MATERNAL AND CHILD HEALTH

It refers to mother and child relationship to one another and consideration of the entire family as well as the nature of
socioeconomic environment as framework of the patient.

Goals
1. To ensure that every expectant and nursing mother maintains good health, learns the art of child care, has a
normal delivery and bears healthy children.

2. That every child, wherever possible lives and grows up in a family unit with love and security, in healthy
surroundings, receives adequate nourishment, health supervision and efficient medical attention, and is taught
the elements of healthy living.

The overall goal can be simply stated as “to ensure children are not only physically, mentally and emotionally well
born but also born well”

Philosophy
 Pregnancy, labor and delivery and puerperium are part of the continuum of the total life cycle.
 Personal, cultural and religious attitudes and beliefs influence the meaning of pregnancy for individuals to make
each experience unique.
 Maternal-child nursing is family centered. The father of the child is as important as the mother.

MATERNAL CARE
PRENATAL CARE
Objective
To reach all pregnant women, to give sufficient care to ensure a healthy pregnancy and the birth of a full term
healthy baby.

Classifications of Pregnant women

Normal patient
Following the initial evaluation they will be given healthy instructions and counseling.

Patients with serious or potential serious complications

Following the initial evaluation, these patients shall be referred to the most skilled source of medical and
hospital care.

Patient with mild complications

A thorough evaluation of the needs of the patients with mild complications will determine the frequency of
follow-up of these cases by the rural health unit or city health clinic.

High risk Pregnancy

> 18 y/o <35 y/o
Less than 4’11
Malnourish/ obese
More than 5 pregnancies
Pregnancies within 2 years
History of bleeding, Miscarriage/abortion
Abnormal presentation
Endocrine or cardiovascular problem
Nursing Care during Pregnancy
All RHUs and BHS should have a master list of pregnant women in their respective catchment areas. BHWs,
Traditional Birth Attendants (TBAs) or hilots and other community members concerned with maternal health or
community health, should be encouraged to help identify pregnant women in the community and motivate them to
submit prenatal care.
The Home Based Mother’s Record (HBMR) shall be used when rendering prenatal care as a guide in the
identification of risk factors, danger signs, and to be able to do appropriate measures.
In areas where licensed health personnel are not available, BHW or TBA shall be trained to do regular prenatal
visits using the Home Based Mother’s Record (HBMR) to identify risks/danger signs, and to make correct referral to
health facilities.

PRENATAL PERIOD OF PREGNANCY

VISITS
1ST visit As early as pregnancy as possible before four months or during first
trimester
2nd visit During second trimester
3rd visit During third trimester
Every two After 8th month of pregnancy until delivery
weeks

Standard prenatal examination

 Weight
 Height
 Blood pressure
 Examination of eyes and palms of the hands
 Abdominal examination
 Face, hands and lower extremities
 Examination of the breast and neck

Basic Prenatal Delivery

 History taking
 Physical examination
 Treatment of disease
 Tetanus toxoid immunization
 Iron supplementation
 Health education
 Laboratory examination
 Oral dental examinations

Micronutrient supplementation
Vitamins Dosage Schedule of giving Remarks
th
Vitamin 10,000 IU Twice a week starting on the 4 Do not give before the 4th month of
A month of pregnancy pregnancy- it might cause congenital
problem in the baby
Iron 600mg/400ug tablet Shall be given from the 5th month of
(100-200mg) pregnancy up to 2 months
postpartum (210 days)

IMPORTANCE OF VITAMIN A
  Necessary for growth and development of skeletal and soft tissues through its effect upon protein synthesis and
differentiation of bone cells.
 For good vision
 Integrity of the skin

IMPORTANCE OF IRON
 Carrier of oxygen needed for cellular respiration
 Necessary for hemoglobin formation
 Growth and development

 In goiter endemic areas, all pregnant women shall be given one iodized oil capsule every year.
 In malaria infested areas, all pregnant women shall be given prophylaxis in the form of chloroquine (150mg/tab),
2 tablets per week for the whole duration of pregnancy

Nursing Care during Child Birth

“All birth attendants shall ensure clean and safe deliveries at home or at the facilities”

AT HOME

Home deliveries for normal pregnancies attended by licensed health personnel shall be encouraged. Trained
hilots (TBAs) may be allowed to attend home deliveries only in the following circumstances:
 In areas where there are no licensed health personnel or maternal care
 When at that time of delivery, such personnel is not available

At risks pregnancies and mothers who develop obstetrical complications during labor should be immediately referred to
the nearest facility or institution with capability to manage obstetric emergencies but obstetric first aid should be
administered first before transport.

Actively participating but untrained birth attendants (hilots) should be identified, trained and supervised by a personnel
of the nearest BHS/RHU trained on Maternal Care.

Qualified for home delivery:

 full term
 Less than 5 pregnancies
 cephalic presentation
 without existing disease such as diabetes, bronchial asthma, heart disease, hypertension, goiter, tuberculosis
and severe anemia
 No history of complications like hemorrhage during previous deliveries.
 No previous caesarian section
 Imminent deliveries
 In case of imminent deliveries by risk mothers they should still referred to the appropriate level of health
facility if the risk remains after the delivery but if the risk condition has disappeared then no referral is needed.
 No premature rupture of membranes
 abdominal enlargement is appropriate for age of gestation

HOME DELIVERY KIT

 2 pairs of clamps (or string)
 a pair of scissors (or blade)
 Antiseptic (alcohol/ povidine)
 soap and hand brush
 Clean towel/ piece of cloth
 Flashlight
  BP apparatus

HOME DELIVERY KIT (optional)

 plastic sheet
 suction bulb
 weighing scale
 ophthalmic ointment
 sterile gloves
 Thermometer

Pointers during home deliveries

The three cleans
1. Clean hands
2. Clean surface
3. Clean cord
 Safe delivery- attendants must be aware of early signs of complication to be able to refer properly and timely

Guide for Home Delivery

For registered patients (get the ff. info)
1. Time when regular pains started
2. Whether bag of water ruptured or not
3. Presence or absence of vaginal discharge, bleeding etc.
4. Fetal movements are felt by mother or not
5. Unusual symptoms such as bleeding, headache
6. Whether mother moved her bowels and has urinated

Guide for Home Delivery

For unregistered patients (get the ff. info)
1. Get the same info as those foe registered patients
2. Get medical and obstetrical history

PREPARATION FOR DELIVERY

First Stage
1. Wash hands with soap and water, prepare room and bed; set up the things needed for delivery
2. Explain to mother the course of labor and reasons for procedures
3. Palpate abdomen to determine the presentation
4. Listen to fetal heartbeat
5. Take blood pressure, temperature and pulse
6. Examination for edema
7. Examine the vulva to determine if there is slow, bleeding or bulging
8. Note interval, duration and intensity of uterine contraction
9. Empty bladder when full
10. Put Kelly pad or newspaper under mother
11. Give enema if indicated
12. If mother has not taken a bath, scrub from waist to knee with soap and water
13. Give soft diet during early labor

Second Stage
1. Cleanse vulva with soap and water/ mild disinfectant
2. Put on mask and scrub hands with clean brush in soap and water
3. Put on clean gown or apron
4. Wear sterile rubber gloves
5. Set up sterile area
 6. Line Kelly pad with clean dressing towel
7. As the head crowns encourage the mother to bear down slowly to avoid sudden expulsion of the head and
prevent extensive laceration of the perineum.
8. Protect the perineum; do not press the head of the fetus to avoid injury of the brain
9. Grease hand on either side between extended fingers and palms of hands. Feel to determine if the cord is
around the neck. If it is loose, slip it over the shoulder or head. If it is tight, clamp it with clamps and cut in
between. Wipe mouth nose with dry gauze.
10. As head restitutes and rotates, give steady, gentle downward pull to allow the anterior shoulder to go under
the symphysis pubis, slowly give upward lift to allow the posterior shoulder to slide over the perineum.
11. After the trunks and legs are expulsed. Lay the baby on his/her right with a clean receiver on the abdomen of
the mother if he/she breaths readily. If not with face downward, hold up by the feet, remove mucus from the
throat with care as indicated.

Third Stage
1. Mother
a. Place placenta basin against the perineum and lay maternal end of the cord with the clamp in the basin.
b. Do not interfere with the delivery of the placenta. When signs of separation is present, apply fundal pressure
contraction and deliver the placenta.
c. Signs and symptoms of placental separation
1. Lengthening of the cord
2. Gushing of blood
3. Raising of the fundus 2 fingers above globular in shape
d. Note the amount of blood loss
e. Watch for hemorrhage at least one hour after delivery
f. Instruct member of the family to watch mother for hemorrhage for at least two hours just after the nurse or
midwife has left the house after delivery. The first two hours after delivery are dangerous due to atony of the uterus
g. Reiterate encouragement family planning

2. The Baby
a. As soon as the baby is breathing normally and pulsation of the cord ceases, clamp the cord with 2 clamps and
cut between them.
b. Wipe eyes of baby with cotton (from inner canthus, outward) and instill 10% ophthalmic ointment
c. Place baby in receiving blanket and have helper keeps him warm in a safe place.
d. Examine baby for trauma and malformation
e. Take and record weight, length, temperature and general condition
f. Dress cord aseptically
g. Spread vernix caseosa
h. Put dress of baby and keep him warm
i. Fill up birth certificate

APGAR SCORING
Apgar score provides a valuable index for evaluation of newborn infant’s condition at birth. It should be done at
1 minute and 5 minute after delivery.
Neonatal examinations are done right after delivery, after the baby is cleaned, at ages 1-3 days and at one
month age.
 CRITERIA 0 1 2
HEAT RATE Absent Slow < 100bpm > 100bpm
RESPIRATORY Absent Weak cry, minimal cry Good, strong/vigorous
EFFORT cry
MUSCLE TONE Flaccid/ limp Minimal flexion Active motion
REFLEX No response Grimace, weak Good, strong/vigorous
(IRRITABILITY) cry
COLOR Blue/ pale all over Extremities are pale/bluish Completely pink

APGAR SCORING
0-3 poor Immediate resuscitation
4-6 fair condition Oxygenation and suctioning
7-10 Good Routine care

COMPLICATION OF LABOR
All health personnel and hilots should be well versed in the early recognition of a complicated labor.
The early recognition of prolonged labor is particularly important. It is almost certain that many infant deaths
occurring during the first 48 hrs. of life, and labelled as asphyxia and “congenital debility” are due to effects of
intrapartum anoxia and could have been averted by transfer of the mother to the hospital or clinic where she
could be admitted for delivery.

 Hemorrhage is the major cause of maternal death.

 High risks labors should be hospitalized at the onset of labor. These include:
• Antepartum hemorrhage
• Abnormal presentation
• Spontaneous pre-term labor
• Spontaneous premature rupture of membrane
• Diabetes
• Cardiac Diseases
• Pre-eclampsia

Delivery in Healthy Facility

All lying-in Clinics, Birthing Homes, or within the BHSs/RHUs where deliveries are attended to.

Normal pregnancies with labor progressing normally shall be encouraged to deliver in these facilities.

The basic services which will be delivered are: normal vaginal delivery and emergency obstetric measures for
common complications.

Delivery in Hospitals
The following risk pregnancies should be advised to deliver in the hospitals:
 Pregnancy more than 4
 Previous caesarian section
 History of postpartum hemorrhage
 Presence of medical illness such as heart disease, goiter, TB, DM, Severe anemia, Hypertension, bronchial
asthma
 Placenta previa, Abruption plancenta
 Multifetal pregnancies
 Post term and pre term pregnancies
 Previous uterine surgery
 Nursing Care after Delivery
1. The cord must be cut between two clamps using sterile scissors or blade. Then the baby is immediately put to
the mother’s breast. The mother must be closely watched during the first 2 hrs. after delivery for bleeding.

The ff. should be checked:

 Mother
• The uterus is contracted and hard
• Blood pressure and pulse rate must be normal
• Placenta must be completely expelled
• Lacerations along the birth canal
 Baby
• Vital signs/ reflexes with use of APGAR
• Congenital defects

Properly timed clamping

• Clamp the cord after the pulsation have stopped.
• Do not milk the cord towards the baby
• 1st clamp: plastic sterile clamp (2cm from the umbilical base)
• Strip the cord of blood before applying the 2 nd clamp
• 2nd clamp: Kelly forceps ( 5cm from the umbilical base)
• Cut the cord closer to the 1st clamp
• Assess for the presence of 3 cord vessels
• Exposed to hasten drying
Note: Cord stump normally falls off after 7-10 days
2. Midwives should be made aware of he deliveries attended by TBAs. They must see to it that these deliveries must
be reported by the TBAs to the nearest facility for purpose of continuing of services.
3. Each baby must be registered in the civil registry. This birth certificate should be filled-up by the attendant at
birth.
4. All newborns should be enrolled for Under Fives and should be issued a Growth Monitoring Chart.
5. For home deliveries, the first postpartum visit shall be done within 24 hrs. after delivery, the next visit shall be at
least one week after delivery and third visit 2-4 weeks thereafter. The visit to the health care facility shall be within
4-6 weeks after delivery.
Post-partum check-up should include:
 For Mothers
• Check for bleeding and infection
• Check for vital signs and breast feeding practices
• Post partum counseling to include birth spacing, cord care, hygiene BF and nutrition
 For Babies
• Check sucking reflex and Breast feeding prsctices and problems
• Check the umbilical stump for bleeding and signs of infection
• Observation for pathologic jaundice and pallor
RECORDING AND REPORTING
• The HBMR shall be used when rendering services during pregnancy, childbirth and post partum period. It shall
be used for risk identification and health education.
• Facility based records such as the Individual Treatment Records (ITR), Target Clients List (TLC) and Master list
shall also continue to be used.
Management of referred cases from lower levels.