase can be a difficult
time for a woman because
contractions grow strong,
last longer, and begin to
cause true discomfort. It is
also an exciting time,
because something
dramatic is suddenly
happening.
- can be subdivided into the
following periods:
acceleration (4 to 5 cm) and
maximum slope (5 to 9 cm).
During the period of
maximum slope, cervical
dilatation proceeds at its
most rapid pace, averaging
3.5 cm per hour in nulliparas
and 5 to 9 cm per hour in
multiparas.
3. Transition Period
- contractions reach their
peak of intensity, occurring
duration of 60 to 90 seconds
and causing maximum
cervical dilatation of 8 to 10
cm. If the membranes have
not previously ruptured or
been ruptured by
amniotomy, they will rupture
as a rule at full dilatation (10
cm).
- a woman may experience
intense discomfort, so strong
that it is accompanied by
nausea and vomiting.
Because of the intensity and
duration of the contractions,
a woman may also
experience a feeling of loss
of control, anxiety, panic, or
irritability. Sensations may
be so intense it may seem as
though labor has taken
charge of her.
- peak of the transition phase
can be identified by a slight
slowing in the rate of cervical
dilatation when 9 cm is
reached (termed
deceleration on a labor
graph). As a woman reaches
the end of this stage at 10
cm of dilatation, a new
sensation (i.e., an irresistible
urge to push) occurs.
Second Stage
• period from full dilatation and cervical
effacement to birth of the infant; with
uncomplicated birth, this stage takes
about 1 hour.
• feels contractions change from the
characteristic crescendo–decrescendo
pattern to an overwhelming,
uncontrollable urge to push or bear down
with each contraction as if to move her
bowels. She may experience momentary
nausea or vomiting because pressure is
no longer exerted on her stomach as the
fetus descends into the pelvis. She
pushes with such force that she perspires
and the blood vessels in her neck may
become distended. As the fetal head
touches the internal side of the perineum,
appears tense. The anus may become
everted, and stool may be expelled. As
the fetal head pushes against the
perineum, the vaginal introitus opens and
the fetal scalp appears at the opening to
the vagina. At first, the opening is slitlike,
then becomes oval, and then circular.
The circle enlarges from the size of a
dime, then a quarter, then a half-dollar.
This is called crowning.
Third Stage
• placental stage, begins with the birth of
the infant and ends with the delivery of
the placenta. Two separate phases are
involved:
1. Placental Stage
- Active bleeding on the
maternal surface of the
placenta begins with
separation; this bleeding
helps to separate the
placenta still farther by
pushing it away from its
attachment site. As
separation is completed, the
placenta sinks to the lower
uterine segment or the upper
vagina. The following signs
indicate that the placenta
has loosened and is ready to
deliver: • Lengthening of the
umbilical cord • Sudden
gush of vaginal blood •
Change in the shape of the
uterus • Firm contraction of
the uterus • Appearance of
the placenta at the vaginal
opening
- shiny and glistening from the
fetal membranes, this is
called a Schultze
presentation.
Approximately 80% of
placentas separate and
present in this way.
- s raw, red, and irregular, with
the ridges or cotyledons that
separate blood collection
spaces showing; this is
called a Duncan
presentation.

2. Placental Expulsion
- After separation, the
placenta is delivered either
by the natural bearing-down
effort of the mother or by
gentle pressure on the
contracted uterine fundus by
a physician or nursemidwife
(Credé’s maneuver).
Pressure must never be
applied to a uterus in a
noncontracted state,
because doing so may
cause the uterus to evert and
hemorrhage. This is a grave
complication of birth,
because the maternal blood
sinuses are open and gross
hemorrhage could occur
(Poggi, 2007). If the placenta
does not deliver
spontaneously, it can be
removed manually. With
delivery of the placenta, the
third stage of labor is
complete.
Placental Previa
- is a condition of pregnancy in
which the placenta is
implanted abnormally in the
uterus. It is the most
common cause of painless
bleeding in the third trimester
of pregnancy.
- It occurs in four degrees:
implantation in the lower
rather than in the upper
portion of the uterus (low-
lying placenta); marginal
implantation (the placenta
edge approaches that of the
cervical os); implantation
that occludes a portion of the
cervical os (partial placenta
previa); and implantation
that totally obstructs the
cervical os (total placenta
previa).
Placental Abruption
- occurs when the placenta
partially or completely
separates from the inner wall
of the uterus before delivery.
This can decrease or block
the baby's supply of oxygen
and nutrients and cause
heavy bleeding in the
mother.
Mechanisms of Labor
• Descent
• Engagement
• Neck flexion
• Internal rotation
• Crowning
• Extension of the presenting part
• Restitution
• Internal rotation
• Lateral flexion
1. Descent: The fetus descends into the
pelvis.
Occurs due to: Uterine contractions,
Amniotic fluid pressure and abdominal
muscle contraction.
Descent is encouraged by:
- Increased abdominal muscle
tone
- Braxton hicks in late stages of
pregnancy
- Fundal dominance of the uterine
contractions during labour
- Increased frequency and
strength of contractions during
labour
- As the head descends, it moves
towards the pelvic brim in either
the left or right occipito-
transverse position (this means
the occiput can be facing the left
side or right side of the mother’s
pelvis.
2. Engagement: This is when the largest
diameter of the fetal head descends into
the maternal pelvis.
Pregnancy
The term engagement is referring to the
widest part of the fetal head successfully
First trimester
negotiating its way down deep into the
The first trimester is the most crucial to the baby's
maternal pelvis. Engagement is identified
development. During this period, the baby's body
structure and organ systems develop. Most
by abdominal palpation, where the fetal
head is 3/5th palpable or less.
3. Neck Flexion: As the fetus comes into
contact with the pelvic floor, cervical
flexion occurs. This allows the
presenting part of the fetus to be sub-
occipito bregmatic.
In this position, the fetal skull has a
smaller diameter which assists passage
through the pelvis
4. Internal Rotation: The pelvic floor has a
gutter shape with a forward and
downward slope, encouraging the fetal
head to rotate from the left or right
occipito-transverse position a total of 90-
degrees, to an occipital-anterior (occiput
facing forward) position, to lie under the
subpubic arch.
This rotation will occur during established
labour and it is commonly completed by
the start of the second stage. Further
descent leads to the fetus moving into the
vaginal canal and eventually, with each
contraction, the vertex becomes
increasingly visible at the vulva.
5. Crowning: When the widest diameter of
the fetal head successfully negotiates
through the narrowest part of the
maternal bony pelvis, the fetal head is
considered to be ‘crowning’. This is
clinically evident when the head, visible
at the vulva, no longer retreats between
contractions. Complete delivery of the
head is now imminent.
6. Extension of presenting part: The
occiput slips beneath the suprapubic
arch as the head extends and the nape
of neck is pivoting against the arch
7. Restitution: the head externally rotate to
face the right or left medial thigh of the
mother.
8. Internal Rotation: the shoulders, having
reached the pelvic floor, will complete
their rotation from a transverse position
to an anterior-posterior position.
miscarriages and birth defects occur during this
period.
The body also undergoes major changes during
the first trimester. These changes often cause a
variety of symptoms, including nausea, fatigue,
breast tenderness and frequent urination.
Although these are common pregnancy
symptoms, every woman has a different
experience. For example, while some may
experience an increased energy level during this
period, others may feel very tired and emotional.
Second Trimester
The second trimester of pregnancy is often called
the "golden period" because many of the
unpleasant effects of early pregnancy disappear.
During the second trimester, you're likely to
experience decreased nausea, better sleep
patterns and an increased energy level. However,
you may experience a whole new set of
symptoms, such as back pain, abdominal pain,
leg cramps, constipation and heartburn.
Somewhere between 16 weeks and 20 weeks,
you may feel the baby's first fluttering movements
Third Trimester
The mother may feel more uncomfortable now as
she continues to gain weight and begins to have
false labor contractions (called Braxton-Hicks
contractions).
During the third trimester of pregnancy, fetus
development continues to grow in size and
weight. The lungs are still maturing and the fetus
begins to position itself head-down. By the end of
the third trimester, the fetus is about 19 to 21
inches long and weighs, on average, six to nine
pounds.
Fetal development during the third trimester
includes:
• The fetus can see and hear.
• The brain continues to develop.
• The kidneys and lungs continue to
mature.
• By the 36th week, the head may
"engage" (drop into the pelvic area) - a
process called "lightening."
• The bones of the skull remain soft to
make it easier to pass through the birth
canal.
• For many babies, the irises of the eyes
are slate blue. The permanent eye color
 will not appear until several days or
weeks after birth.
• The fetus can suck its thumb and has the
ability to cry.
• By 38 to 40 weeks, the fetus' lanugo has
disappeared almost completely.
• By 38 to 40 weeks, the lungs have
matured completely.
• The baby is covered in vernix caseosa (or
simply called vernix), a creamy,
protective coating on the skin.
• The head will usually turn downward
during the last couple of weeks of
pregnancy.
Changes in the mother's body
In the third trimester of pregnancy, some women
become increasingly uncomfortable as their due
date nears. As the fetus grows in size and crowds
the abdominal cavity, some mothers-to-be have
difficulty taking deep breaths or getting
comfortable at night for sleep, while others are
free from any discomfort as they anxiously await
the arrival of their new son or daughter.
The following is a list of changes and symptoms
that a woman may experience during the third
SIGNS OF PREGNANCY
trimester and includes:
Presumptive Signs:
• Increased skin temperature as the fetus
radiates body heat, causing the mother to
feel hot.
• The increased urinary frequency returns
due to increased pressure being placed
on the bladder.
• Blood pressure may decrease as the
fetus presses on the main vein that
returns blood to the heart.
• Swelling of the ankles, hands and face
may occur (called edema), as the mother
continues to retain fluids.
• Hair may begin to grow on a woman's
arms, legs, and face due to increased
hormone stimulation of hair follicles. Hair
may also feel coarser.
• Leg cramps may become more frequent.
• Braxton-Hicks contractions (false labor)
may begin to occur at irregular intervals
in preparation for childbirth.
• Stretch marks may appear on the
abdomen, breast, thighs and buttocks.
• Colostrum (a fluid in the breasts that pregnancy).
nourishes the baby until the breast milk c) Chronic illness (tuberculosis,
becomes available) may begin to leak endocrine disorders, or central nervous
from the nipples. system abnormality).
• Dry, itchy skin may persist, particularly on d) Anemia.
the abdomen, as the skin continues to • 1.2. NAUSEA AND VOMITING
grow and stretch. (MORNING SICKNESS)
• A woman's libido (sexual drive) may 1.2.1 Usually occurs in early morning
decrease. during the first weeks of pregnancy.
• Skin pigmentation may become more 1.2.2 Usually spontaneous and
apparent, especially dark patches of skin subsides in 6 to 8 weeks or by the twelfth
on the face. to sixteenth
• Constipation, heartburn and indigestion week of pregnancy.
may continue. 1.2.3 Hyperemesis gravidarum. This is
• Increased white-colored vaginal referred to as nausea and vomiting that
discharge (leukorrhea) which may is
contain more mucus. severe and lasts beyond the fourth month
• Backaches may persist and increase in of pregnancy. It causes weight loss and
intensity. upsets fluid and electrolyte balance of the
mother.
• Hemorrhoids may persist and increase in
1.2.4 Nausea and vomiting are
severity.
unreliable signs of pregnancy
• Varicose veins in the legs may persist
since they may result from other
and increase.
conditions such as:
a) Gastrointestinal disorders (hiatal
hernias, ulcers, and appendicitis)
b) Infection (influenza and malaria)
c) Emotional stress, upset (anxiety and
anorexia nervosa)
- signs and symptoms that are
d) Indigestion
usually noted by the client, which
impel her to seek council. These • 1.3 FREQUENT URINATION:
Frequent urination is caused by pressure of
signs and symptoms are not
the expanding uterus on the bladder.
proof of pregnancy but they will
1.3.2 It subsides as pregnancy
make the health provider and
progresses and the uterus rises out of the pelvic
woman suspicious of pregnancy
cavity.
• AMENORRHEA (CESSATION OF
1.3.3 The uterus returns during the last
MENSTRUATION) Amenorrhea is one of
weeks of pregnancy as the head of the
the earliest clues of pregnancy. The
fetus presses against the
majority of clients have no periodic
bladder.
bleeding after the onset of pregnancy.
1.3.4 Frequent urination is not a
However, at least 20 percent of
definite sign since other factors can be
women have some slight,
apparent (such as tension,
painless spotting during early gestation
diabetes, urinary tract infection, or
for no apparent reason and a large
tumors).
majority of these continue to term and
have normal infants. • 1.4 Breast Changes
1.4.1 In early pregnancy, changes
• Other causes for amenorrhea must be
start with a slight, temporary enlargement
ruled out, such as:
of the breasts causing a sensation
a) Menopause.
of weight, fullness, and mild tingling.
b) Stress (severe emotional shock,
1.4.2 As pregnancy continues the
tension, fear, or a strong desire for
patient may notice:
a) Darkening of the areola--the
brown part around the nipple.
b) Enlargement of Montgomery
glands--the tiny nodules or sebaceous
glands
within the areola.
c) Increased firmness or
tenderness of the breasts.
d) More prominent and visible veins
due to the increased blood supply.
e) Presence of colostrum (thin
yellowish fluid that is the precursor of
breast
milk). This can be expressed during the
second trimester and may even leak out
in the latter part of the pregnancy.
1.4.3 These breast changes can be more
positive if the patient has not recently
delivered and is not presently
breastfeeding.
1.5 VAGINAL CHANGES
1.5.1 CHADWICK'S SIGN: The
vaginal walls have taken on a deeper
colour caused by the increased
vascularity because of increased
hormones. It is noted at the sixth week
when associated with pregnancy. It
may also be noted with a rapidly growing
uterine tumor or any cause of pelvic
congestion.
1.5.2 LEUKORRHEA: This is an
increase in the white or slightly gray
mucoid discharge that has a
faint musty odour. It is due to
hyperplasia of vaginal epithelial cells of
the cervix because of
increased hormone level from
the pregnancy. Leukorrhea is also
present in vaginal infections.
1.6 QUICKENING (FEELING OF LIFE)
1.6.1 This is the first perception of fetal
movement within the uterus. It usually
occurs toward the end of the fifth month
because of spasmodic flutter.
a A multigravida can feel
quickening as early as 16 weeks.
b A primigravida usually cannot
feel quickening until after 18 weeks.
Once quickening has been established,
the patient should be instructed to report
 any instance in which fetal
movement is absent for a 24-hour period.
1.6.3 Fetal movement early in
pregnancy is frequently thought to be
gas.
1.7 SKIN CHANGES
1.7.1 Striae gravidarum (stretch
marks). These are marks noted on the
abdomen and/or buttocks. Striae
gravidarum may also be classified as a
probable sign of regnancy.
1.7.2 These marks are caused by
increased production or sensitivity to
adrenocortical hormones during
pregnancy, not just weight gain.
1.7.8 These marks may be seen on a
patient with Cushing's disease or a
patient with sudden weight gain.
1.7.9 1.8 LINEA NIGRA
1.8.1 This is a black line in the midline
of the abdomen that may run from the
sternum or umbilicus to the symphysis
pubis.
LINEA NIGRA
1.8.2 This appears on the primigravida
by the third month and keeps pace with the
rising height of the fundus.
1.8.3 The entire line may appear on
the multigravida before the third month.
1.8.4 This may be a probable sign if the
patient has never been pregnant.
1.9 CHLOASMA
1.10 This is called the "Mask of
Pregnancy." It is a bronze type of facial coloration
seen more on dark-haired women. It is seen after
the sixteenth week of pregnancy.
1.10 FINGERNAILS
Some patients note marked thinning and
softening by the sixth week.
1.11 FATIGUE
This is a common complaint by most patients
during the first trimester. Fatigue may also be
a result of anemia, infection, emotional
stress, or malignant disease.
Probable Signs
are those signs commonly noted by the health
providers upon examination of the client. These
signs include: uterine changes; abdominal
changes; cervical changes; basal body
temperature; a positive pregnancy test and fetal
palpation.
UTERINE CHANGES
2.1.1 POSITION: By the twelfth week, the
uterus rises above the symphysis pubis and it
should reach the xiphoid process by the
36th week of pregnancy. These guidelines
are fairly accurate only as long as
pregnancy is normal and there are no twins,
tumors, or excessive amniotic fluid.
2.1.2 SIZE: The uterine increases in width and
length approximately five times its normal
size. Its weight increases from 50 grams
to 1,000 grams.
2.1.3 HEGAR'S SIGN: This is softening of the
lower uterine segment just above the cervix.
When the uterus is compressed between
examining fingers, the wall feels tissue paper
thin. The physician will use a bimanual maneuver
simultaneously (abdominal and vaginal)
and will cause the uterus to tilt forward (see figure
3-1). Hegar's sign is noted by the sixth to
eighth week of pregnancy.
2.1.4 BALLOTTEMENT: This is demonstrated
during the bimanual examination done at the
16th to 20th week. Ballottement is when
the lower uterine segment or the cervix is
tapped by the examiner's finger which is
left in place during the procedure. The fetus
floats upwards, then sinks back and a
gentle tap is felt on the finger (see figure 3-2).
This is not considered diagnostic
because it can be elicited in the presence of
ascites or ovarian cysts.
2.2 ABDOMINAL CHANGES
This corresponds to changes that occur
in the uterus. As the uterus grows, the abdomen
gets larger. Abdominal enlargement alone is not
a sign of pregnancy. Enlargement may be due to
uterine or ovarian tumors, or edema.
CERVICAL CHANGES
2.3.1 GOODELL'S SIGN: The cervix is
normally firm, like the cartilage at the end of the
nose. Goodell's sign occurs when there is
marked softening of the cervix. This is present at
the 6th week of pregnancy.
2.3.2 FORMATION OF A MUCOUS PLUG:
This is due to hyperplasia of the cervical glands
as a result of increased hormones. It serves
to seal the cervix of the pregnant uterus
and to protect it from contamination by bacteria in
the vagina (see figure 3-3). The mucous is
expelled at the end of pregnancy near or at the
onset of labour.
2.3.3 BRAXTON-HICK'S CONTRACTIONS: This
involves painless uterine contractions occurring
throughout pregnancy. It usually begins
at about the 12th week of pregnancy and
becomes progressively stronger. These
contractions will, generally, cease with walking
or other forms of exercise. Braxton-Hick's
contractions are distinct from contractions of
true labour by the fact that they do not cause the
cervix to dilate and can usually be stopped by
walking.
2.3.4 BASAL BODY TEMPERATURE: This is
a good indication if the patient has recorded her
temperature over several previous
cycles. A persistent temperature elevation
spanning the 3 weeks from ovulation is noted as
an indicator of pregnancy. Basal body
temperature (BBT) is 97 percent accurate.
2.3.5 POSITIVE PREGNANCY TEST: This
may be misread by doing it too early or too late.
Even if the test is positive, it could be the
result of ectopic pregnancy or a hydatidiform
mole (an abnormal growth of a fertilized
ovum) (see figure 3-4).
2.3.6 FETAL PALPATION: This is a probable
sign in early pregnancy. The physician can
palpate the abdomen and identify
fetal parts. It is not always accurate.
POSITIVE SIGNS:
are those signs that are definitely confirmed as a
pregnancy. They include fetal heart sounds,
ultrasound scanning of the fetus, palpation of the
entire fetus, palpation of fetal movements, x-ray,
and actual delivery of an infant.
a. FETAL HEART SOUNDS: The fetal heart
begins beating by the 24th day following
conception. It is audible with a doppler by 10
weeks of pregnancy and with a fetoscope after
the 16th week (see figure 1.4). It is not to be
confused with uterine souffle or the swish like
tone from pulsating uterine arteries. The normal
fetal heart rate is 120 to 160 beats.
b. ULTRASOUND SCANNING OF THE FETUS:
Pregnancy ultrasound is a method of imaging the
fetus and the female pelvic organs during
pregnancy. The gestation sac can be seen.
CHANGES OF THE SKIN DURING
PREGNANCY
Alterations in hormonal balance and mechanical
stretching are responsible for several changes in
the integumentary system. The following changes
occur during pregnancy:
a. LINEA NIGRA: This is a dark line that runs from
the umbilicus to the symphysis pubis and may
extend as high as the sternum. It is a
hormone- induced pigmentation. After
delivery, the line begins to fade, though it may
not ever completely disappear.
b. MASK OF PREGNANCY (CHLOASMA): This
is the brownish hyper pigmentation of the skin
over
the face and forehead. It gives a bronze
look, especially in dark-complexioned women.
It begins about the 16th week of pregnancy
and gradually increases. It usually fades after
delivery.
c. STRIAE GRAVIDARUM (STRETCH MARKS):
This may be due to the action of the
adrenocorticosteroids. It reflects a
separation within underlying connective tissue of
the skin. This occurs over areas of
maximal stretch--the abdomen, thighs, and
breasts. It will usually fade after delivery
although the marks never completely
disappear.
d. SWEAT GLANDS: Activity of the sweat glands
throughout the body usually increases which
causes the woman to perspire more
profusely during pregnancy.
4.2 CHANGES OF THE BREASTS
a. IN EARLY PREGNANCY, the breast may feel
full or tingle and increase in size as pregnancy
progresses. The areola of the nipples
darkens and the diameter increases. The
Montgomery's glands (the sebaceous
glands of the areola) enlarge and tend to
protrude. The surface vessels of the
breast may become visible due to increased
circulation and give a bluish tint to the breasts.
b BY THE 16TH WEEK (2nd trimester) the
breasts begin to produce colostrum. This is the
precursor of breast milk. It is a thin,
watery, yellowish secretion that thickens as
pregnancy progresses. It is extremely high
in protein.
AGE OF GESTATION (AOG)
Gestation is the period of time between
conception and birth. During this time, the baby
grows and develops inside the mother's womb.
Gestational age is the common term used during
pregnancy to describe how far along the
pregnancy is. It is measured in weeks, from the
first day of the woman's last menstrual cycle to
the current date. A normal pregnancy can range
from 38 to 42 weeks.
Infants born before 37 weeks are considered
premature. Infants born after 42 weeks are
considered postmature.
Information
Gestational age can be determined before or
after birth.
Before birth, your health care provider will use
ultrasound to measure the size of the baby's
head, abdomen, and thigh bone. This provides a
view on how well the baby is growing in the
womb.
After birth, gestational age can be measured by
looking at the baby's weight, length, head
circumference, vital signs, reflexes, muscle tone,
posture, and the condition of the skin and hair.
If the baby's gestational age findings after birth
match the calendar age, the baby is said to be
appropriate for gestational age (AGA). AGA
babies have lower rates of problems and death
than babies that are small or large for their
gestational age.
The weight for full-term infants that are born AGA
will most often be between 2,500 grams (about
5.5 lbs or 2.5 kg) and 4,000 grams (about 8.75 lbs
or 4 kg).
Infants weighing less are considered small for
gestational age (SGA).
Infants weighing more are considered large for
gestational age (LGA).
Gestational Age by LMP is calculated from the
first day of the last menstrual period. EDD by LMP
is calculated by adding 280 days (40 weeks) to
the first day of the last menstrual period.
Gestational Age by US is measured by
ultrasound (US) on the Ultrasound Date.
EDC
Because the human egg is capable of fertilization
for only 12 to 24 hours after ovulation the date of
ovulation may be taken as being the date of
conception. However, ultrasound determination
of the date of ovulation has the same imprecision
as does the ultrasound estimate of the gestational
age and, therefore, a precise date of conception
cannot usually be determined as with in vitro
fertilization.
In addition, although a woman is most likely to
become pregnant if she has sex on the day of
ovulation conception may also occur from live
sperm still in her reproductive tract on the day of
ovulation if she had sex for up to five days before
ovulation.
Determining the Estimated Due Date
The estimated due date (EDD or EDC) is the date
that spontaneous onset of labor is expected to
occur. The due date may be estimated by adding
280 days ( 9 months and 7 days) to the first day
of the last menstrual period (LMP). This is the
method used by "pregnancy wheels". The
accuracy of the EDD derived by this method
depends on accurate recall by the mother,
assumes regular 28 day cycles, and that
ovulation and conception occurs on day 14 of the
cycle. Use of the LMP to establish the due date
may overestimate the duration of the pregnancy,
and can be subject to an error of more than 2
weeks.
In cases where the date of conception is known
precisely, such as with in vitro fertilization, the
EDD is calculated by adding 266 days to the date
of conception. Ultrasound uses the size of the
fetus to determine the gestational age (the time
elapsed since the the first day of the last
menstrual period). The accuracy of the
ultrasound estimate of the gestational age varies
according to the gestational age. "Ultrasound
measurement of the embryo or fetus in the first
trimester (up to and including 13 6/7 weeks of
gestation) is the most accurate method to
establish or confirm gestational age.The Society
of Obstetricians and Gynaecologists of Canada
recommends the earliest ultrasound with a crown
rump length equivalent to at least 7 weeks (or 10
mm) should be used to determine the gestational
age.
LEOPOLD’S MANEUVER
Leopold's maneuvers are four specific
steps in palpating the uterus through the
abdomen in order to determine the lie and
presentation of the fetus. In summary the steps
are:
Step 1. The top of the uterus (fundus) is felt
(palpated) to establish which end of the fetus
(fetal pole) is in the upper part of the uterus. If
either the head or breech (buttocks) of the fetus
are in the fundus then the fetus is in vertical lie.
Otherwise the fetus is most likely in transverse lie.
Step 2. Firm pressure is applied to the sides of
the abdomen to establish the location of the spine
and extremities (small parts).
Step 3. Using the thumb and fingers of one hand
the lower abdomen is grasped just above the
pubic symphysis to establish if the presenting part
is engaged. If not engaged a movable body part
will be felt. The presenting part is the part of the
fetus that is felt to be in closest proximity to the
birth canal.
Step 4. Facing the maternal feet, the tips of the
fingers of each hand are used to apply deep
pressure in the direction of the axis of the pelvic
outlet. If the head presents, one hand is arrested
sooner than the other by a rounded body (the
cephalic prominence) while the other hand
descends deeply into the pelvis. If the cephalic
prominence is on the same side as the small
parts, then the fetus is in vertex presentation. If
the cephalic prominence is on the same side as
the back, then the head is extended, and the fetus
is in face presentation.
GPTPALM
Refers to:
· Gravida = # of pregnancies
· Para = # of pregnancies past 20 weeks
· Term = # of births after 37 weeks
· Preterm = # of births between 21-36 weeks
· Abortions = # of surgical/miscarriages
· Living = # of living children
· Multiples = # of sets
BREASTFEEDING RA 7600
RA 7600 or “THE ROOMING-IN AND
BREASTFEEDING ACT OF 1992″ AN ACT
PROVIDING INCENTIVES TO ALL
GOVERNMENT AND PRIVATE HEALTH
INSTITUTIONS WITH ROOMING-IN AND
BREASTFEEDING PRACTICES AND FOR
OTHER PURPOSES.
This law is in promotion of the State policy to
encourage the practice of breastfeeding in the
Philippines. It composes of 14 Sections divided
into 4 chapters.
Chapter 1 states the rules and regulations which
contain standard procedures to be followed for
rooming-in and breastfeeding in all private and
government health institutions. Specific
provisions are made for complicated births. The
right of the mother to breastfeed and the right of
the infant to receive breast milk is expressed, and
mothers may only exercise their right to bottle
feed after being fully informed of the benefits of
breastfeeding and by expressing their intention to
formula feed in writing.
The regulations cover the establishment and
operation of human milk banks and the donation
of human milk which is stated in Chapter 2 of the
act.
Provisions are stated in Chapter 3 of the act for
the continuing education and training of health
personnel and the education and counseling of
parents.
Other provisions indicated in Chapter 4 states
that the only milk formula to be stocked in the
hospital is to be kept in a closed cabinet out of
sight and used for only emergency purposes
upon issuance of a prescription. These
prohibitions extend to the use of pacifiers, the
donation of samples of formula, and the
promotion of infant formulas in hospitals.
Government and private hospitals will receive
financial incentives for compliance.
Noncompliance will place health personnel and
institutions in danger of losing their licenses and
of being found guilty of a wrongdoing
EO51 MILK CODE
EXECUTIVE ORDER NO. 51 October 20, 1986
ADOPTING A NATIONAL CODE OF
MARKETING OF BREASTMILK SUBSTITUTES,
BREASTMILK SUPPLEMENTS AND RELATED
PRODUCTS, PENALIZING VIOLATIONS
THEREOF, AND FOR OTHER PURPOSES
WHEREAS, in order to ensure that safe and
adequate nutrition for infants is provided, there is
a need to protect and promote breastfeeding and
to inform the public about the proper use of
breastmilk substitutes and supplements and
related products through adequate, consistent
and objective information and appropriate
regulation of the marketing and distribution of the
said substitutes, supplements and related
products;
WHEREAS, consistent with Article 11 of the
International Code of Marketing of Breast-milk
Substitutes, the present government should
adopt appropriate legislation to give effect to the
principles and aim of the aforesaid International
Code;
NOW, THEREFORE, I, CORAZON C. AQUINO,
President of the Philippines, do hereby order:
Sec. 1. Title. This Code shall be known and cited
as the "National Code of Marketing of Breastmilk
Substitutes, Breastmilk Supplements and Other
Related Products".
Sec. 2. Aim of the Code The aim of the Code is to
contribute to the provision of safe and adequate
nutrition for infants by the protection and
promotion of breastfeeding and by ensuring the
proper use of breastmilk substitutes and
breastmilk supplements when these are
necessary, based on adequate information and
through appropriate marketing and distribution.
Sec. 3. Scope of the Code The Code applies to
the marketing, and practices related thereto, of
the following products: breastmilk substitutes,
including infant formula; other milk products,
foods and beverages, including bottle-fed
complementary foods, when marketed or
otherwise represented to be suitable, with or
without modification, for use as a partial or total
replacement of breastmilk; feeding bottles and
teats. It also applies to their quality and
availability, and to information concerning their
use.
Sec. 4. Definition of Terms. For the purposes of
this Code, the following definition of terms shall
govern:
(a) "Breastmilk Substitute" means any food being
marketed or otherwise represented as a partial or
total replacement for breastmilk, whether or not
suitable for that purpose.
(b) "Complementary Food" means any food,
whether manufactured or locally prepared,
suitable as a complement to breastmilk or to
infant formula, when either becomes insufficient
to satisfy the nutritional requirements of the
infant. Such food is also commonly called
"weaning food" or "breastmilk supplement."
(c) "Container" means any form of packaging of
products for sale as a normal retail unit, including
wrappers.
(d) "Distributor" means a person, corporation or
any other entity in the public or private sector
engaged in the business (whether directly or
indirectly) of marketing at the wholesale or retail
level a product within the scope of this Code. A
"primary distributor" is a manufacturer's sales
agent, representative, national distributor or
broker.
(e) "Infant" means a person falling within the age
bracket of 0-12 months.
(f) "Health care system" means governmental,
non-governmental or private institutions or
organizations engaged, directly or indirectly, in
health care for mothers, infants and pregnant
women; and nurseries or child care institutions. It
also includes health workers in private practice.
For the purpose of this Code, the health care
system does not include pharmacies or other
established sales outlets.
(g) "Health Worker" means a person working in a
component of such health care system, whether
professional or non-professional, including
volunteer workers.
(h) "Infant Formula" means a breastmilk
substitute formulated industrially in accordance
with applicable Codex Alimentarius standards to
satisfy the normal nutritional requirements of
infants up to between four to six months of age
and adapted to their physiological characteristics.
Infant formula may also be prepared at home in
which case it is described as "home-prepared".
(i) "Label" means any tag, brand, mark, pictorial
or other descriptive matter, written, printed,
stenciled, marked, embossed or impressed on, or
attached to, a container of any product within the
scope of this Code.
(j) "Manufacturer" means a corporation or other
entity in the public or private sector engaged in
the business or function (whether directly or
through an agent or an entity controlled by or
under contract with it) of manufacturing a product
within the scope of this Code.
(k) "Marketing" means product promotion,
distribution, selling, advertising, product public
relations, and information services.
(l) "Marketing personnel" means any person
whose functions involve the marketing of a
product or products coming within the scope of
this Code.
(m) "Sample" means single or small quantities of
a product provided without costs.
(n) "Supplies" means quantities of a product
provided for use over an extended period, free or
at a low price, for social purposes, including those
provided to families in need.
Sec. 5. Information and Education
(a) The government shall ensure that objective
and consistent information is provided on infant
feeding, for use by families and those involved in
the field of infant nutrition. This responsibility shall
cover the planning, provision, design and
dissemination of information, and the control
thereof, on infant nutrition.
(b) Information and educational materials,
whether written, audio, or visual, dealing with the
feeding of infants and intended to teach pregnant
women and mothers of infants, shall include clear
information on all the following points: (1) the
benefits and superiority of breastfeeding; (2)
maternal nutrition, and the preparation for and
maintenance of breastfeeding; (3) the negative
effect on breastfeeding of introducing partial
bottle-feeding; (4) the difficulty of reversing the
decision not to breastfeed; and (5) where needed,
the proper use of infant formula, whether
manufactured industrially or home-prepared.
When such materials contain information about
the use of infant formula, they shall include the
social and financial implications of its use; the
health hazards of inappropriate foods or feeding
methods; and the health hazards of unnecessary
or improper use of infant formula and other
breastmilk substitutes. Such materials shall not
use any picture or text which may idealize the use
of breastmilk substitutes.
Sec. 6. The General Public and Mothers
(a) No advertising, promotion or other marketing
materials, whether written, audio or visual, for
products, within the scope of this Code shall be
printed, published, distributed, exhibited and
broadcast unless such materials are duly
authorized and approved by an inter-agency
committee created herein pursuant to the
applicable standards provided for in this Code.
(b) Manufacturers and distributors shall not be
permitted to give, directly, or indirectly, samples
and supplies of products within the scope of this
Code or gifts of any sort to any member of the
general public, including members of their
families, to hospitals and other health institutions,
as well as to personnel within the health care
system, save as otherwise provided in this Code.
(c) There shall be no point-of-sale advertising,
giving of samples or any other promotion devices
to induce sales directly to the consumers at the
retail level, such as special displays, discount
coupons, premiums, special sales, bonus and tie-
in sales for the products within the scope of this
Code. This provision shall not restrict the
establishment of pricing policies and practices
intended to provide products at lower prices on a
long-term basis.
(d) Manufacturers and distributors shall not
distribute to pregnant women or mothers of
infants any gifts or articles or utensils which may
promote the use of breastmilk substitutes or
bottle feeding, nor shall any other groups,
institutions or individuals distribute such gifts,
utensils or products provided by this Code.
(e) Marketing personnel shall be prohibited from
advertising or promoting in any other manner the
products covered by this Code, either directly or
indirectly, to pregnant women or with mother of
infants, except as otherwise provided by this
Code.
(f) Nothing herein contained shall prevent
donations from manufacturers and distributors of
products within the scope of this Code upon
request by or with the approval of the Ministry of
Health.
Sec. 7. Health Care System
(a) The Ministry of Health shall take appropriate
measures to encourage and promote
breastfeeding. It shall provide objective and
consistent information, training and advice to
health workers on infant nutrition, and on their
obligations under this Code.
(b) No facility of the health care system shall be
used for the purpose of promoting infant formula
or other products within the scope of this Code.
This Code does not, however, preclude the
dissemination of information to health
professionals as provided in Section 8(b).
(c) Facilities of the health care system shall not
be used for the display of products within the
scope of this Code, or for placards or posters
concerning such products.
(d) The use by the health care system of
"professional service" representatives, "mother
craft nurses" or similar personnel, provided or
paid for by manufacturers or distributors, shall not
be permitted.
(e) In health education classes for mothers and
the general public, health workers and community
workers shall emphasize the hazards and risks of
the improper use of breastmilk substitutes
particularly infant formula. Feeding with infant
formula shall be demonstrated only to mothers
who may not be able to breastfeed for medical or
other legitimate reasons.
Sec. 8. Health Workers
(a) Health workers shall encourage and promote
breastfeeding and shall make themselves familiar
with objectives and consistent information on
maternal and infant nutrition, and with their
responsibilities under this Code.
(b) Information provided by manufacturers and
distributors to health professionals regarding
products within the scope of this Code shall be
restricted to scientific and factual matters and
such information shall not imply or create a belief
that bottle-feeding is equivalent or superior to
breastfeeding. It shall also include the information
specified in Section 5(b).
(c) No financial or material inducements to
promote products within the scope of this Code
shall be offered by manufacturers or distributors
to health workers or members of their families,
nor shall these be accepted by the health workers
or members of their families, except as otherwise
provided in Section 8(e).
(d) Samples of infant formulas or other products
within the scope of this Code, or of equipment or
utensils for their preparation or use, shall not be
provided to health workers except when
necessary for the purpose of professional
evaluation or research in accordance with the
rules and regulations promulgated by the Ministry
of Health. No health workers shall give samples
of infant formula to pregnant women and mothers
of infants or members of their families.
(e) Manufacturers and distributors of products
within the scope of this Code may assist in the
research, scholarships and continuing education,
of health professionals, in accordance with the
rules and regulations promulgated by the Ministry
of Health.
Sec. 9. Persons Employed by Manufacturers and
Distributors Personnel employed in marketing
products within the scope of this Code shall not,
as part of their job responsibilities, perform
educational functions in relation to pregnant
women or mothers of infants.
Sec. 10. Containers/Label
(a) Containers and/or labels shall be designed to
provide the necessary information about the
appropriate use of the products, and in such a
way as not to discourage breastfeeding.
(b) Each container shall have a clear,
conspicuous and easily readable and
understandable message in Pilipino or English
printed on it, or on a label, which message cannot
readily become separated from it, and which shall
include the following points:
(i) the words "Important Notice" or their
equivalent;
(ii) a statement of the superiority of breastfeeding;
(iii) a statement that the product shall be used
only on the advice of a health worker as to the
need for its use and the proper methods of use;
and
(iv) instructions for appropriate preparation, and a
warning against the health hazards of
inappropriate preparation.
(c) Neither the container nor the label shall have
pictures or texts which may idealize the use of
infant formula. They may, however, have
graphics for easy identification of the product and
for illustrating methods of preparation.
(d) The term "humanized", materialized" or similar
terms shall not be used.
(e) Food products within the scope of this Code
marketed for infant feeding, which do not meet all
the requirements of an infant formula, but which
can be modified to do so, shall carry on the label
a warning that the unmodified product should not
be the sole source of nourishment of an infant.
(f) The labels of food products within the scope of
this Code shall, in addition to the requirements in
the preceding paragraphs, conform with the rules
and regulations of the Bureau of Food and Drugs.
Sec. 11. Quality
(a) The quality of products is an essential element
for the protection of the health of infants, and
therefore shall be of high recognized standard.
(b) Food products within the scope of this Code
shall, when sold or otherwise distributed, meet
applicable standards recommended by the
Codex Alimentarius Commission and the Codex
Code of Hygienic Practice for Foods for Infants
and Children.
(c) To prevent quality deterioration, adulteration
or contamination of food products within the
scope of this Code, distribution outlets, including
the smallest sari-sari store, shall not be allowed
to open cans and boxes for the purpose of
retailing them by the cup, bag or in any other
form.
NEWBORN SCREENING RA 9288
DESCRIPTION
The Comprehensive Newborn Screening (NBS)
Program was integrated as part of the country’s
public health delivery system with the enactment
of the Republic Act no. 9288 otherwise known as
Newborn Screening Act of 2004. The Department
of Health (DOH) acts as the lead agency in the
implementation of the law and collaborates with
other National Government Agencies (NGA) and
key stakeholders to ensure early detection and
management of several congenital metabolic
disorders, which if left untreated, may lead to
mental retardation and/or death. Early diagnosis
and initiation of treatment, along with appropriate
long-term care help ensure normal growth and
development of the affected individual. It has
been an integral part of routine newborn care in
most developed countries for five decades, either
as a health directive or mandated by law. It is
also a service that has been available in the
Philippines since 1996. Under the DOH, NBS is
part of the Child Development and Disability
Prevention Program at the Disease Prevention
and Control Bureau.
VISION
The National Comprehensive Newborn
Screening System envisions all Filipino children
will be born healthy and well, with an inherent
right to life, endowed with human dignity; and
Reaching their full potential with the right
opportunities and accessible resources
MISSION
To ensure that all Filipino children will have
access to and avail of total quality care for the
optimal growth and development of their full
potential.
GOAL
To reduce preventable deaths of all Filipino
newborns due to more common and rare
congenital disorders through timely screening
and proper management
POSTPARTUM ASSESSMENT
In postpartum, the patient is normally a well
patient. Complications are possible, but for
the most part the patient is a healthy
individual under temporary confinement
expecting to take home a healthy infant. The
following are some guidelines to promote
physiological psychological safety of the
postpartum patient. ASSESSMENT: An
assessment on 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): BREASTS:
Palpate each breast for firmness, fullness,
tenderness, shininess, and contour. Does
the mom complain of sore nipples, are the
nipples red, cracked or bleeding? Is she
wearing a support bra? Encourage all moms
to wear a support bra whether nursing or
non-nursing. UTERUS: It is firm or is it
boggy? The fundus should be firm; if not,
gently massage to obtain firmness and note
if excess bleeding or clots are expelled
during the massage. What is the fundal
height? It should decrease in height by one
fingerbreadth below the umbilicus each day
post delivery. Nursing mothers may involute
a little more quickly due to the release of
oxytocin while nursing. It is best to have the
mother void and then have her lie flat in bed
before checking fundal height. If the fundus
is above the uterus or displaced to the right
or left, the mom may have a full bladder or
retained placenta fragments. C-SECTION: If
the patient had a C-Section, inspect the
dressing or incision at this time noting site,
redness, discharge, and approximation of
the incision if uncovered. Don't forget to
check for bowel sounds.
LOCHIA [lo´ke-ah]
a vaginal discharge occurring after childbirth. Lo
chia discharge should be checked every 15 minu
tes for the first hour after delivery, once every ho
ur for the first 8 hours, and then every 8 hours. a
dj., adj lo´chial.
lochia al´ba the final vaginal discharge after chil
dbirth, largely mucus, when the amount of blood
is decreased and the leukocytes are increased; i
t is usually of 10 to 14 days' duration but may las
t for 6 weeks.
• lochia cruen´ta lochia rubra.
• lochia purulen´ta lochia alba.
• lochia ru´bra that occurring immediately
after childbirth, consisting of blood, frag
ments of decidua, and mucus. It usually
lasts from 1 to 3 days.
• lochia sanguinolen´ta (lochia sero´sa)
the vaginal discharge occurring 3 to 10
days after delivery. It is pink or brown-
tinged and contains blood, mucus, and l
eukocytes.
When examining the fundus, check the
lochia for color, amount, odor, and the
number of pads used.
Ø The first two to three days, lochia is
bright red, similar to menses and is
known as RUBRA.
Ø The next few days lochia becomes
serous and more watery and is known
as SEROSA.
Ø 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 an infection. The doctor
should be notified of any unusual odor,
excessive bleeding, or clotting.
Ø EPISIOTOMY: Inspect the incision for
REEDA.
Ø Also check for a hematoma. The patient
may need to be medicated for
discomfort.
Ø Also check the rectum at this time for
hemorrhoids and initiate appropriate
measures if uncomfortable to the
patient.
REMEMBER: WEAR YOUR GLOVES
WHEN CHECKING A POSTPARTAL
PATIENT
BUBBLE-HE
BUBBLE-HE is a acronym used to denote the The breasts will be very tender with a feeling of
components of the postpartum maternal nursing heaviness
assessment. This method enhances the
standard physical assessment process typically A firm, snug-fitting bra is ideal for the woman
performed on hospitalized patients by the RN, whose not breastfeeding. Also this will help,
engorgement may still occur
such as those on a Medical-Surgical floor. For
stable patients, vital signs are taken every 15
Ice and cabbage leaves can provide relief. There
minutes during the first hour following delivery is an enzyme in the cabbage leaves that helps
and then gradually less frequently. While
performing the BUBBLE-HE, the RN often uses Do not express milk as it will encourage additional
the assessment time to provide for patient production
education.
Any warmth over the breasts and stimulation of
the nipples will create a faucet-like effect
The BUBBLE-HE Acronym
Breastfeeding Mom
B: Breast Focus on the nipple and areola. The nipple should
be erect, but some are flat or inverted. Hopefully,
U: Uterus this was identified during the pregnancy in order
for shield to be placed upon them
B: Bladder
B: Bowels Assess the nipples for signs of bruising, crackling,
chapping. A deep crack or blister may indicate
L: Lochia incorrect placement or another issue
H: Homan’s Avoid placing want cold packs on the breasts
E: Episiotomy and perineum
Mastitis Infection: Nursing Considerations
B: Breast Mastitis is an infection of the breast surrounding
the ducts that’s characterized by fulness, pain,
Breast Assessment warmth, and hardness of the breast. It’s crucial
Assessment include evaluating the breast in to differentiae infection from engorgement.
the postpartum period Mastitis may involve fever, while localized
symptoms are limited to specified area that
The first step is to determine if the new mamma usually appears red and feels warm and possibly
is breastfeeding or bottle-feeding: This will guide hardened
the assessment along with patient education
Mastitis needs to be treated with antibiotics and
Breast Evaluation the patient is usually encouraged to continue
breastfeeding. The cause of infection is
• Size associated with stagnant milk in the ducts. In
• Shape most cases, the milk is not infected; only the ducts
• Firmness
• Redness The best way to feed is to start on the uninfected
• Symmetry breast first. The mother should
Bottle-Feeding Mom: Lactation Suppression then switch to the affected breast within a few
minutes so this breast can be fully emptied and
Teach the mom about breast engorgement. This drained. The infant is the best drainer- no breast
usually occurs about 72 hours after birth
pump can ever compare. The only time a
breastfeeding mom is asked to stop is when boils
and/or cysts are present
Breast and Bottle Feeding
The decision to breast or bottle feed is highly
personal. While the benefits of breast milk
nutritionally and physiologically outweigh those
of formula, it may not always be possible or in
the best interest of the mom and baby to
breastfeed. The nurse’s role is to educate the
mom and support the family in whatever choice is
made, not pass judgment.
Benefits of Bottle Feeding
Not solely a “Mom-only” responsibility
Breastfeeding does not always “come naturally”
to al moms- it may be difficult for some
May be considered more socially acceptable to
whip out a bottle in the middle of a restaurant
versus a breast
May be easier for moms who work outside of the
home
Bonding ↔ dad and baby or other relatives who
feed
Disadvantages of Bottle Feeding
• No passive immunity
• Harder for baby to digest
• Expensive, especially if a specialized
formula is needed
• More allergies
• Overfeeding is easier
• Stool is more odorous
Benefits of Breast Feeding
• Passive immunity
• Less incidents of ear infections (formula
pools into the Eustachian tube)
• Easy digestibility
• Bonding between mom and baby
• No cost and always available and at the
right temperature
For the foodies: Some moms may enjoy being
able to eat an extra 500 calories/day
Benefits to Mom: Release of oxytocin (the “let-
down”) causes the uterus to contract, which
promotes quicker return to pre-pregnancy weight.
It also decreases risks of ovarian and breast
cancer
Breastfeeding Teaching
• Positioning: holds- chest to chest or
tummy to tummy in some way, grab
under the breasts and push down and
out (taking the milk ducts and pushing it
forward, make a C- Hold around the
areola (pull back, down, and forward
while bringing forward)
• get a nice big drop of colostrum on the
nipple
• tickle the lip with nipple, shove as much
breast as possible into the mouth once
it’s open
• 5 to 15 minutes a first to prevent
soreness
• Start with the breasts that was left from
• Try to feed every 2 hours
Formula Teaching
• Ready-to-feed: most expensive but
convenient
• Concentrate: do not ever add more water
or concentrate it
• Powder: follow directions per label
• Throw the bottle contents out after the
feeding- do not save for next feeding
• Start off small by only preparing 2 ounces
at a time
• No need to warm formula up
U: Uterus
Uterine Assessment
Fundus: firm or boggy- make a “C-shape” with
your hand and push up on the lower fundus; if it’s
not stabilized, the uterus can prolapse, or fall
into the vagina. Massage of not firm- secure
lower uterine segment. The concern is for
hemorrhage; the primary causes are a distended
bladder (uterus can’t contract or uterine atony, or
failure to contract fully) and retrained placental
fragments (usually a later cause)
Fundal Height: where is it in relation to the
umbilicus? “U/U” or “At the U” (1/U =
1 cm above the umbilicus)- drops one centimeter
or finger width. The position drops one centimeter
every 24 hours for 10 days postpartum
Midline or Deviated to the Left or Right: if
deviated, it’s usually a sign of a full bladder
Uterine afterpains of a breastfeeding mom get
worse with each pregnancy. The uterus is a
muscle and the more it is stretched, the more
force is needed in order to contract.
Nursing Consideration. A boggy fundus may be
a sign of uterine atony, which places the patient
at risk for developing a postpartum hemorrhage
and other complications. Also, fundal location that
lies out of range with anticipated location
according to postpartum status may be another
indication. The nurse should perform a uterine
massage, which promotes blood movement out
of the uterus, and also encourage the patient to
void, as a full or distended bladder can impede
uterine involution and contractions. The nurse is
often in the position as the first member health
care team to learn of these warning signs and
therefore must take swift action if an issue is
suspected.
B: Bladder
Bladder Assessment
• Ask mom when she last voided
• Establish a Voiding Schedule to prevent
bladder distension and urinary stasis
• Encourage mom to urinate every time
before she feed baby (as they may fall
asleep)
Possible Obstacles to Voiding
• Mom may become so engrossed with
baby that she forgets to void
Assess the color, odor, and amount
• Internal inflammation from labor trauma
may impair ability to void The lochia color should forward in the
• Mom may hesitate to void from fear of progression of lightness, never go backwards
pain, especially if she has an episiotomy
or vaginal tearing
• C-section patients may also have issue Lochia Color
with voiding following removal of the folly
Nursing Interventions for Postpartum Bladder
Care Lochia Rubra: bright red, may have small clots,
usually lasts 3 days
Peri-bottle- teach mom to always bring the bottle,
which is used for perineal irrigation, to the Lochia Serosa: pink, serous, other tissues
restroom to use rather than toilet paper; the
bottle is filled with warm (NOT hot) water from Lochia Alba: tissue, whitish
the faucet and occasionally mixed with an
antiseptic or analgesic solution if ordered by the
provider or permitted by hospital policy. The Lochia Odor
contents are sprayed on the area following each
void/bowel movement to use rather than toilet
paper NCLEX: lochia should have “no odor” or “no foul
odor”
Teach mom to use Tuck’s Pads, which contain
witch hazel
Real world: virtually all lochia has an unpleasant
or at least a neutral odor associated with it and
Dermaplast is a topical spray, may be applied to
moms may be quick to describe it as “foul”
help control pain
It’s important for the nurse to assess the odor to
A strait cath may need to be used if mom doesn’t
eliminate subjective patient description of the
void within an acceptable time (usually 12
scent
hours postpartum)
A truly foul odor or a change in odor may be a
sign of infection
WARNING SIGNS: Perineal area is dark, moist,
and bloody, especially when combined urinary
stasis
Lochia Amount
B: Bowels Scant = 2.5 centimeters saturation *
Bowels Assessment Light = < 10 centimeters saturation
Bowels in shock- just moved into some strange
positions.
Moderate = > 10 centimeters saturation
Take a stool softener- don’t want ripping or the
episiotomy or trauma to the C-section incision Heavy = pad is completely saturated within 2
hours
Postpartum hemorrhage is clinically defined as a
L: Lochia pad saturated within 15-30 minutes
Lochia Assessment
NCLEX world: The pad is saturated within 15
minutes to be considered a hemorrhage situation.
In the real world, a pad that becomes saturated
within 30 minutes is a cause for additional
evaluation
Scant saturation in the immediate postpartum
period can be just as concerning as excessive
lochia production. Clots: up to cherry sized are
okay, peach or plum sized is not. Clots are the
most common in the morning following the first
void due to the saggy texture of the vagina,
which releases the lochia build-up from the night.
E: Episiotomy and Perineum
REEDA Assessment
R: Redness
E: edema
E: ecchymosis
D: discharge
A: approximation. Read more about REEDA
Perineal Area Assessment
• Pull the labia from front to back
• Check the episiotomy or areas of vaginal
tearing
• Look for hematoma formation- a
collection of blood in between tissue
• Look for hemorrhoids (developed during
pregnancy or during labor from the
pushing process)
Nursing Intervention. Always help mom get up
and ambulate the first two times after birth to
assess for mobility, reduce the risk of falling, and
prevent trauma to the perineum and C-section
incision
Hematoma Care
• Start with cold to stop the bleeding, once
it stops, begin warm
• Continue to monitor
If it get worse, that active area of bleeding
is non-healing and it will need to be
opened and the active area is discovered
and cauterized
• May not appear so much of an out-
pouching as much as a disfigurement
Hemorrhoids
Vasculature that forms a pouch
Color can match the skin of the rectal area and
may look more like a blood blister when irritated
Severe hemorrhoids appear as grape clusters
Dermaplast spray
Patient may not be aware, may only known that
business down there is not as usual
Nursing Interventions. Seitz Bath: a rotating fluid
that moves the water. May fit over the commode
or one can be performed with no special
equipment using the bathtub other than a
bathing ring. Turn tub on and allow drain to open
and use a ring for circulating water. It’s very
shallow and only bathes the perineal area.
H: Homan’s Sign
Assess for Signs of DVT by the Homan’s Sign
• A positive Homan’s sign is indicative of
DVT, although it’s not the most reliable
indicator
• All of the characteristic changes to
maternal clotting factors are higher than
any other point as the body prepares for
labor
• Combine this with being in bed,
especially if mom underwent a C-section,
and it’s easy to see why the postpartum
woman is at such a huge risk for DVT!
Performing the Homan’s Test
• Most commonly performed with the mom
in a supine position while laying in bed
Common Postpartum Assessment Findings
• The calf is flexed at a 90° angle
• The nurse manipulates the foot in a • The Taking In Phase. May be considered
dorsiflexion movement as a self-focused, re-lived experience.
• If pain is felt in the calf, the Homan’s Sign This is different from the maladaptive
is said to be positive • Taking Hold Phase. A little bit about the
mamma, a little about the baby. The
Signs of DVT
world appears to be revolved around the
• A sudden and unexplainable pain, baby and mamma as an unit
usually in the back of the leg or calf
Letting-In Phase. Mamma allows other people in
• Tachycardia and shortness of breath or
dyspnea (from decreased oxygenation
status)
Comparing Blues, Depression, and Psychosis
• Edema, redness, and warmth localized
over the area of the DVT (from the - Postpartum Blues. Usually
vascular build- up around the clot) occurs within 2-3 weeks.
Mamma may be sensitive,
such as crying during a
Preventing a DVT commercial, mamma may
view it as humorous in
• Dangle at the side of the bed within 6 hindsight
hours - Postpartum Depression
• Stand up within 8 hours (PPD). When the blues
• Encourage ambulation at first and moves to the point where
independent walking when ready momma can’t care for
herself or the baby
- Postpartum Psychosis. A
Potential Complications of a DVT severe form of depression
that warrants immediate
Pulmonary embolism (PE) occurs when a clot intervention. When mamma
breaks way from the leg area and travels to the harms herself or the
lungs neonate or considers doing
A PE is medical emergency! so. Typically is predicated by
depressive episodes
E: Emotional Status
Nursing Interventions
Emotional Status and Bonding Patterns
The patient should fill out a form to assess
Fluctuations in estrogen levels are blamed for the emotional risks. The form will ask if the patient
emotional roller-coaster that many moms has a history of PPD or depression not associated
experience after birth with pregnancy
High levels of stress, increased responsibility, There’s always a social worker available in the
and sleep deprivation exacerbate this event that the patient is acting strangely.
Bonding refers to the interactions between the The nurse may need to fill out a document such
mamma and baby as a Risk Assessment Form
Caregiving of self and baby is an indicator of Natural Family Planning
emotional status
 • Avoiding pregnancies by observation of
natural signs and symptoms of the fertile
and infertile phase of the menstrual
cycle.
Lactational amenorrhea method (LAM)
• Natural effect of breastfeeding on the
mother’s fertility, that there is a delay in
the return of fertility after childbirth.
• Breastfeeding suppresses the secretion
of gonadotropin-releasing hormone by
the hypothalamus, thereby inhibiting
pituitary secretion of gonadotropin and
development of ovarian follicle.
FAB methods
• Based on scientific analysis of the fertile
time in the woman’s menstrual cycle.
1. Billing’s ovulation method
(BOM) – cervical mucus
method, fertility management
based on cervical mucus, the
body’s natural sign of fertility.
2. Basal body temperature (BBT) –
hormonal changes observed
around the time of ovulation
3. Symptothermal method
4. Standard Days Method (SDM)
5. Two-Day Method – uses
cervical secretions as an
indicator of fertility
Artificial Family Planning
1. Combined oral contraceptives (COCs) –
simply called pills, preparations that
contain hormones similar to the
woman’s natural hormones (estrogen
and progesterone)
2. Depot medroxyprogesterone acetate –
progestin-only preparation injected IM
every 3 months.
3. Intrauterine device (IUD) – small plastic
or metal device inserted inside a
woman’s uterus to prevent pregnancy
4. Barrier methods – use of devices that
mechanically or chemically prevent
fertilization
5. Permanent methods – vasectomy for the
male and bilateral tubal ligation (BTL) for
female
a. Vasectomy – vas deferens is tied
and cut or blocked
b. Bilateral tubal ligation (BTL) –
cutting or blocking the two fallopian
tubes
Newborn Screening
• Procedure to find out if a baby has a
congenital metabolic disorder that may
lead to mental retardation or even death
Newborn screening
• Obtained through a heel prick. Few
drops of blood are taken from the baby’s
heel, blotted on a special absorbent filter
card then sent to NSC
Newborn hearing screening
• Health care practitioners obligation to
inform the parents or legal guardian of
the newborn of the availability, nature,
and benefits of hearing loss screening
among newborns 3 months old and
below
Anthropometric Measures
Measurement of physical dimensions
and gross composition of the body
• Weight-for-age – reflects body weight
relative to the child’s age
• Length/height-for-age – reflects attained
growth in length or height in relation to
child’s age at a given time
• Mid-upper arm circumference (MUAC)
BCG Vaccine
BCG, or bacille Calmette-Guerin, is a vaccine
for tuberculosis (TB) disease. Many foreign-
born persons have been BCG-vaccinated.
BCG is used in many countries with a high
prevalence of TB to prevent childhood
tuberculous meningitis and miliary disease.
However, BCG is not generally
recommended for use in the United States
because of the low risk of infection with
Mycobacterium tuberculosis, the variable
effectiveness of the vaccine against adult
pulmonary TB, and the vaccine’s potential
interference with tuberculin skin test
reactivity. The BCG vaccine should be
considered only for very select persons who
meet specific criteria and in consultation with
a TB expert.
Heptitis B Vaccine
The hepatitis B vaccine is an injection (or
shot) that is generally given in the arm and as
a three-dose series on a 0, 1, and 6-month
schedule. The recommended doses depend
on the vaccine brand and the person's age.
1st Shot - At any given time, but newborns
should receive this dose in the delivery room
2nd Shot - At least one month (or 28 days)
after the 1st shot
3rd Shot - At least 4 months (16 weeks) after
the 1st shot (and at least 2 months after the
2nd shot). Infants should be a minimum of 24
weeks old at the time of the 3rd shot.
Vitamin K Vaccine
Vitamin K helps the blood to clot and prevents
serious bleeding. In newborns, vitamin K
injections can prevent a now rare, but
potentially fatal, bleeding disorder called
‘vitamin K deficiency bleeding’ (VKDB), also
known as ‘haemorrhagic disease of the
newborn’ (HDN).
Crede’s Prophylaxis
-installation of 1% silver nitrate solution into the
conjunctiva of newborns to prevent opthalmia
neonatorum
Ophthalmia neonatorum (ON), also called
neonatal conjunctivitis, is an acute, mucopurulent
infection occurring in the first 4 weeks of
life,2 affecting 1.6% to 12% of all
newborns,3,4 caused by chemical, bacterial, or
viral processes.
Newborn Reflexes
What reflexes should be present in a
newborn?
Reflexes are involuntary movements or actions.
Some movements are spontaneous and occur as
part of the baby's normal activity. Others are
responses to certain actions. Healthcare
providers check reflexes to determine if the brain
and nervous system are working well. Some
reflexes occur only in specific periods of
development. The following are some of the
normal reflexes seen in newborn babies:
Rooting reflex
This reflex starts when the corner of the baby's
mouth is stroked or touched. The baby will turn
his or her head and open his or her mouth to
follow and root in the direction of the stroking.
This helps the baby find the breast or bottle to
start feeding. This reflex lasts about 4 months.
Suck reflex
Rooting helps the baby get ready to suck. When
the roof of the baby's mouth is touched, the baby
will start to suck. This reflex doesn't start until
about the 32nd week of pregnancy and is not fully
developed until about 36 weeks. Premature
babies may have a weak or immature sucking
ability because of this. Because babies also have
a hand-to-mouth reflex that goes with rooting and
sucking, they may suck on their fingers or hands.
Moro reflex
The Moro reflex is often called a startle reflex.
That’s because it usually occurs when a baby is
startled by a loud sound or movement. In
response to the sound, the baby throws back his
or her head, extends out his or her arms and legs,
cries, then pulls the arms and legs back in. A
baby's own cry can startle him or her and trigger
this reflex. This reflex lasts until the baby is about
2 months old.
Tonic neck reflex
When a baby's head is turned to one side, the arm
on that side stretches out and the opposite arm
bends up at the elbow. This is often called the
fencing position. This reflex lasts until the baby is
about 5 to 7 months old.
Grasp reflex
Stroking the palm of a baby's hand causes the
baby to close his or her fingers in a grasp. The
grasp reflex lasts until the baby is about 5 to 6
months old. A similar reflex in the toes lasts until
9 to 12 months.
Stepping reflex
This reflex is also called the walking or dance
reflex because a baby appears to take steps or
dance when held upright with his or her feet
touching a solid surface. This reflex lasts about 2
months.
Fetal Circulation
The blood that flows through the fetus is actually
more complicated than after the baby is born
(normal heart). This is because the mother (the
placenta) is doing the work that the baby’s lungs
will do after birth.
The placenta accepts the bluest blood (blood
without oxygen) from the fetus through blood
vessels that leave the fetus through the umbilical
cord (umbilical arteries, there are two of them).
When blood goes through the placenta it picks up
oxygen and becomes red. The red blood then
returns to the fetus via the third vessel in the
umbilical cord (umbilical vein). The red blood that
enters the fetus passes through the fetal liver and
enters the right side of the heart.
The red blood goes through one of the two extra
connections in the fetal heart that will close after
the baby is born.
The hole between the top two heart chambers
(right and left atrium) is called a patent foramen
ovale (PFO). This hole allows the reddest blood
to go from the right atrium to left atrium and then
to the left ventricle and out the aorta. As a result
the blood with the most oxygen gets to the brain.
Blood coming back from the fetus’s body also
enters the right atrium, but the fetus is able to
send this blue blood from the right atrium to the
right ventricle (the chamber that normally pumps
blood to the lungs). Most of the blood that leaves
the right ventricle in the fetus bypasses the lungs • Redness
through the second of the two extra fetal • Warmer than the skin around it
connections known as the ductus arteriosus. • Tender to the touch
• Drainage or bad odor
The ductus arteriosus sends the bluer blood to • When the cord falls off, you might notice
the organs in the lower half of the fetal body. This a small pink area in the bottom of the
also allows for the bluest blood to leave the fetus belly button. This is expected, and
through the umbilical arteries and get back to the normal skin will grow over it.
placenta to pick up oxygen. • Do not pull the cord off yourself, even if it
is hanging on just by a thread.
Since the patent foramen ovale and ductus
arteriosus are normal findings in the fetus, it is
APGAR Score
impossible to predict whether or not these
connections will close normally after birth in a The Apgar score is a test given to newborns soon
normal fetal heart. These two bypass pathways in after birth. This test checks a baby's heart rate,
the fetal circulation make it possible for most muscle tone, and other signs to see if extra
fetuses to survive pregnancy even when there medical care or emergency care is needed.
are complex heart problems and not be affected
until after birth when these pathways begin to What Does "Apgar" Mean?
close.
Apgar stands for
Cord Care "Appearance, Pulse, Grimace, Activity,
and Respiration."
A clamp is placed on the umbilical cord before it
is cut. The clamp can be removed when the cord
In the test, five things are used to check a baby's
has dried, usually before your baby leaves the
health. Each is scored on a scale of 0 to 2, with 2
hospital.
being the best score:
The cord begins to dry and shrink. The color
changes from pale to dark brown and it may look
1. Appearance (skin color)
like a scab. The cord falls off by itself in about two
2. Pulse (heart rate)
to three weeks.
3. Grimace response (reflexes)
4. Activity (muscle tone)
Because the umbilical cord may be a place for
5. Respiration (breathing rate and effort)
infection to enter your baby's body, it is important
Doctors, midwives, or nurses add up these five
to care for it properly.
factors for the Apgar score. Scores are between
10 and 0. Ten is the highest score possible, but
• When the umbilical cord becomes wet few babies get it. That's because most babies'
with urine, gently clean the base of the hands and feet remain blue until they have
umbilical cord with mild soap and warm
warmed up.
water. Rinse the area and pat it dry.
• Keep the belly button area dry. You may
need to fold the top of the diaper down.
• Change your baby’s diaper frequently,
with every feeding. A wet diaper on the
cord keeps the cord from drying and
increases the risk of infection.
• Do not bathe your baby in a tub or sink
until the cord falls off. You may give your
baby a sponge bath until then.
Call your baby’s doctor for the following signs of
an infection in the belly button:
 The Ballard score is based on the neonate's mmHg diastolic may indicate the
physical and neuromuscular maturity and can be development of postpartal pregnancy-
used up to 4 days after birth (in practice, the induced hypertenstion, an unusual but
Ballard score is usually used in the first 24 serious complication of the puerperium.
hours). The neuromuscular components are
more consistent over time because the physical
components mature quickly after birth. However, Vital Signs of the Newborn
the neuromuscular components can be affected
by illness and drugs (eg, magnesium l Temperature - the temperature of newborns
sulfate given during labor). Because the Ballard is about 37.2°C at birth because they have
score is accurate only within plus or minus 2 been confined in an internal body organ. The
weeks, it should be used to assign gestational temperature falls almost immediately to
age only when there is no reliable obstetrical below normal because of heat loss and
information about the estimated date of immature temperature-regulating
confinement or there is a major discrepancy mechanims. The temperature of birthing
between the obstetrically defined gestational rooms, approximately 21° to 22°C, can add
age and the findings on physical examination. to this loss of heat.

l Pulse - the heart rate of a fetus in utero

A baby who scores a 7 or above on the test is
considered in good health. A lower score does not
mean that your baby is unhealthy. It means that
your baby may need some immediate medical
care, such as suctioning of the airways or oxygen
to help him or her breathe better. Perfectly Vital Signs of the Mother
healthy babies sometimes have a lower-than- Vital sign changes in the postpartum period
usual score, especially in the first few minutes reflect the internal adjustments that occur as a
after birth. woman’s body returns to its prepregnant state.
• Temperature - a woman may show a
A slightly low score (especially at 1 minute) is
slight increase in temperature during the
common, especially in babies born:
first 24 hours after birth because of
dehydration that occurred during labor.
• after a high-risk pregnancy Any woman whose oral temperature
• through a C-section rises above 38°C, excluding the first 24-
• after a complicated labor and delivery hour period, is considered by criteria of
• prematurely the Joint Commission on Maternal
Welfare to be febrile.
At 5 minutes after birth, the test is given again. If • Pulse - a woman’s pulse rate during the
a baby's score was low at first and hasn't postpartal period is usually slightly lower
improved, or there are other concerns, the than normal. This increased stroke
doctors and nurses will continue any necessary volume reduces the pulse rate to
medical care. The baby will be monitored closely. between 60 and 70 beats per minute.
• Blood Pressure - blood pressure should
also be monitored carefully during the
postpartal period, because a decrease in
Ballard Score this can indicate bleeding. In contrast, an
elevation above 140 mmHg systolic or 90
averages 120 to 160 beats per minute.
Immediately after birth, as the newborn
struggles to initiate respirations, the heart
rate may be as rapid as 180 bpm. Within 1
hour after birth, as the newborn settles down
to sleep, the heart rate stabilizes to an
average of 120 to 140 bpm.
l Respiration - the respiratory rate of a
newborn in the first few minutes of life may
be as high as 80 breaths per minute. This
rate settles to an average of 30 to 60 breaths
per minute when the newborn is at rest.
l Blood Pressure - the blood pressure of a
newborn is approximately 80/46 mmHg at
birth. By the 10th day, it rises to about 100/50
mmHg.
Phototherapy
An infant’s liver processes little bilirubin in utero
because the mother’s circulation does this for an
infant. With birth, exposure to light apparently
triggers the liver to assume this function.
Additional light supplied by phototherapy appears
to speed the conversion potential of the liver. In
phototherapy, an infant is continuously exposed
to specialized light such as quartz halogen, cool
white daylight, or special blue fluorescent light.
The lights are placed 12 to 30 inches above the
newborn’s bassinet or incubator. Specialized
fiberoptic light systems incorporated into a
fiberoptic blanket also have been developed and
are ideal for home care. The infant is undressed
except for a diaper so as much skin surface as
possible is exposed to the light. Term newborns
are generally schedule for phototherapy when the
total serum bilirubin level rises to 10 to 12 mg/dL
at 24 hours of age; preterm infants may have
treatment begun at levels lower than this.
Continuous exposure to bright lights this way may
be harmful to a newborn’s retina, so the infant’s
eyes must always be covered while under
bilirubin lights. Eye dressings or cotton balls can
be firmly secured in place by an infant mask.
Perineal Care
l Perineal Hygiene - most women have an
increased vaginal discharge during
pregnancy and may desire to cleanse with a
douche. Douching is contraindicated during
pregnancy. The force of irrigating fluid could
cause it to enter the cervix and lead to
infection. In addition, douching alters the pH
level of the vagina, leading to an increased
risk of bacterial growth.
l Perineal Cleaning - to remove vaginal or
rectal secretions and prepare the cleanest
environment for the birth of the baby, clean
the perineum with a warmed antiseptic such
as Iodophor (cold solution causes cramping)
and then rinse it with a designated solution
1. People pass through stages in a specific order,
before birth, according to the policy of the
physician, nurse-midwife, or agency. Always
clean from the vagina outward, so that
2. Stages are related to age.
microorganisms are moved away from the
3. Development is discontinuous, with qualitatively
vagina and not toward it, using a clean
compress for each stroke. Be sure and
include a wide area (vulva, upper inner
thighs, pubis, and anus).
l Perineal Care - before beginning perineal
care, wash your hands and pull on clean
gloves to prevent the risk of infection
transmission. Place a plastic-covered pad
under the woman’s buttocks to protect the
bed during the procedure. With the woman
lying in a supine position, remove the
perineal pad from the front to back; the
direction is important to prevent the portion
of the pad that was over her rectal area from
sliding forward to contaminate the vaginal
opening. Perineal care is a clean but not
sterile procedure. Agencies differ to what
type of cleansing will be done. If actual
washing is to be done, use a clean gauze
square or a clean portion of a washcloth with
soap and water for each stroke, always
washing it front to back, from the pubis
toward the rectum. Rinse the area in the
same manner and dry it.
Many babies with low scores are perfectly healthy
and do just fine after adjusting to life outside the
womb.
If your doctor or midwife is concerned about your
baby's score, he or she will let you know and will
explain how your baby is doing, what might be
causing problems (if any), and what care is being
given.
THEORIES OF DEVELOPMENT
Development is the series of age-related
changes that happen over the course of a life
span. Several famous psychologists,
including Sigmund Freud, Erik Erikson, Jean
Piaget, and Lawrence Kohlberg, describe
development as a series of stages. A Stage is a
period in development in which people exhibit
typical behavior patterns and establish particular
capacities. The various stage theories share
three assumptions:
with each stage building on capacities developed
in the previous stage.
different capacities emerging in each stage.
Sigmund Freud’s Theory of Personality
The Austrian psychiatrist Sigmund Freud first
described personality development as a series of
stages. Of these stages, Freud believed that early
childhood was the most important. He believed
that personality developed by about the age of
five.
Erik Erikson’s Theory of Psychosocial
Development
Like Freud, Erik Erikson believed in the
importance of early childhood. However, Erikson
believed that personality development happens
over the entire course of a person’s life. In the
early 1960s, Erikson proposed a theory that
describes eight distinct stages of development.
According to Erikson, in each stage people face
new challenges, and the stage’s outcome To some degree, personality is stable, because
depends on how people handle these challenges. childhood experiences influence people even as
Erikson named the stages according to these adults. However, personality also changes and
possible outcomes: develops over the life span as people face new
Stage 1: Trust vs. Mistrust challenges. The problem with Erikson’s theory, as
with many stage theories of development, is that
In the first year after birth, babies depend he describes only a typical pattern. The theory
completely on adults for basic needs such as doesn’t acknowledge the many differences
food, comfort, and warmth. If the caretakers meet among individuals.
these needs reliably, the babies become attached
and develop a sense of security. Otherwise, they
may develop a mistrustful, insecure attitude. Erikson’s Theory of Psychosocial
Stage 2: Autonomy vs. Shame and Doubt Development
Between the ages of one and three, toddlers start Conflict Typical AgeMajor
to gain independence and learn skills such as StageFaced Range Challenge(S)
toilet training, feeding themselves, and dressing
themselves. Depending on how they face these Having basic
challenges, toddlers can develop a sense of needs met,
Trust vs.First year ofattaching to
autonomy or a sense of doubt and shame about
themselves. 1 mistrust life people
Stage 3: Initiative vs. Guilt Autonomy
Between the ages of three and six, children must vs. shame Gaining
learn to control their impulses and act in a socially 2 and doubt 1–3 years independence
responsible way. If they can do this effectively,
children become more self- confident. If not, they Acting in a
may develop a strong sense of guilt. socially
Stage 4: Industry vs. Inferiority Initiative vs. responsible
Between the ages of six and twelve, children 3 guilt 3–6 years way
compete with peers in school and prepare to take
on adult roles. They end this stage with either a Competing
with peers,
sense of competence or a sense of inferiority.
Industry vs. preparing for
Stage 5: Identity vs. Role Confusion
4 inferiority 6–12 years adult roles
During adolescence, which is the period between
puberty and adulthood, children try to determine
Identity vs.
their identity and their direction in life. Depending
role Determining
on their success, they either acquire a sense of
5 confusion Adolescenceone’s identity
identity or remain uncertain about their roles in
life. Developing
Stage 6: Intimacy vs. Isolation Intimacy vs.Early intimate
In young adulthood, people face the challenge of 6 isolation adulthood relationships
developing intimate relationships with others. If
they do not succeed, they may become isolated Generativity
and lonely. vs. self-Middle Being
Stage 7: Generativity vs. Self-Absorption 7 absorption adulthood productive
As people reach middle adulthood, they work to
Integrity vs. Evaluating
become productive members of society, either
through parenting or through their jobs. If they fail, 8 despair Old age one’s life
they become overly self-absorbed. Piaget’s Theory of Cognitive Development
Stage 8: Integrity vs. Despair While conducting intelligence tests on children,
In old age, people examine their lives. They may Swiss psychologist Jean Piaget began to
either have a sense of contentment or be investigate how children think. According to
disappointed about their lives and fearful of the
Piaget, children’s thought processes change as
future. they mature physically and interact with the world
Erikson’s theory is useful because it addresses around them. Piaget believed children
both personality stability and personality change. develop Schema, or mental models, to represent
the world. As children learn, they expand and
modify their schema through the processes of
assimilation and
accommodation. Assimilation is the broadening
of an existing schema to include new
information. Accommodation is the modification
of a schema as new information is incorporated.
Example: Suppose a young boy knows his pet
parrot is a bird. When he sees a robin outside and
calls it a bird too, he exhibits assimilation, since
he broadened his bird schema to include
characteristics of both parrots and robins. His bird
schema might be “all things that fly.” Now
suppose a bat flaps out at him one night and he
shrieks, “Bird!” If he learns it was a bat that
startled him, he’ll have to modify his bird schema
to “things that fly and have feathers.” In modifying
his definition, he enacts accommodation.
Piaget proposed that children go through four
stages of cognitive development:
Stage 1: Sensorimotor Period
In this stage, which lasts from birth to roughly two
years, children learn by using their senses and
moving around. By the end of the sensorimotor
period, children become capable of Symbolic
Thought, which means they can represent
objects in terms of mental symbols. More
important, children achieve object permanence in
this stage. Object Permanence is the ability to
recognize that an object can exist even when it’s
no longer perceived or in one’s sight.
Example: If a three-month-old baby sees a ball,
she’ll probably be fascinated by it. But if someone
hides the ball, the baby won’t show any interest
in looking for it. For a very young child, out of sight
is literally out of mind. When the baby is older and
has acquired object permanence, she will start to
look for things that are hidden because she will
know that things can exist even when they can’t
be seen.
Stage 2: Preoperational Period
This stage lasts from about two to seven years of
age. During this stage, children get better at
symbolic thought, but they can’t yet reason.
According to Piaget, children aren’t capable of
conservation during this stage. Conservation is
the ability to recognize that measurable physical
features of objects, such as length, area, and
volume, can be the same even when objects
appear different.
Example: Suppose a researcher gives a three-
year-old girl two full bottles of juice. The girl will
agree that they both contain the same amount of
juice. But if the researcher pours the contents of
one bottle into a short, fat tumbler, the girl will
then say that the bottle has more. She doesn’t
realize that the same volume of juice is conserved
in the tumbler.
Piaget argued that children are not capable of
conservation during the preoperational stage
because of three weaknesses in the way they
think. He called these
weaknesses Centration, Irreversibility,
and Egocentrism:
• Centration is the tendency to focus on one
aspect of a problem and ignore other key aspects.
In the example above, the three-year-old looks
only at the higher juice level in the bottle and
ignores the fact that the bottle is narrower than
the tumbler. Because of centration, children in the
preoperational stage cannot carry
out Hierarchical Classification, which means
they can’t classify things according to more than
one level.
• Irreversibility is the inability to mentally reverse
an operation. In the example, the three-year-old
can’t imagine pouring the juice from the tumbler
back into the bottle. If she poured the juice back,
she’d understand that the tumbler holds the same
amount of liquid as the bottle.
• Egocentrism is the inability to take someone
else’s point of view. Animism, or the belief that
even inanimate objects are living, results from
egocentrism. Children assume that since they are
alive, all other things must be too.
Talking Tables And Dancing Dishwashers
Animism explains the popularity of children’s
movies featuring characters such as talking
vegetables or singing candlesticks. Young
children can readily believe that objects around
them are alive, which means they can be
entertained by stories involving living objects.
Children and adolescents past the age of seven
generally lose interest in heroic toasters and
prefer stories about people.
Stage 3: Concrete Operational Period
From the age of seven to about eleven, children
become capable of performing mental operations
or working through problems and ideas in their
minds. However, they can perform operations
only on tangible objects and real events. Children
also achieve conservation, reversibility, and
decentration during this stage:
• Reversibility is the ability to mentally reverse
actions.
• Decentration is the ability to focus
simultaneously on several aspects of a problem.
Furthermore, children become less egocentric
during this stage as they start to consider
simultaneously different ways of looking at a
problem.
Stage 4: Formal Operational Period
In this stage, which begins around eleven years
of age and continues through adulthood, children
become capable of applying mental operations to
abstract concepts. They can imagine and reason
about hypothetical situations. From this point on,
people start to think in abstract, systematic, and
logical ways.
Critiques of Piaget’s Theories
Although Piaget made important contributions to
the research on cognitive development, his
theory has come under attack for several
reasons:
• Recent research has shown that he greatly
underestimated children’s capabilities. For
example, researchers have shown that babies
achieve object permanence much sooner than
Piaget said they do.
• Children sometimes simultaneously develop
skills that are characteristic of more than one
stage, which makes the idea of stages seem less
viable.
• Piaget ignored cultural influences. Research has
shown that children from different cultures tend to
go through Piaget’s stages in the same order, but
the timing and length of stages vary from culture
to culture.
• Some people never develop the capacity for
formal reasoning, even as adults.
Piaget’s Theory of Cognitive Development
Important
Stage Age Features
First twoObject
years ofpermanence,
1Sensorimotor life symbolic thought
Centration,
irreversibility,
egocentrism, and
2Preoperational 2–7 years animism
• People often show the reasoning characteristic of
Concrete Reversibility,
3operational 7–11 years decentration,
decrease in
egocentrism,
conservation
Formal 11 through
4operational adulthood Abstract thought
Kohlberg’s Theory of Moral Development
Lawrence Kohlberg focused on Moral
Reasoning, or why people think the way they do
about right and wrong. Influenced by Piaget, who
believed that moral reasoning depends on the
level of cognitive development, Kohlberg
proposed that people pass through three levels of
moral development. He divided each level into
two stages.
Level 1: The Preconventional Level
At this level, children ascribe great importance to
the authority of adults. For children in the first
stage of this level, an action is wrong if it’s
punished, whereas in the second stage, an action
is right if it’s rewarded.
Level 2: The Conventional Level
In the next level, children value rules, which they
follow in order to get approval from others. In the
first stage of this level, children want the approval
only of people who are close to them. In the
second stage, children become more concerned
with the rules of the broader society.
Level 3: The Postconventional Level
In the final level, people become more flexible
and consider what’s personally important to them.
In the first stage of this level, people still want to
follow society’s rules, but they don’t see those
rules as absolute. In the second stage, people
figure out right and wrong for themselves, based
on abstract ethical principles. Only a small
proportion of people reach this last stage of moral
reasoning.
Critiques of Kohlberg’s Theories
Research supports key parts of Kohlberg’s
theory. People do tend to progress in order
through Kohlberg’s stages, and cognitive and
moral development do affect each other.
However, critics of Kohlberg’s theory have two
main concerns:
several different levels simultaneously. For
instance, in one situation, a person might reason
as if he is at a conventional stage, and in another
situation, he might use reasoning typical of a
postconventional stage.
• Kohlberg’s theory of moral development favors
cultures that value individualism. In other
cultures, highly moral people may base their
reasoning on communal values rather than
abstract ethical principles.

Kohlberg’s Theory of Moral Development

What Determines
Level StageRight And Wrong
Punishment by
1.Preconventional 1 adults
2 Reward by adults
Rules set by close
2.Conventional 3 people
4 Rules set by society
Rules set by society,
judged by what’s
personally
3.Postconventional5 important
Rules based on
abstract ethical
6 principles