MATERNAL AND CHILD HEALTH NURSING

Definition:It involves care of the woman and family throughout pregnancy and childbirth
and the health promotion and illness care for the children and families.

I. PHILOSOPHY OF MATERNAL AND CHILD NURSING

PHILOSOPHY OF MCN

1. Family centered
2. Community centered
3. Research oriented
4. Based on nursing theory
5. Protects the rights of the family members
6. Uses a high degree of independent functioning
7. Places importance on health promotion
8. Based on the belief that pregnancy or childhood illness are stressful because they are
crises
9. Based on the belief that personal cultural and religious attitudes and beliefs influence
the meaning of illness and its impact on the family
10. A challenging role for the nurse
11.A major factor in promoting high level wellness in families
PRINCIPLES OF MCN

1. The family is the basic unit of the society. It is the structural unit of the society.
2. Families represent racial, ethnic, cultural and socioeconomic diversity.
3. Children grow both individually as a part of the family.
PHASES OF HEALTH CARE IN MCN

1. Health Promotion – educating the client to be aware of healthy living through

teaching and role modeling.
2. Health Restoration – promptly diagnosing and treating illness using
interventions that will turn client to wellness most rapidly.
3. Health Maintenance – intervening to maintain health when risk of illness is
present.
4. Health Rehabilitation - preventing further complications from an illness bringing
ill client back to optimal state of wellness for helping the client accept inevitable
death.
TRENDS IN MATERNAL AND CHILD HEALTH CARE

a) Families are smaller in size than in previous decades.

b) Single parents are increasing in number.
c) An increasing number of mothers work outside the home.
d) Families are more mobile than previously.
 e) Abuse is a more common than ever before.
f) Families are more health conscious than previously.
g) Health care must respect cost containment.
II. NURSING CARE OF THE CHILD BEARING FAMILY
A. REVIEW OF THE REPRODUCTIVE ANATOMY AND PHYSIOLOGY
 MALE REPRODUCTIVE SYSTEM

1. EXTERNAL ORGANS

a. PENIS
a. the male organ of copulation and
urination
b. has the following parts:
i. shaft or body ii. glans penis –
the most sensitive part iii.
prepuce – a fo9ld of
retractable skin
covering the glans and which is removes during
circumcision. iv. urethral meatus – a slit-like
opening located at the tips of the penis which
serves as a passageway of both sperm and
urine.

b. SCROTUM – is a sack-like structure containing the testes

that hang behind the penis; keeps the sperm viable.
2. INTERNAL ORGANS

a. TESTES
a. are oval shaped organs lying within the abdominal cavity in the
early fetal life and descend to the scrotum after 34-38 weeks
of gestation.
b. male gonads (testicles) – made up of loops of 900 coiled
seminiferous tubules.
c. principal function of the TESTES
i. Hormone Production ii.
Spermatogenesis – production
of sperm.
b. EPIDIDYMIS – is a long coiled tube, approximately 20 feet long at
which the sperm travels for 12 – 20 days
c. VAS DEFERENS – the contractile power of this part of the duct system
propels the spermatozoa to the urethra during ejaculation. d.
EJACULATORY DUCT – connects the seminal vesicle to the urethra
e. ACCESSORY GLANDS

1. SEMINAL VESICLE – the pouch like organs that lie

behind the bladder and in front or the rectum.
2. PROSTATE GLAND – main responsible in the production
of semen. – a conical body lying below the bladder
which secretes an alkaline fluid.
3. COWPER’S / BULBOURETHRAL GLAND – pea size, a
small gland located below the prostate that secretes an
alkaline fluid which helps neutralize the acidic nature of
the semen.
4. SEMINAL FLUID/SEMEN – are secretions from the
seminal vesicle, prostate gland, Cowper’s gland,
ejaculatory duct and spermatozoa.
5. MALE FERTILITY TEST/SPERM ANALYSIS – can be
assessed by examining the semen.
Characteristics of the semen which are analyzed for fertility are:

a. VOLUME- 2.5 – 6 ml (average is 3.5 ml) after 3 days

abstention.
b. SPERM COUNT – normal sperm count is 120 million
sperms per ml (1 teaspoon) after 3 days abstention. c.
SPERM MOTILITY

3 1
 a. sperm tends to remain only in
one spot exhibiting motion only of
the tail
2. Grade 2
a. sperm move rapidly across
microscopic field.
3. Grade 3
a. 60 % of sperm motility which is
normal.
d. SPERM MORPHOLOGY – abnormal forms may be 2 headed
sperms, abnormally shaped heads and abnormal tails.
FEMALE REPRODUCTIVE ORGAN

1. EXTERNAL ORGANS

a) MONS PUBIS/MONS VENERIS – lies over the symphysis pubis covered

by the skin and at puber5ty by short hairs; protects the surrounding
delicate tissues from trauma.
b) LABIA MAJORA – two folds of skin with fat underneath; contain
Bartholin’s glands
 c) LABIA MINORA – two thin folds of delicate tissues; form an upper fold
encircling the clitoris (called the PREPUCE) and unite posteriorly (called
the FOURCHETTE).
d) GLANS CLITORIS – small erectile structure at the anterior junction of
the labia minora, which is comparable to the penis in its being
sensitive.
e) VESTIBULE – narrow space seen when the labia minora are separated.
f) URETHRAL MEATUS – located on the anterior edge of the vestibule
and surrounded by the SKENE’S GLAND or the paraurethral ducts
which corresponds 6to the prostate in the male.
g) VAGINAL ORIFICE / INTROITUS – external opening of the vagina
covered by a thin membrane (HYMEN)
h) PERINEUM (vulva) – area between the mons pubis, buttocks and the
thigh externally. Perineal muscles are the bulbocavernosus,
ischiocavernosus, “sphincter” of the urethra, superficial and deep
transverse perineal muscles and the external sphincter of the anus.
2. INTERNAL ORGANS

a) VAGINA – a 3-4 inches long dilatable canal located between the

bladder and the rectum; contains rugae; organ of copulation;
passageway for menstrual discharges.
b) BARTHOLIN’S GLAND – these are located beneath the
vestibule on either side of the vagina and open at the lateral border
of the vagina.
c) UTERUS – hollow pear shaped fibromuscular organ, 3 inches long, 2
inches wide, 1 inch thick, and weighing 50 grams in a non-pr5egnant
woman; organ of menstruation and implantation; nourishes the
products of conception.
d) FALLOPIAN TUBES/OVIDUCT/UTERINE TUBES – 4 inches long from
each side of the fundus; widest part (called
AMPULLA) spreads into finger like projections; fertilization takes place in its
outer third or outer half.
e) OVARIES – almond shaped, dull
white sex glands near the fimbrae,
kept in place by ligaments.
OTHER STRUCTURES:

Bones composing the bony pelvis:

1. Ilium
2. Ischium
3. Pubis
4. Sacrum
5. Coccyx
 FOUR TYPES OF PELVIS

a) GYNECOID – female pelvis shaped found in approximately 50 %

of women; the anteroposterior and the transverse diameters are
relatively equal, with straight pelvic sidewalls; the ischial spines
are not usually prominent.
Shape: transversely rounded

b) ANDROID – male pelvic shape; characterized by convergent

sidewalls, prominent ischial spines, and a narrow pubic arch.
Shape: wedge shape or angulated

c) ANTHROPOID – heart-shaped pelvic characterized by the

anteroposterior diameter being greater than the transverse
diameter.
Shape: heart or oval shape

d) PLATYPELLOID – is characterized by the transverse diameter

being greater than the anteroposterior diameter, with wide
sidewalls.
Shape: flat in shape but with oval inlet.
CONJUGATES – found in pelvic inlet

a) OBSTETRIC CONJUGATE – shortest anteroposterior

diameter between the sacral promontory and the
symphysis pubis; it can only be measured radio
graphically;
11 cm
b) DIAGONAL CONJUGATE – the distance between the
sacral promontory of the sacrum and the lower margin of
the symphysis pubis;
12.5 cm
c) TRUE CONJUGATE – conjugate vera; distance between
the sacral promontory of the sacrum to the upper margin
of the symphysis pubis;
11.5 cm
OTHER RELATED STRUCTURES

LIGAMENTS OF THE UTERUS

1. BROAD LIGAMENTS – extend from the lateral margin of the uterus to the pelvis; the
uterine vessels and the uterus are contained within the base of the broad ligaments.
2. ROUND LIGAMENT – connective tissue that extend from the lateral uterine fundus to the
upper portion of the labia majora.
3. UTEROSACRAL LIGAMENT – connective tissue that extends from the
 inferior and posterior portion of the uterus and attach to the fascia over the sacrum.
4. CARDINAL LIGAMENTS – connective tissue located at the base of the broad ligament;
provide most of the support to the uterus.

B. COMPONENTS OF HUMAN SEXUALITY

•PUBERTY
– encompasses the physiologic changes leading to the
development of adult reproductive capacity; the process includes
maturation of the hypothalamus, pituitary glands and gonads.

•ADOLESCENCE

- encompasses the physiologic, social and cognitive changes

leading to the development of adult identity.

•THELARCHE
- budding of the breast.

•ADRENARCHE
- development of axillary and pubic hair

•SEX
- act of copulation, coitus
•SEXUALITY
- the sum of the physical, functional and psychological
attributes that are expressed by one’s gender identity and
sexual behavior, whether or not related to the sex organs
or to procreation.

•BIOLOGIC GENDER
- term used to denote a person’s chromosomal sex.

•GENDER/SEXUAL IDENTITY
- is the inner sense a person has of being male or female.
•GENDER ROLE
- the expression of a person’s gender identity; the
image that a person presents to both himself/herself
and others demonstrating maleness/femaleness.
 SEXUAL DEVELOPMENT

(HUMAN SEXUAL CYCLE)

1. EXCITEMENT
•vaginal lubrication and vasocongestion of the genitalia
•penile erection due to vasocongestion
•physical and psychological stimulus
•stimulation of the penis
•arterial dilation and venous constriction in the genital area

2. PLATEAU
•Formation of orgasmic platform due to
prominent vasocongestion
•Generalized muscle tension, hyperventilation, increase BP,
tachycardia in the late plateau phase
•Reached first before orgasm
•WOMEN – formation of orgasmic platform, increased nipple
engorgement
•MEN – full distension of the penis; pre-ejaculatory phase of
life spermatozoa
3. ORGASM
•Strong rhythmic contractions of vagina and uterus
•In males, vas deferens, seminal vesicle, ejaculatory duct and prostate
contract 3-4 times over a few seconds causing pooling of seminal fluid in
the prostatic urethra
•Rhythmic contractions in males occur at 0.8 seconds
•Discharge of accumulated sexual tension
•Shortest stage

4. RESOLUTION
•Rapid decline in pelvic vasocongestion
•External and internal organs return to an unaroused state
•Generally takes 30 minutes

5. REFRACTORY PHASE
•Only in males, the period during which no amount of stimulation can
cause another erection
•Not manifested in females because females are multi-orgasmic •This
phase lengthens with age
TANNER STAGING
M - utual
C - onsent
F - oreplay
A - rousal
P - lateau
C - oitus
O - rgasm
R - esolution
R - efractory

SEXUAL STIMULATION
1. physical/Foreplay or Actual
2. Psychological Stimulation
 C. MENSTRUAL CYCLE AND FAMILY PLANNING METHODS
HORMONES ENVOLVED
GnRH - Gonadotropin Releasing Hormone (APG- Anterior Pituitary Gland)
- initiates the menstrual cycle.

FSH (Follicle Stimulating Hormone)

- stimulates the development of the primordial follicle (immature follicle) into Graafian
follicle (mature) follicles

LH- Luteinizing Hormone (ICSH)

- stimulates ovulation and development of corpus luteum (yellow body); corpus
albican (white body) - thickens the endometrium

ESTROGEN
- hormone of women
- secondary sex characteristics
- female cervical mucus
- maintains the endometrium
- stimulates uttering contraction
- inhibits the production of FSH
- causes hypertrophy of myometrium
- stimulates the development of ductile structures of the breast - increases the
pH and the quantity of the cervical mucus

PROGESTERONE
- hormone of mothers
- prepares the endometrium
- relaxes the myometrium
- increases the basal body temperature
- infertile mucus
- maintains pregnancy
- increases the fibrinogen, hematocrit and hemoglobin
- Inhibits the production of LH
- transport to the fertilized ovum (zygote) into the uterus
- increase uterine motility
PHASES OF THE MENSTRUAL CYCLE
A.MENSTRUAL PHASE (1-5 DAYS)

•Extends from the first day of menstruation to the fifth day

 •The first day of menses is considered the first day of the cycle
•Characterized by desquamation of the superficial layers of the
endometrium caused by corpus luteum regression and the consequent
withdrawal of the progesterone and estrogen •About 2/3 of
endometrium is shed off every menstrual period
B. PROLIFERATIVE PHASE (6-14 DAYS)

•From the 6th to day 15 of a 28 day cycle

•The very low estrogen level stimulates the hypothalamus to secrete
follicle stimulating hormone releasing factor (FSHRH). In a 28 day cycle,
estrogen level is lowest on the 3rd day before ovulation
•FSHRF stimulates the anterior pituitary gland to secrete follicle
stimulating hormone
•FSH stimulates the primordial follicle to develop into graafian follicle
•As the graafian follicle develops, it produces large amount of estrogen,
while at the same time an ovum is maturing inside •Estrogen promotes
regeneration and proliferation of the cells of
endometrium and formation of new
capillaries Also called:
ESTROGENIC PHASE
FOLLICULAR PHASE
POST-MENSTRUAL PHASE
C. SECRETORY PHASE (15-23 DAYS)

•From the 14th day to the 24th day or from the day of ovulation until about 3-4
days before the next menstruation
•The rising pituitary gland to secrete FSH, the very low progesterone level
triggers the hypothalamus to release LHRF
•LHRF stimulates the anterior pituitary gland to secrete Luteinizing
Hormone (LH)
•LH promotes ovulation. As the graafian follicles becomes overly distended,
with follicle fluid, it finally ruptures releasing the mature ovum
•After ovulation, the graafian follicle will be called corpus luteum
•The corpus luteum produce large amount of progesterone
•Progesterone is said to cause “opening of the uterus: as this hormone further
decreases the vascularity of endometrium and stimulates endometrial glands to
secrete mucin, nutrient and glycogen. As a result, the lining of the uterus becomes
soft, spongy and edematous, this occurs in preparation for implantation and
pregnancy
•The corpus luteum has an average lifespan of about 8 days. If no fertilization occurs at
this time, it regresses resulting in withdrawal of estrogen and progesterone.
•If no fertilization occurs, the fertilized ovum or zygote implant between 7-10 days after
fertilization, the time when the corpus luteum is suppose to atrophy •The secretion of
 human chorionic gonadotropin (HCG) by the trophoblast cells of the zygote will prolong
the life of the corpus luteum.
•The corpus luteum then will continue to produce estrogen and progesterone until the
third time or 12th week of pregnancy when the placenta is mature enough to take over
the function of hormone production
•The corpus luteum having accomplished its role after 12 weeks will now atrophy •The
secretory phase is the endometrial phase that proceeds nidation or implantation
Also called:
PROGESTATIONAL PHASE-OVULATORY PHASE/ LUTEAL PHASE

D. ISCHEMIC/PREMENSTRUAL PHASE (24-28 DAYS)

•As mentioned earlier, the life of the corpus luteum is only 8-10 days, if
fertilization does not take place, the corpus luteum shrivels
•Degeneration of the corpus luteum in withdrawal of estrogen and
progesterone
•Absence of progesterone results in arteriolar spasm and
vasoconstriction. Blood supply, then, to endometrium is cut off.
•Lack of blood vessels and endometrial sloughing
•The desquamated cells are discharge, thus menstruation occurs •The
onset of menstruation signals the beginning of another menstrual cycle
Also called:
POST-OVULATORY PHASE
PREMENSTRUAL PERIOD

FAMILY PLANNING METHOD

 A. Natural Family Planning Methods

1. Techniques including checking the body temperature or cervical

mucus daily and recording menstrual cycles on a calendar to
determine the days when the body is most fertile.
2. Effectiveness 81%
3. Accepted by religions and inexpensive.
B. Artificial Family Planning Methods

1. Spermicides
Chemicals in the form of foams, creams, jellies or suppositories that are inserted
into the vagina to kill the sperm before they can enter the uterus.
Typical effectiveness 70%
Available over the counter and can be used with other methods to improve
effectiveness

2. Condoms
Male condom is a sheath of latex or animal tissue placed on erect penis
 Female condom is a plastic sac with a ring on each end inserted into the vagina.
Both may be used with a spermicide

3. Birth Control Pills

Prescription drugs that contains the female hormones (estrogen).
One pill is taken daily to prevent ovaries from releasing eggs and
thickens the cervical mucus to prevent sperm reaching egg.

4. Diaphragm

Shallow latex cup with flexible rim inserted into vagina over cervix to
prevent sperm from entering uterus with spermicide.
 5. Intrauterine Device

small device inserted by a health care professional into the uterus and prevents
eggs from being fertilized and implanting in uterus.

6. Cervical Cap
Thimble-shaped latex cap inserted into a vagina over cervix to prevent sperm
from entering uterus used with spermicide.

7. Hormonal Injection (Depo-Provera)

injection given by a health care professional in

the arm or buttocks every 12 weeks to prevent
ovaries from releasing an egg of thickened
cervical mucus to keep sperm from reaching the
egg.
8. Hormonal Implant (Norplant)

Six small capsules inserted by a health care professional under the skin of the
upper arm that deliver small amounts of hormone to prevent ovaries from
releasing eggs.
C. Permanent Methods of Reproductive Life Planning

1. Tubal Ligation

surgical procedure to permanently block woman’s fallopian tubes to

prevent eggs from reaching by sperm.
2. Vasectomy

surgical procedure to permanently block the male’s vas deferens to

prevent sperm from reaching eggs.
DIFFERENT MENSTRUAL CONCERNS
AMENORRHEA – absence of menses

DYSMENORRHEA – painful, difficult menstruation

METRORRHAGIA – bleeding in between menses

MENORRHAGIA – excessive bleeding during regular menstruation

MENOPAUSE – cessation of menstruation

OLIGOMENORRHEA – markedly diminished menstrual flow, nearing

amenorrhea

POLYMENORRHEA – frequent menstruation occurring at intervals of less than 3

weeks

OVULATION – monthly growth and release of mature, non-fertilized ovum; usually occur in the
middle of the menstrual cycle; the interval between ovulation and menstruation is
approximately 14 days.
D. CONCEPTION AND FETAL DEVELOPMENT
 Terminologies:
Fertilization- union of the sperm and the mature ovum in the outer third or outer half
of the fallopian Tube.
Implantation/ Nidation – immediately after fertilization, the fertilized ovum or

zygote stays in the fallopian tube for 3

days, during which time rapid cell division (mitosis) is taking place.

Zonapellucida- inner layer of zygote

•The thick, transparent, non-cellular membrane that encloses the
mammalian ovum.
 •It is secreted by the ovum during its development in the ovary and is
retained until nnear the time of implantation.

Corona Radiata- outer layer of zygote

•An aggregate of cells that surrounds the zona pellucid of the ovum

Morula- a solid, spherical mass od cells resulting from the cleavage of the fertilized ovum
in the early stages of embryonic development
- Represents an intermediate stage between the zygote and the
blastocyst.

Blastocyst- corpus luteum

- The embryonic form that follows the morula in
human development
- A spheric mass of cells having a central, fluid filled cavity(blastocele)
surrounded by two layers of cells.
- The outer layer (trophoblast) later forms the placenta, the inner layer
(embryoblast) later forms the embryo.
 Trophoblast or Trophectoderm
- Fingerlike projections form around the blastocyst
and this trophoblast are the ones which will implant high
on the anterior or posterior surface of the uterus.
- It is the layer of tissue that forms the wall of the
blastocyst in the uterine wall and in supplying nutrients
to the embryo. - At implantation the cells differentiate
into two layers, the inner cytotrophoblast, which forms
the chorion and the syncitiotrophoblast, which developd
into the outer layer of the placenta.

Terms to Denote Fetal Growth

Ovum- female germ cell extruded from the ovary at ovulation.

Zygote- the developing ovum from the time it is fertilized until, as blastocyst, it is implanted in
the Uterus.

Embryo (chick)- the stage of prenatal development between the time of implantation of the
fertilized ovum about 2 weeks after conception until the end of the 7 th or 8th week.
-The period is characterized by rapid growth, differentiation
of the major organ systems, and development of the main external features.

Fetus- the human being in utero after the embryonic period and the beginning of the
development of the major structural features, usually from the 8 th week fertilization until
birth.

Conceptus- the product of conception; the fertilized ovum and its enclosing membranes at
all stages of intrauterine development, from implantation to birth.
 STAGES OF HUMAN PRENATAL DEVELOPMENT

Zygote – first 12-14 days

Embryo- from 15th day up to the 8

Fetus- from 8th week up to time of birth

DEVELOPMENT OF EMBRYONIC AND FETAL STRUCTURES

MILESTONES OF FETAL GROWTH AND DEVELOPMENT
 First Lunar Month

•Germ layers differentiate by the 2nd week

•Fetal membranes appear by the 2nd week
•Nervous system develops rapidly by the 3rd week
•FHR begins to form as early as the 16th day of life.
•Digestive and respiratory tract exist as a single tube until
3rd week of life when they start to separate
Second Lunar Month
•All vital organs are formed by the 3rd week; placenta fully
developed
•Sex organs are formed by the 8th week
•Meconium are formed in the intestines by the 5 th – 8th week

Third Lunar Month

•Kidneys are able to function- urine is formed by the
12th week.
•Buds of milk
teeth form
•Beginning of
bone ossification.
•Fetal swallows amniotic fluid
Fourth Lunar Month
•LANUGO appears – fine
tiny hairs •Buds of
permanent teeth form.
•FHR maybe audible with Fetoscope
•.
Fifth Lunar Month
•V
ER
NI
X
CA
SE
OS
A
ap
pe
ars
•L
an
ug
o
 co
ve
rs
en
tir
e
bo
dy
•Q
UI
CK
EN
IN
G
fel
t.

Sixth Lunar Month

•Skin markedly wrinkled
•Attains proportions of full-termed baby
Seventh Lunar Month
•Alveoli begins to form (28 weeks AOG)

Eight Lunar Month

•FETUS is viable
•LANUGO begins to disappear
•Nails extend to end of fingers
•Subcutaneous fat deposition begins

Ninth Lunar month

•LANUGO and VERNIX CASEOSA disappear
•Amniotic fluid volume somewhat decreases

Tenth lunar month

•All characteristics of the normal newborn
ASSESMENT OF FETAL GROWTH DEVELOPMENT
 1. Age of gestation (AOG)
A. NAGALE’S RULE
•Calculation of expected date of confinement (EDC)
•Count back 3 months from the first day of the LMP then add
7days. Substitute number for month for easy computation
•For example: September 0 – = 9 – 0
mo – 0 (JUNE)
= 0 + 7 days – 10
= EDC – JUNE 10

B. MCDONALDS METHOD
•Determine AOG by measuring from the fundus to the symphysis pubis
(in cm) then divide by 4-AOG in months
•Example
= Fundic height of 10cm / 4=4 months AOG= 10 weeks AOG
2. Measuring fundic Height
A. BARTHOLOMEW’S RULE
•Estimate AOG by the relative position of the uterus in the abdominal cavity
•By the 3rd lunar month, the fundus is palpable slightly above the symphysis pubis
•On the 5th lunar month the fundus is at the level of the umbilicus
•On the 9th month, the fundus id below the xiphoid process

B. HAASE’S RULE
•Determines the length of the fetus in centimeters
•During the first half of pregnancy, square the number if the month
•(e.g. 1st lunar month 1x1 = 1cm)
•During the second half of the pregnancy, multiply the month by 5
•(e.g. 6th lunar month: 6x5 = 30 cm)

C. JOHNSON’S RULE
•Estimates the weight of the fetus in GRAMS
•FORMULA: fundic height in cm. n x k
•“K” is a constant, it is always 155
•“n” is = 12(if fetus is engaged) = 11(if fetus is not yet engaged)
FOCUS OF FETAL DEVELOPMENT

1ST Trimester
Period of organogenesis.

2nd Trimester
Period of continued fetal growth and development, rapid increase in fetal
length.
3rd Trimester
Period of most rapid growth and development because of rapid deposition of
subcutaneous fat
TERATOGENS
Maternal Risk factors:

1. German measles (Rubella)

•The risk of maternal & fetal or congenital infection is
related to the trimester of placental infection
•Maternal infection during the first 8 weeks of gestation
carries the highest rate of maternal & fetal infection
2. Sexually transmitted diseases

Syphilis
•My cross the placenta
•Usually leads to spontaneous abortions
•Incidence & mental abnormality

Genital herpes
•May cross placenta
•Fetus contaminated after membranes rupture or with vaginal
delivery
Gonorrhea
•The fetus is contaminated at the time of delivery
•May result to postpartum infection
•Pneumonia
•Sepsis

Human Immunodeficiency Virus (HIV)

•The virus is transmitted through blood, blood products, & other
bodily fluids such as urine, semen & vaginal fluid.
3. Substance Abuse

•Many substances cross the placenta; therefore no drugs, including over the
counter medications should be taken unless prescribed by the physician
•Substances commonly abused include alcohol, cocaine, crack, marijuana,
amphetamines, barbiturates, & heroin
•Substances abuse threatens normal fetal growth & successful term completion
of the pregnancy
•Substance abuse places the pregnancy at risk for fetal growth retardation
abruption placenta, & fetal bradycardia.
•Physical signs of drug abuse include dilated or constricted pupils, fatigue, trace
marks, skin abscesses, and inflamed nasal mucosa.
•Alcohol during pregnancy may lead to fetal alcohol syndrome & can cause
jitteriness, physical abnormalities, congenital anomalies, & growth deficits
•Smoking causes vasoconstriction leading to low birth weight babies, a higher incidence of
birth defects & stillbirths
•Drinking – in moderation is not contra indicated but when excessive can
cause transient respiratory depression in the newborn and fetal withdrawal
syndrome; besides, alcohol supplies only empty calories.
•Drugs – dangerous to fetus especially during the first trimester when the
placental barrier is till incomplete and the different body organs are
developing
•Thalidomide – causes Amelia or phocomelia
•Steroids – can cause cleft palate and even abortion
•Iodine – causes enlargement of the fetal thyroid gland, leading to tracheal
ecompressin and dyspnea at birth
•Vitamin k – causes hemolysis and hyperbilirubinemia
•ASA and Phenobarbital – causes bleeding disorders.
•Streptomycin and Quinine – cause damage to the 8 th cranial nerve
•Tetracycline – cause staining and tooth enamel
ADOLESCENT PREGNANCY
 Factors that result in adolescent pregnancy include:

a.) The early onset of menarche

b.) changing sexual behaviors in this age group
c.) faulty family development
d.) poverty
e.) lack of knowledge of reproduction & birth control
The major concerns related t adolescent pregnancy includes:

1. Poor nutritional status

2. Emotional and behavioral difficulties
3. Lack of support systems
4. Increased risk of still birth
5. Increased risk of maternal complications: such as hypertension,
anemia, prolonge labor & infections
6. Low birth weight newborn infants
7. Fetal mortality
8. cephalopelvic disproportion
CAPACITATION – property of the sperm cell to transform for fertilizing ovum
↓
Hyalorunidase – dissolves the corona radiate
↓
ACROSIN – sperm cell enters the ovum and nucleus 2 sex cells –
fertilization
 FETAL CIRCULATION

Fetal Circulation

O2→ unbilical vein → ductusvenosus → Inferior vena cava → atrum

→forameovale → atrium → ventricle → ascending Aorta → superior vena
cava → RAtrum → pulmonary artery → ductusarteriosisus → aorta
→hypograstie artery → placenta
STRUCTURE LOCATION FUNCTION
1. Placenta attached to interus gas exchange during fetal life
2. umbilical arteries two arteries in a cord carry in oxygenated
B
lood from fetus 3. umbilical veins one vein in cord carry
oxygenated
Blood i
 foramen ovale opening in interatrial septum s

5. ductusvenosus accessory vein connecting supply blood to liver Umbilical v

Liver & IVC

6. ductusarteriosus connection between shunting larger portion

Fetal lungs & aorta blood away from lungs & dire

AFTER BIRTH*

1. FO – connects atrium L+R → fossa ovalis

2. U.U – O2 blood fr. Placenta → ligamentumteres
3. UA - unoxygenated blood → umbilical ligament Fr. Fetus to
placenta
4. DV – O2 blood from UV to IVC → ligamentumvenosum
5. DA – O2 blood from PA to aorta → ligamentumarteriosum
Medication
OXYTOTIC MED.
Description: smooth muscle stimulant promotes contraction to uterus.
Uses: use to induce labor to promote milk let down
A/E: contradiction: initially hypotension leading to rebound HPN

ERGOT ALKALOIDS
•Ergonovine (ergotrate)
•Methylergovine (methergine)
• -after delivery placenta
Description:
↑ Forces & frequency uterine contraction
Use: it prevents post partrum hemorrhage
A/E: HPN / bradycardia
Input: monitor BP & HR
UTERINE RELAXANT (tocolytics)
•Ritodrvine (yutopar)
•Terbutaline sulfate
Description: it relaxes uteine muscles
Use: Tx for preferm labor
A/E: maternal tachycardia
Implication: monitor HR mother if ↑1306pm stop ritodrine

PROSTAGLANDINS
•Misoprostol (cytotec)
•Dinoprostone (cervidil)
Description: promotes cervical dilatation if enhances at 2 nd stage of labor
Applied as gel
Mg SO4
Description: CNS depressant, uterine relaxant laxative effect
Use: DOC for DIH (pregnancy include HPN)
A/E: toxicity calcium lactate
Antidote: calcium gluconate
Imp.: monitor Mg level, normal 4-7 mg/dl, monitor BP, UO, RR & patellar reflex
•Pre elampsia- ↑BP, edema
•Eclampsia- ↑BP, anasarca(generalize edema), convulsion

MEPERIDINE HCL (Demerol)

-
Narcotic
analgesic
Use: ↓pain
using labor
A/E: respiratory depression
Antidote: naloxone HCl / narcan
Implication:
monitor RR
Teratogenicity
cigarettes Env’tl
teratogens
E. SIGNS OF PREGNANCY
 DIAGNOSIS OF PREGNANCY:

Presumptive Signs – subjective evidence

Probable Signs – objective evidence
Positive Signs – absolute evidence
First Trimester

PRESUMPTIVE PROBABLE

Amenorrhea Ultrasound evid

Morning Sickness 12 weeks by Do
Urinary Frequency Chadwick’s sign
Enlargement of Uterus Goodell’s sign
Hegar’s sign
Positive HCG
Elevation of BBT

Second Trimester

PRESUMPTIVE PROBABLE P

Quickening ( fetal Kick ) Enlarged abdomen Fetal Heart Tone

↑skin pigmentation auscultation Fet
(chloasma and linea nigra Braxton Hicks the Examiner at
Striae Gravidarum Contraction ( false labor, a painless Fetal outline on
uterine contraction) Sonography

Ballotement

F. PHYSIOLOGICAL CHANGES OF PREGNANCY

A. Reproductive Tract Changes:
• UTERUS
Weight increase to about 1000 grams at full term
Hegar’s sign – softening of uterine segment
Operculum – mucus plugs in the cervix that are produced to seal out bacteria
Goodell’s sign - softening of the cervix

• VAGINA
Chadwick’s sign - bluish discoloration of the vagina
Leukorrhea – increase estrogen leads to ↑ vaginal discharge
Alkaline vaginal pH:
2 microorganisms which thrive in alkaline environment
•Trichomonas
•Candida Albicans
• OVARIES
No changes
No ovulation
Placenta take over the function which supervises estrogen and progesterone
B. INTEGUMENTARY CHANGES:

•Linea Nigra – line running from navel to symphysis

•Melasma or Chloasma – “Mask of Pregnancy”
•Abdominal Wall
•Striae Gravidarum – pink or reddish

streaks C. BREAST CHANGES:

•COLOSTRUM IS FORMED (4th Month)

•Feeling of fullness and tingling sensation
•↑ in size and nipples more erect
•Montgomery gland become more bigger and protuberant
•Areola becomes more darker and ↑ diameter
•Skin surrounding areola turns dark
D. SYSTEMIC CHANGES:
•Circulatory or Cardiovascular
Easy fatigability and SOB
Undue bleeding due to ↑ fibrinogen
Slight hypertrophy of the Heart
Systolic murmurs are common
Epistaxis, palpitation, bipedal edema
Vulva and rectal varicosities

E. GI CHANGES:
  Morning Sickness
 Hemorrhoids
 Heartburn or Pyrosis
 Constipation and flatulence

F. RESPIRATORY CHANGES:
Shortness of Breath
G. URINARY CHANGES
•Urinary frequency
• 1st Trimester
d/t ↑ blood supply to the kidneys and uterus rising out of the pelvic
cavity.
•3rd Trimester
d/t pressure of enlarged uterus on the bladder.

H. MUSCULOSKELETAL CHANGES:
•Lordosis – “Pride of Pregnancy”

I. ENDOCRINE CHANGES
•Placenta take over lactogen
•Slight hypertrophy / enlargement of Parathyroid Gland to supply
child calcium
•Slight ↑of the thyroid gland leads to ↑ activity of adrenal cortex
and ↑ production of cortisol anti-diuretic hormone leads to
hyperglycemia.
G. PSYCHOLOGICAL TASKS OF PREGNANCY
•First Trimester
Accepting the Pregnancy
The Fetus is unidentified concept with great future implications but
without tangible evidence of reality

•Second Trimester
Accepting the baby
Fetus is perceived as a separate entity

•Third Trimester
Preparing for parenthood
Has personal identification with a real baby about to be born and
realistic plan for future childcare responsibilities
Let pregnant woman listen to the fetal heart
sounds
H. NURSING CARE DURING PREGNANCY
Health Assessment During First Prenatal Visit:

GRAVIDA – a pregnant woman

Nulligravida = who has never been pregnant

Primigravida = first time pregnancy
Multigravida = 2 or more pregnancies
Grandmultigravida = 5 or more pregnancies

PARTURIENT – woman in labor

PARTURITION/CONFINEMENT – process of labor and delivery

VIABLE – capable of living, such as fetus that has reached a stage of development,
usually 20-28 weeks, which will permit to live outside the uterus; dependent on
level of technology
PARITY – the number of pregnancies in which the fetus have reached viability,
whether the fetus is born alive or its stillborn after viability is reached does not affect
parity

Nullipara = a woman who has not completed a pre

with a fetus that has reached the age of viability
Primipara = a woman who has completed one pregnancy with a
fetus that has reached the age of viability
Multipara = a woman who has completed two or m
pregnancy with a fetus to the stage of viability
Grandmultipara = a woman who has completed at least four
pregnancies
OB SCORE:
•G – number of pregnancies
•P – number of pregnancies that reached the age of viability
•T – number of babies born at term
•P – number of preterm babies
•A – number of abortions
•L – number of children currently living
•M– number of multiple pregnancies

PRE-NATAL = before birth

PERINATAL = 20th or 28th week of gestation through the end of t
28th day after birth
POST-NATAL = after birth
PREPARTUM = before delivery
INTRAPARTUM = labor and delivery
THE PRENATAL CLINIC:

•Consists of care and supervision given to the woman

throughout pregnancy to ensure the health and well-being of
both the mother and the baby by:

Ascertaining the patient’s general physical condition at

the beginning of the pregnancy.
Preparing the patient psychologically for pregnancy, labor,
delivery and infant care.
The term “antepartal” has been used by some to refer to the
mother and “antenatal” or “prenatal” to refer more specifically to
the fetus.

Prenatal Visits are Scheduled:

Once a month up to the 6th month (28th weeks)
Every two weeks from the 7th or 8th months (28-32 weeks)
Once a week from the 9th month until delivery.
INITIAL PRENATAL VISIT

•It includes both the diagnosis or verification of pregnancy and

the establishmenteof the data base for ongoing prenatal care.
A. INTERVIEW
Probability of pregnancy with symptoms noted
Menstrual History
Menarche
Duration and amount of flow
LMP
Obstetric History
OB Scoring
Estimation of AOG based on LMP
Fundic Height
Ultrasonography
Computation of EDC
Outcomes of previous pregnancies
Contraceptive
History
Previous major
illness
 Current health problems and all medications being used
Reaction to pregnancy
FETAL HEART TONE
Cephalic presentations, fetal heart sounds are heard loudest midway between the
umbilicus and the anterior superior iliac spine.
In LOA and LOP positions they are heard loudest in the Left Lower Quadrant; and in ROA
and ROP positions they are heard loudest in the Right Lower Quadrant.
In breech presentation, the fetal heart sounds are heard loudest at the level of the
umbilicus or above.
The normal fetal heart rate is 120 – 160 bpm regular.

PELVIC EXAMINATION
Its purpose is to permit visual and digital examination of the internal and external
genitalia and the pelvic contour.
Nursing Responsibilities:
•Give psychological care.
•Help the mother relax during the procedure.
•Maintain woman in Lithotomy Position. Drape her accordingly and avoid
unnecessary exposure.
•When the examination is complete, assist the mother into sitting position and then
stand.
•Provide wipes for the removal of lubricant.
PELVIC MEASUREMENTS
Done only two weeks before EDC
X – ray Pelvimetry – is the most effective method of diagnosing Cephalopelvic
Disproportion (CPD)

URINE EXAMINATIONS
Routine Analysis –to determine pyuria.
Pregnancy test
Analysis for glucose albumin
Heat and Acetic acid test – to determine albuminuria. Albumin in the urine should
be reported immediately because it is a sign of toxemia. Benedict’s Test – glycosuria,
a sign of possible gestational diabetes.

BLOOD STUDIES
Hemoglobin and hematocrit
Venereal Disease Research Lab (VDRL) or Rapid Plasma Reagin Test (RPR)
Blood typing and Rhesus factor
Antibody titer for Rubella
Blood sugar
PAPANICOLAU SMEARS (CYTOLOGIC EXAMINATION)
To detect abnormalities of cell growth by examining cells and secretions from
the cervix and vagina and to diagnose Cervical
Carcinoma/
Classification of Findings:
Class 1 – absence of atypical or abnormal cells
Class 2 – atypical or abnormal cytology but no evidence of malignancy
Class 3 – cytology suggestive malignancy
Class 4 – cytology strongly suggestive malignancy
Class 5 – conclusive of malignancy
CLINICAL STAGES:
Reflect localization or spread of malignant and cervical changes
Stage 1 – CA confined to cervix
Stage 2 – CA extends beyond the cervix into the vagina, but
not into the pelvic wall or l lower 1/3 of the vagina.
Stage 3 – metastasis to the pelvic wall
Stage 4 – metastasis beyond pelvic wall into the bladder and rectum.
Speculum placement
PHYSICAL EXAMINATION
Vital Signs
Height and Weight
Breast examination
Abdominal examination
Contour of uterus, fundal height
Leopold’s Maneuver
Fetal Heart Rate, if applicable
Vaginal or bimanual examination for changes consistent with
pregnancy
Pap’s smear – done during 1st prenatal visit and 1st postpartum visit.

LABORATORY TEST
Pregnancy test
CBC
Urine exams for glucose and protein
DANGER SIGNS TO BE REPORTED IMMEDIATELY:

Vaginal Bleeding
Swelling of the face, fingers and legs
Severe continuous headache
Dizziness or blurring of vision
Flashes of light or dots before eyes
Abdominal or chest pain
Persistent vomiting
Chills and fever
Sudden escape of vaginal fluids
COMMON DIAGNOSTIC PROCEDURES IN MCN
1. Assessment of Lochia
To detect the presence of infection and bleeding (side-lying position).
The normal color of lochia is as follows:
•Lochia Rubra (Reddish) – 1 to 3 days postpartum
•Lochia Serosa (Brownish) – 4 to 10 days
•Lochia Alba (Whitish) – 10 to 14 days
The longest possible time for the patient to have lochial discharge can be up to 3 weeks to
sixty days postpartum.

2. Alpha – Protein Levels

Assesses presence of neural tube defects and Dawn’s Syndrome.

3. Amniocentesis
Assesses fetal growth and maturity, determine genetic disorders and sex of fetus.

4. APGAR Scoring
Appearance, pulse, grimace, activity and respiration. At first, it detects the cardiorespiratory
nervous functioning, and the second is used for planning nursing care.
•0 – 3 Poor ( needs resuscitation )
•4 – 6 Fair (needs suctioning and oxygenation )
•7 – 10 Good ( needs only admission care )
5. Chorionic Villi Sampling
Determine some genetic aberrations.

6. Contraction Stress Test ( Oxytocin Challenge Test )

Indicates uteroplacental insufficiency and identifies pregnancies at risk
•NEGATIVE RESULT – indicates absence of abnormal deceleration with all
contractions.
•POSITIVE RESULT – indicates FHR abnormal deceleration with all
contractions.

7. Non – Stress Test (NST)

Assess fetal activity and well being .
Types:
•Reactive Test – acceleration of FHR > 15 bpm lasting for 15 seconds and
more.
•Non – Reactive Test – acceleration of FHR < 15 bpm may indicate fetal
jeopardy.

8. Coomb’s Test
•Direct – used to test antibodies on patient’s erythrocytes.
•Indirect – used to test antibodies on patient’s serum.
9. FHR Monitoring
Assess FHR abnormalities.
 •Early Decelerations – indicate fetal head compression, reflects mirror image
in the monitor and no treatment required.
•Late Decelerations – placental insufficiency, reverse mirror image in the
monitor Tx: Administer oxygen.
•Variable Decelerations – cord compression, reflects V/W shape image in the
monitor.
Tx: Change the patient’s position to Left Lateral
Recumbent Position and Administer oxygen.
10. Guthrie Capillary Blood Test
Used to screen Phenylketonuria or PKU
Normal level is 2mg/dl
Provide the patient a high protein diet, 24 – 48 hours before the test.
11. Hysterosalpingography
Determines patency of the fallopian tube and to detect pathology in the uterine
cavity.
12. Laparoscopy
Evaluates pelvic pain and infertility, and treats endometriosis lesions.
NPO before the procedure.
13. Mammography
Detects the presence of breast tumor.

14. Self – Breast Exam

Best done a week after the menstruation.

15. Pelvic Ultrasound

Detects abnormalities of the organs in the abdomen.
The patient should ↑ Oral Fluid Intake 30 mins. – 1 hour before the test to
distent the bladder to promote visualization of organs.

16. Percutaneous Umbilical Cord Blood Sampling (PUBS)

Cardiocentesis or Funicentesis
Removal of blood from Umbilical vein using an amniocentesis technique for
analysis
RhoGam is given to Rh negative women to prevent sensitization, since there
is a possibility that the fetal blood could enter the maternal circulation.
The fetus is monitored by NST before and after the procedure.
CONDITIONS ASSOCIATED WITH FIRST TRIMESTER BLEEDING
A. Spontaneous Miscarriage

Spontaneous interruption of pregnancy

Early Miscarriage – before week 16 of
pregnancy Late Miscarriage – between week 16
– 24 TYPES:
•Threatened Miscarriage
•Imminent Miscarriage
•Complete Miscarriage
•Incomplete Miscarriage
•Missed Miscarriage
Early pregnancy failure: Recurrent Pregnancy Loss d/t
•Defective Spermatozoa or Ova
•Endocrine Factors
•Deviations of the Uterus
•Infection and autoimmune disorders
B. PREGNANCY
Implantation occurs outside the uterine cavity.
The most common site is in the Fallopian Tube.
Causes:
•Obstruction
•PID
•Smoking
•Use of IUD

C. Abdominal Pregnancy

The placenta continues to

grow in the fallopian tube,
spreading perhaps into the
uterus for a better blood
supply, or it may escape into
the pelvic cavity and implant
on an organ such as intestine.
CONDITIONS ASSOCIATED WITH SECOND TRIMESTER BLEEDING
 A. Gestational Trophoblastic Disease/ Hydatidiform Mole
Abnormal proliferation and degeneration of the trophoblastic villi.

B. Premature Cervical Dilatation

Incompetent cervix
Refers to a cervix that dilates prematurely and therefore cannot hold a
fetus until term.
CONDITIONS ASSOCIATED WITH THIRD TRIMESTER BLEEDING
A. Placenta Previa
Low implantation of the placenta, a painless vaginal bleeding. Low-lying
Placenta – implantation on the lower rather than in the upper portion of the
uterus.
Marginal Implantation – the placenta edge approaches that of the cervical
os.
Partial Placenta Previa – implantation that occludes a portion of the
cervical os.
Total Placenta Previa – implantation that totally obstructs the cervical os.
Causes:
•↑ Parity
•Advanced
maternal age
•Past cs birth
•Past uterine
curettage
•Multiple gestation
 B. Abruptio Placenta
Detachment of placenta from the uterus and a painful vaginal bleeding.
Apparent Hemorrhage – partial separation
Concealed Hemorrhage – complete separation

C. Disseminated Intravascular Coagulation ( DIC )

An acquired disorder of blood clotting in which the fibrinogen level fails to
below effective limits.
It occurs when there is such a extreme bleeding and so many platelets and
fibrin from the general circulation rush to the site that not enough are left in
the rest of the body fur further clotting.
The high thrombin level continues to encourage anticoagulation.
PROMOTION OF NUTRITIONAL HEALTH DURING PREGNANCY
•Nutrition
•Women who need special attention
•Pregnant teenagers
•Extremes in weighing scale – low pregnant weight and obese
•Low income women
•Successive pregnancies
•Vegetarians

Nutritional Assessment is based on taking a diet history first:

•Food preferences or eating habits
•Cultural or Religious Influences
•Educational or Occupational
Computation of Caloric Equivalents:
•CHO x 4
•CHON x 4
•Fats x 9

Food Sources:
•Protein Rich Foods
 •Vitamin A
•Vitamin D
•Vitamin E
•Vitamin C
•Vitamin B
•Folic Acid
•Calcium or Phosphorus
•Iron
Weight Gain during Pregnancy:
•1st Trimester – 1.5 – 3 lbs is normal
•2nd and 3rd Trimester – 10 – 11 lbs per Trimester is recommended
•Total allowable weight gain during entire pregnancy – 20- 25 lbs ( 10 – 12 kgs )

Distribution of Weight Gain during Pregnancy:

•Fetus - 7 lbs
•Placenta - 1lb
•Amniotic Fluid - 1 ½ lb
•↑ Uterine weight - 2 lbs
•↑ Blood Volume - 1 lb
•↑ Breast weight - 1 ½ - 3 lbs
•Additional Fluid - 2 lbs
•Fat and Fluid Accumulation - 4 - 6 lbs
•TOTAL = 20 – 25 lbs
MALNUTRITION
•Results in prematurity; pre-eclampsias, absorption, low birth weight
babies, congenital defects or even stillbirths.

Normal Pre-pregnancy BMI:

•Underweight = under 18.5
•Normal weight = 18.5 – 24.9
•Overweight = 25 – 29.9
•Obese = above 30
COMMON DISCOMFORTS IN PREGNANCY:
First Trimester
B
r
e
a
s
t
T
e
n
d
e
r
n
e
s
s
P
a
l
m
a
r
E
r
y
t
h
e
m
a
C
o
n
s
t
i
p
a
t
i
o
n
Nausea, vomiting, and pyrosis
F
a
t
i
g
u
e
M
u
s
c
l
e
c
r
a
m
p
s
H
y
p
o
t
e
n
s
i
o
n
V
a
r
i
c
o
s
i
t
i
e
s
H
e
m
o
r
r
h
o
i
d
s
P
a
l
p
i
t
a
t
i
o
n
s
F
r
e
q
u
e
n
t
u
r
i
n
a
t
i
o
n
A
b
d
o
m
i
n
a
l
d
i
s
 c
o
m
f
o
r
t
L
e
u
k
o
r
r
h
e
a

Second and Third Trimester

B
a
c
k
a
c
h
e
H
e
a
d
a
c
h
e
D
y
s
p
n
e
a
A
n
k
 l
e
e
d
e
m
a
B
r
a
x
t
o
n

H
i
c
k
s
C
o
n
t
r
a
c
t
i
o
n
HEALTH PROMOTION DURING PREGNANCY
 Self-care needs:

•Dental care
•Perineal care
•sexual activity
•Exercise such as Kaegel’s Exercise
•Taylor Sitting
Preparations for Childbirth and Parenting:

“ Gate Control of Pain”

Premises:
-Discomforts during labor can be minimized if the woman comes
into labor informed about what is happening and prepared with breathing
exercises to use during labor.
- Discomforts during labor can be minimized if the woman’s
abdomen is relaxed and the uterus is allowed to rise freely against the
abdominal wall during contractions.
Major approaches to Prepared Childbirth

Grantly – Dick Read Method

- Fear leads to tension and tension leads to pain
- Breathing techniques

Lamaze
•Psychoprophylactic Childbirth
•Based on stimulus response conditioning. To be effective, full concentration on
breathing exercises during labor should be observed, mouthing silently words or songs
with rhythmical tapping of fingers.

Leboyer Method
•the contrast of uterine environment and the external world causes infant
to suffer psychological shock at the time of delivery •relaxing the
craniosacral axis.
I. LABOR AND DELIVERY
Theories of Labor Onset

Uterine Stretch Theory – any hollow body organ when stretched to

capacity will necessarily contract and empty. Oxytocin Theory – labor,
being considered a stressful event stimulates the hypophysis to produce
oxytocin from the posterior pituitary gland. Oxytocin causes contraction of
the smooth muscles of the body.
Progesterone Deprivation Theory – progesterone, being the hormone
designed to promote pregnancy, is believed to inhibit uterine motility. Thus, if
its amount decreases labor pain occurs. Prostaglandin Theory – initiation of
labor is said to result from the release of arachidonic acid produced by
steroid action on lipid precursors. Arachidonic acid is said to increase
prostaglandin synthesis, which in turn causes uterine contractions.
Theory of Aging Placenta – because of the decrease in blood supply, the
uterus contracts.
SIGNS OF LABOR
 Preliminary Signs/ Prodromal Signs of Labor

1. Lightening – refers to the settling of the fetal head into the pelvic brim. It
results in increase in urinary frequency, relief of abdominal tightness and
diaphragmatic pressure, shooting pains down the legs because of
pressure on the sciatic nerve.
2. Engagement – occurs when the presenting part has descended into the
pelvic inlet.
3. Increase activity level
4. Loss of weight
5. Braxton Hicks Contraction – painless, irregular practice contractions.
6. Ripening of the Cervix – from Goodell’s sign, the cervix becomes “butter-
soft”.
7. Rupture of the Membranes – BOW ruptured, integrity of the uterus is
already destroyed.
8. Show – due to pressure of the descending presenting part of the fetus
which causes rupture of minute capillaries in the mucus membrane of the
cervix. It is only Pinkish Vaginal Discharge.
Uterine Contractions
 The surest sign that labor has begun is the initiation of effective,
productive uterine contractions

Phases:
•INCREMENT – first phase which the intensity of contraction increase,
also known as CRESCENDO.
•ACME – the height of the uterine contraction; also known as
APEX
•DECREMENT – last phase during which intensity of contraction
decreases; also known as DECRESCENDO.
Differences between False and True Labor Pains
False Labor Pains True Labors
1. Remain irregular of uterine 1. Maybe slightly irregular at first but become regular and predictable
contraction. (3-4 contraction every 2hours)

2. Generally confined to the 2. First felt in the lower back and sweep around to the abdomen in a
abdomen. movement)

3. No increase in duration, 3. Increase in duration, frequency and intensity.

frequently and intensity
 4. Often disappears if the woman 4. Continue no matter what the woman’s level of activity is being don
ambulates/walking.

5. Absent cervical changes 5. Accompanied by cervical effacement and dilatation. (thinning of th

Effacement
•Shortening and thinning of the cervical canal as district from the uterus.
Dilatation
•Enlargement of the external cervical os up to 10cm primarily as a result of uterine contractions and
secondarily as a result of pressure of the presenting part and the BOW.
Length of Normal Labor
Stage of Labor Primis M

First Stage 12 ½ hours 7 hours, 20

Second Stage 80 minutes 30 minutes

Third Stage 10 minutes 10 minutes

TOTAL 14 minutes 8 hours

COMPONENTS OF LABOR

Passage
Passenger
Power
STAGES OF LABOR
 A. First Stage (Stage of Dilatation)
begins with true labor pains and ends with complete dilatation of the
cervix.
Power/ Forces: involuntary uterine contractions

3 PHASES (LAT)

•Latent – early in time labor

•Cervix dilates only 3-4cm. Contractions are of short duration and occur
regularly 5-10 minutes apart.
•Active/ Accelerated
•Cervical Dilatation reaches 4-8cm. Rapid increase n duration, frequency
and intensity of constractions.
•Transition Period
•When the mood of the women suddenly changes and the nature of the
contractions intensify.
B. Second Stage (Stage of Expulsion)
Begins with complete dilatation of the cervix and ends with the delivery
of the baby.
Power/ Forces: Involuntary uterine contractions and contraction of the
diaphragmatic and abdominal muscles.
Mechanisms of Labor/ Fetal Position Changes (ED FIRE ERE)

•Engagement
•Descent – maybe preceded by engagement.
•Flexion – as descent occurs, pressure from the pelvic floor causes the chin
to bend forward onto the chest.
•Internal Rotation – from AP to transverse, then AP to AP.
•Extension – as head comes out, the back of the neck stops beneath the pubic
arch. The head extends and the forehead, nose, mouth and chin appear.
•External Rotation (also called as the Restitution) – anterior shoulder rotates
externally to the AP position.
•Expulsion – delivery of the rest of the body.
•C. Third Stage (Placental Stage)
begins with the delivery of the baby and ends with the delivery of the
placenta.

•Signs of Placental Separation

•Calkin’s Sign – the earliest sign of placental separation.
•Sudden gush of blood from the vagina.
•Lengthening of the cord.
 •Types of Placental Delivery
Schultz – if placenta separates first at its center and last at its
edges, it tends to fold on itself like an umbrella and presents the
fetal surface which is shiny (SHINY for SCHULTZ), 80% of placentas
separate in this manner.
Duncan – if placenta separates first at its edges, it slides along the
uterine surface and presents with the maternal surface, which is raw,
red, beefy and dirty (DIRTY for
DUNCAN). Only about 20% placentas separate this way.
D. FOURTH STAGE

•First 1 – 2 hours after delivery, which is said to be the most critical stage for the
mother because of unstable VS.(Blood Pressure)
 First Stage

•Station – relationship of the fetal presenting part to

the level of the ischial spines
•Station 0 – at the level of the ischial spines, synonymous
to engagement
•Station -1 – presenting part above the level of the ischial
spines.
•Station +1 – presenting part below the level of the ischial
spines.
•Station +3 or +4 – synonymous to crowning
encircling of the largest diameter of the fetal head
by the vulvar ring.
PRESENTATION
•Relationship of the long axis of the mother to the long axis of the fetus; Also
known as LIE

1. VERTICAL
•Cephalic – head is the presenting part
•Vertex – head is sharply flexed, making the parietal bones the presenting
parts.
•In poor flexion – face, brow, chin (MENTUM)
•Breech – buttocks are the presenting parts.
•Complete – thighs are flexed on the abdomen and legs are on the thighs.
•Frank – thighs are flexed and legs are extended, resting on the anterior
surface of the body.

Footling
Single – one leg unflexed and extended; one foot presenting.
Double – legs unflexed and extended; feet are presenting.
2. HORIZONTAL

•Transverse Lie
•Shoulder Presentation
 POSITION

•Relationship of the fetal presenting part to a specific quadrant

in the mother’s pelvis.
Possible Fetal Positions
Vertex RST – right sacrotransverse
LOA – left oxipitoanterior – most favorable FACE
LOP – left oxipitoposterior LMA – left mentoanterior
LOT – left oxipitotransverse LMP – left mentoposterior
ROA – right oxipitoanterior LMT – left mentotransverse
ROP – right oxipitoposterior RMA – right mentoanterior
ROT – right oxipitotransverse RMP – right mentoposterior
RMT – right mentotransverse
BREECH
LSA – left sacroanterior SHOULDER
RSA – right sacroanterior LADA – left acromiodorsoanterior
LSP – left sacroposterior LADP – left acromiodorsoposterior
RSP – right sacroposterior RADA – right acromiodorsoanterior
LST – left sacrotransverse RADP – right acromiodorsoposterior
NURSING CARE DURING LABOR

Monitoring and evaluating important aspects like uterine contraction

(duration, interval, frequency and intensity), BP, FHT.
Emotional support is provided for the women in labor.
Health Teachings – Bath, Ambulation, NPO, Enema Encourage the
mother to void every 2 – 3 hours by offering the bedpan.
Perineal prep done aseptically and perineal shave.
Encourage Sim’s Position.
Woman in labor should not be allowed to push or bear down
unnecessarily during contractions of the first stage.
Abdominal Breathing
Administer analgesics as ordered.
Assist in administration of original anesthesia.
Transition Period
•Nursing Actions are primarily comfort measures.
•Sacral Pressure relieves discomfort from contractions.
•Proper bearing techniques.
•Controlled chest breathing during contractions.
•Emotional support.
 Second Stage
•When positioning legs on lithotomy, put them up at the same time to prevent
injury to the uterine ligaments.
•As soon as the fetal head crowns, instruct mother not to push, but to pant
(rapid and shallow breathing to prevent rapid expulsion of the baby).
•Assist in episiotomy (incision made in the perineum primarily to prevent
lacerations).
Types of Episiotomy
•Median – from middle portion of the lower vaginal border directed toward the anus.
•Mediolateral – begun in the midline but directed laterally away from the anus. •Often
done because it prevents 4th degree laceration should it occur despite episiotomy.
Natural Anesthesia
Apply the Modified Ritgen’s Maneuver
Immediately after delivery, the newborn should be held below the level of the mother’s vulva for a few
minutes to encourage flow of blood from the placenta to the baby. The infant is held with his head in a
dependent position to allow for drainage of secretions.
Wrap the baby in a sterile towel to keep him warm. Chilling increases the body’s need for oxygen.
Put the baby on the mother’s abdomen. The weight of the baby will help contract the uterus.
Cutting the cord is postponed until the pulsations have stopped because it is believed that 50 – 100ml.
of blood is flowing from the placenta to the baby at this time. After cord pulsations have stopped, clamp
it twice, an inch apart and then cut in between.
Show the baby to the mother, inform her of the sex and time of delivery then give the baby to the
circulating nurse.
Third Stage

Do not hurry the expulsion of the placenta by forcefully pulling out the cord or doing
vigorous fundal push as this can cause uterine inversion.
Tract the cord slowly, winding it around the clamp until the placenta spontaneously comes
out, slowly rotating it so that no membranes are left inside the uterus, a method called
BRANDT – ANDREWS MANEUVER.
Take note of the time of placental delivery.
Inspect for completeness of cotyledons; any placental fragment retained can also cause
severe bleeding and possible death.
Palpate the uterus to determine degree of contraction.
Inject oxytocin (Methergin=0.2mg/ ml or Syntocinon=10U/ ml) IM to maintain
uterine contractions, thus preventing hemorrhage. NOTE: OXYTOCIN are not given
before placental delivery.
Inspect the perineum for lacerations.
Make mother comfortable by perineal care and applying clean sanitary napkin snugly to
prevent its moving forward from the anus to the vaginal opening.
Position the newly delivered mother flat on bed without pillows to prevent dizziness due to
decrease in intra abdominal pressure.
The newly delivered mother may suddenly complain of chills due to decreased BP, fatigue
or cold temperature in the delivery room.
NSG. INTERVENTION: Provide addition blankets to keep her warm.
May give initial nourishment.
Allow patient to sleep in order o regain lost energy.
Fourth Stage

•Assessment of the fundus, lochia, bladder, perineum, BP and PR. •Lactation

- suppressing agents, estrogen, androgen preparations given within the first
hours postpartum to prevent breast milk production on mothers who will
not breastfeed.
•Rooming – In Concept (Giving the baby to the mother) •Lochia
Assessment
J. PUERPERIUM
Terminologies:

Puerperium/ Postpartum
a) Refers to the 6 week after delivery of the baby.
b) Involution – return of the reproductive organs to their pregnant
state.
PHASES OF PUERPERIUM
a) Taking in phase (2 – 3 days)
• “Woman is largely passive”
• Is a time reflection
• A time when the new parent review their pregnancy, labor
and birth.
b) Taking Hold Phase
• “Woman initiates action”
c) Letting Go Phase
• “The woman finally redefines her new role”, she gives up the
fantasized image of her child and accepts the real one. She
gives up her old role of being childless
MATERNAL NEWBORN ATTACHMENT

Bonding – breast feeding

Mother – “claiming”
En face position
Father – “engrossment”
Rooming – In
Sibling visitation
A chance to visit the hospital and see the new baby and their mother,
reduces feeling that their mother cares more about the new baby.
It helps relieve from impact of separation.
MATERNAL CONCERNS AND FEELINGS IN THE POSTPARTAL PERIOD

Abandonment
Disappointment
Postpartum blues
Labile mood and affect
Crying spells
Sadness
Insomnia
Anxiety
PHYSIOLOGIC CHANGES DURING PUERPERIUM

1. Systemic changes
2. Reproductive System Changes
 a. Vascular Changes

30%-50% increase in cardiac volume for 5-10 minutes after placental

delivery
Activation of the clotting factors, which encourages
THROMBOEMBOLIZATION
*massage is not advisable
b. Genital Changes
Uterine involution- measure the fundus using fingerbreath
Knee-chest position
Afterpains/ afterbirth pain- abdominal pain for large baby, twin delivery, etc.
•For breastfeeding mothers, it last for not more than 3 days
•Heat packs- not advisable
Lochia- blood, residues, bacteria, mucous
-Increase activity= increase lochia
- breastfeeding= decrease lochia
•Pattern of Lochia
a) Lochia Rubra- red, 1-3 days, moderate amount
b) Lochia Serosa- 4-6 days, lower amount than in lochia rubra
c) Lochia Alba- 10-14 days or up to 6 weeks, minimal amount

Characteristics of Lochia:
•Pattern should not reverse.
•It should approximate menstrual flow.
•It should not have any offensive odor.
•It should not contain large clots.
•It should never be absent regardless of method of delivey.
•Pain in the perineal region may be relieved by Sim’s position.
c. Urinary Changes
Marked dieresis within 12 hours postpartum
Frequent urination- small amount/ scanty
d/t urinary retention overflow

d. GI Changes
Decreased muscle tone
Lack of food + enema during labor
Dehydration
Fear of pain from perineal tenderness

e. Vital Signs
Temperature may be increased
 Bradychardia is common for 6-8 days
There’s no change in the respiratory rate.
NURSING CARE DURING THE PUERPERIUM

•Promote healing and return to normal (involution) of

different parts of the body •Provide emotional support
•Prevent postpartum complication
POSTPARTUM COMPLICATION:

1. PP Hemorrhage- blood loss of more than 500 cc during delivery *normal:

250-350 cc a.early- 1st 24 hours
•Causes: uterine atony, laceration, hypofibrinogenemia
•Uterine Atony- boggy/relaxed uterine CAUSES:
1. CS
2. Over distention of the uterus
3. Placental accidents
4. Prolonged/difficult labor NURSING ACTIONS:
1. Massage the fundus (milking massage)
2. Ice compress (abdominal area)
3. Oxytocin administration
4. Empty the bladder
5. Bimanual compression
6. Hysterectomy
•Hypofibrinogenemia- d/o of clotting factors *administer BT
2. PP Infection

Establish successful lactation

 K. IMMEDIATE CARE OF THE
NEWBORN

Suctioning- 5-10 seconds to prevent hypoxia

- mouth first before nose to prevent vagal stimulation
that leads to bradychrdia
Establish and Maintain Patency of Airway- cover nostril one at a time
Positioning- slight trendelenburg, side lying but avoid prone position (promotes
drainage,prevents increase ICP, promotes closure of foramen ovale and ductus
arteriosus, prevents aspiration) *Signs of Increased ICP:
•High pitch, high shrill cry
•Spontaneous vomiting
•Bregma and Lambda are bulging and very dense
•Increased BP
•Decreased CR & RR
•Widening of pulse pressure
Maintain Appropriate Temperature- normal temp is 36.4˚C -37.2˚C *Temperature is
unstable but stabilizes in 6-8 hours
SECOND PERIOD OF REACTIVITY
•Immature hypothalamus
•Inadequate brown fat
•Shivering mechanism is underdeveloped
*Babies are born wet (more heat loss)
Evaporation
Radiation
Convection

Con
ducti
 on
Nurs
ing
Care
:
Dry once
Wrap
Expose to drop light
Encourage the mother to cuddle and embrace the baby

Complications:
•Hypoglycemia- d/t use of glucose
•Metabolic acidosis
FIRST PERIOD OF REACTIVITY
•Methods:
1. Breastfeeding- best
method Other Purpose:
i. Colostrum- first milk
- high protein-
LACTOGLOBULIN, high antibody-
IgA, high WBC, macrophages and
Lactoferin - these protect infant
against bacterial and viral
infections of the
respiratory and GI systems
- high levels of vitamins
ABCDE, low levels of CHO and
COOH
ii. Promotes uterine contractioniii.
Prevents physiologic jaundiceICTERUS NEONATORUM d/t
stimulation of
gastrocolic reflex
*bilirubin- responsible for jaundice
Rooming-in:
a) Complete- mother and child are together 24 hour a day
b) Partial- infant remains in the woman’s room for most of the time
(8AM-9PM) but he/she is taken to a small nursery near the woman’s
room for the night
3. Senses stimulation:
a) Touch and hearing- highly developed
b) Sight and smell- least developed but one of the best methods to
promote bonding
ASSESSMENT:
 •APGAR Scoring Test by Virginia Apgar
Assess general condition of
infant Done twice at 1 & 5 mins.
Determine the degree of acidosis and the need for CPR To evaluate
ability of the NB to adjust extrauterinely and the prognosis

Score Interpretation
•0-3: poor, serious or severely depressed; needs immediate CPR •4-6: fair,
guarded or moderately depressed; needs further observation and suctioning
•7-10: good of healthy
**therefore: the higher the Apgar score, the better
IDENTIFICATION

•Best accomplished before transfer to the nursery ( footprints, ID

bands, birthmarks )
CARE OF THE NEWBORN IN THE NURSERY
•Recheck ID
•Take the temperature initially- per rectum to determine anal patency
(primary reason)
•Complications related to frequent rectal temperature taking:
• Perforation of the mucous membrane
• Vagal stimulation
•Special initial care:
a. Initial bath- best done with
temperature of the NB stable or at least 37˚C
Water with non-alkaline soap- prevent the destruction
of the acid mantle of the skin
Oil- appropriate in case vernix caseosa is plenty Anti-microbial
solution- most preferred in NB of mothers with infections in the vaginal
canal: Trichomoniasis,
Candidiasis, STD, Gonorrhea
b. Cord dressing
Done with strict aseptic technique practices
Include application of CORD CLAMP- prevent OMPHALANGIA
(bleeding)
Include application of ANTISEPTIC SOLUTIONS:
•Povidone Iodine- Betadine (prevents Tetanus Neonatorum
•Alcohol 70%- prevents Omphalitis
Inspect the blood vessels (2 arteries and 1 vein), in case 1 of the arteries is
absent indicates a congenital disorder of possibly the GIT, CV % GUT
**Cord falls on 7th-10th day
 c. Credes Prophylaxis- Ophthalmic
Ointment
-Prevent or prophylactic treatment against
OPHTHALMIA NEONATORUM
MEDICATIONS:
•Ophthalmic drops- Silver Nitrate 1%
•Ophthalmic
ointment
Teramycin
- most
common
Erythromycin- Chlamydia infections, 4 days
Vit. K injection- left vastus lateralis, prevent bleeding

PHYTONADIONE- Aquamephyton
PHYTOMENADIONE- Konakion
Full term- 1 mg
Preterm- 0.5 mg
Amt- 0.05-0.1 ml
Route- IM
Site- Vastus Lateralis (prevent injury to sciatic nerve that may lead
to paralysis
ANTHROPOMETRIC MEASUREMENTS:

Birth weight- normally 2.5 kg to 3.4 kg or 5.5 lbs to 7.8 lbs

Birth length- normally 47.5 to 53.75
cm Like the BW the BL:
Increases by 50% at age of 1 year
Doubles at 2 years (length at 2 years is half of adult height)
Average of 50 cm at birth
***Note: children under 24 mos- take the RECUMBENT HEIGHT in supine
Children over 24 mos- take height in standing position
Head circumference- 33-35 cm or 13-14 inches
HC < 32 cm- Microcephaly
HC > 37 cm- Macrocephaly
No fetal skull- Anencephaly
Chest circumference- 31-33 cm or 12-13 inches
Abdominal circumference- 29-31 cm or 11-12 inches
PHYSICAL ASSESSMENT
•Vital signs- PR/CR & RR
*RR: 30-60/min; 80/min at birth
> rapid, irregular with normal physiologic apnea of less than 15 seconds Note: observe
signs and symptoms of respiratory distress
 •Tachypnea
•Bradypnea
•Nasal flaring
•Retractions
•Expiratory grunt
*PR: 120-160/min; at birth- 180/min Characteristics:
Rapid, irregular
Increases with activity & as low as 100/min when asleep SITES:
•Apical pulse- most preferred for children under 3 y/o
•Brachial pulse- site to check pulsation in case CPR is necessary
•Femoral pulse
•Pedal pulse
•Radial pulse- common site for children over 3 y/o
*Temperature: at birth
36.4- 37.2˚C
Characteristics:
Unstable
Stabilize between 6-8 hours known as the 2 nd period of
reactivity
*Blood Pressure: at birth- 80/46 mmHg; at 10 th day 100/50
mmHg
Methods:
•Doppler
•Flush- normally 60 mmHg
Head- largest part of the body & ¼ of the total length.
Assess the following:
Fontanels (soft spot):
normally 6 in number
2-paired: Anterolateral & Posterolateral
2 single: Anterior (Bregma) & Posterior (Lambdoid)
a) Anterior- closes between 12 mos- 18 mos,
diamond shaped, 3-4 cm long and 2-3 cm wide. *if
>5cm: sign of Cretinism/ Congenital
Hypothyroidism.
b) Posterior- triangular shaped, center of the 3
sutures, closes between 6 weeks- 12 weeks or 3-4
months, measures 1x1 cm

Assess further for:

a) Bulging- increased ICP
b) Depressed- dehydration
c) Craniostenosis or Craniosynostosis Complications:
•Increase ICP
 •Mental Retardation
Other Structures:
Caput Succedaneum
Affects both hemisphere
Swelling of the sculp
Disappears on or before 3rd day
Cephalhematoma
Collection of blood
Caused by increase pressure of birth
Rupture of periosteal capillaries
Disappears in 3-4 weeks
Craniotabes
 Localized softening of cranial bones
 Caused by early lightening (2wks for primis and 1 day for multis)
 Disappears in 6 wks

Eyes- NB usually cry tearlessly, because their lacrimal ducts do not fully mature until
about 3 months of age.
L. BREASTFEEDING

Physiology of Breastmilk Production

•Estrogen and progesterone levels after placental delivery-

stimulates APG to produce PROLACTIN- acts on acinar cells
to produce foremilk- stored in collecting tubules.
•When infant sucks- PPG is stimulated to produce OXYTOCIN-
causes contraction of smooth muscles of collecting tubules-
 milk ejected forward, LET- DOWN /MILK EJECTION REFLEX-
hindmilk is produced.
Patient teaching:

Line bra with soft cotton, never use plastic lining. Let
nipples air dry 5-15 mins before replacing bra
Wash breasts with water, if soap is used, rinse completely
Use well fitting supportive bra
Avoid using harsh cleanser
Use a breast pump
A tingling sensation is often felt just before leakage begins.
Well balanced diet
It takes about two days for the infant to establish a sucking pattern.
Colostrums will be secreted initially and the infant should be encouraged to take it.
Milk appears 48-96 hours after delivery.
Teach positions for burping the baby, upright, across lap, or on shoulder
Fluid intake of at least 3000 ml/day
Teach the mother to bring the infant to breast, not pulling the breast to the infant
Teach mother to support the infant’s head while feeding such as the cradle or the football hold.
Associated Nursing Diagnosis
•Anxiety
•Breastfeeding, ineffective
•Infant feeding pattern, ineffective
•Knowledge deficit
•Breastfeeding, effective
•Nutrition: Less than body requirements, altered

Associated Problems
•Engorgement- feeling of tension on the breasts during the 3 rd
postpartum day sometimes accompanied by fever.
•Sore nipples
Associated problems:
•Mastitis- localized pain, swelling and redness, lamps in the breast and
milk becomes scanty.
•Nutrition
Lactating mothers should take 3000 calories daily and should
have larger amounts of CHON (96 g/day), Ca, Fe, Vit. A, B & C.
BREASTFEEDING
•Best for babies
•Reduces the incidence of allergies
•Economical
•Antibodies, greater immunity
•Stool inoffensive
 •Temperature is always ideal
•Fresh milk never goes off
•Emotional bonding
•Easy once established
•Digested easily with 2-3 hours
•Immediately available- no mixing req’ts
•Nutritionally optimal
•Gastroenteritis greatly reduced

Additional notes:
•Ambulation
a) 4-8 hours after NSD
b) 24 hours after CS
•Return of sexual activity: 3rd-4th week postpartum
•Menstruation returns: 8th week