CARE OF MOTHER, CHILD, & ADOLESCENT  Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN)

Goals & Philosophies of MCN

Obstetric – care of women during childbirth (Gk: obstare, “to keep watch”)
Pediatrics –Gk: pais, “child”
Major Focus of Nsg: care for childbearing & its family bc to have healthy adults, must
have healthy children
Primary Goal of MCN
- Promote & maintain optimal fam health for optimal childbearing & childrearing
- Keep family at center of care/ primary unit of care
Scope of Practice
1. Preconceptual health care (before conception like family planning)
2. Care of women during 3 trimesters of pregnancy and the puerperium
3. “ “ infants during the perinatal period
4. “ “ children from birth to adolescence
5. Care in settings (birthing room, pediatric intensive care unit, the home) Nsg Theories in MCN
Philosophies of MCHN RAMONA T. MERCER: MATERNAL ROLE ATTAINMENT THEORY / BECOMING A MOTHER
1. MCHN is family centered; assessment include family & individual assessment data - process of becoming mother needs psycho, social, …………..
2. “ community-centered; fam health depends on & influence community health - nurses have opportunity to help women learn, gain confidence, experience growth as they
3. “ evidence based (not experimental), bc it’s means where critical knowledge increases. assume mother identity.
4. maternal & child health nurse as advocate to protect right of all fam members & fetus 4 stages of becoming a mother
5. MCHN includes high degree of independent nursing fx, bc teaching & counselling are 1. Commitment, Attachment, & Preparation (ANTICIPATORY) (pregnancy)
major interventions. - Begins during pregnancy & initial social/ psychological adjustments to pregnancy.
6. Promoting health & disease prevention are important nursing roles bc it protect 2. Acquaintance, Learning, & Physical Restoration (FORMAL) (first 2 weeks)
health of the next generation. - birth & learning and taking on role of mother.
7. MCH nurses as resources for fam during birth & childrearing as these can be stressful 3. Approaching towards a New Normal (INFORMAL) (2weeks - 4 mos)
8. Personal, cultural, religious attitude, belief influence meaning & impact of birth/rearing - Begins as mother develops unique ways of dealing w/role not conveyed by social system.
9. Circumstances like illness/pregnancy are meaningful only in context of total life. 4. Achievement of Maternal Identity (PERSONAL) (4mos & beyond)
10. MCHN is a challenging role for nurses and a major factor in keeping families well and - woman internalizes her role.
optimally functioning.
Standards of Care CHERYL TATANO BECK: POST PARTUM DEPRESSION THEORY
- birth is an occasion for joy, but for some women, joy is not an option.
1. Comprehensive pediatric nsg care focuses on helping children, fam, community
achieve their optimum health potentials (family-centered) symptoms: • Tearfulness; excessive crying • Extreme mood changes
2. Standards developed by: • Loss of appetite (lengthened period postpartum) • Suicidal ideation
American Nurses Association in collaboration w/ Society of Pediatric Nurses • Feelings of inadequacy & inability to cope w/ infant
Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN) Predictors: 1. Prenatal depression 2. Childcare stress 3. Prenatal anxiety 4. Life stress
American Nurses Association in collaboration w/ Society of Pediatric Nurses 5. Social support 6. Marital relationship 7. History of previous depression
 American Nurses Association in collaboration w/ Society of Pediatric Nurses: 8. Infant temperament 9. Maternity blues 10. Low self-esteem
11. Single marital status 12. Low socio-economic status
13. Unplanned/unwanted pregnancy

WHO 17 SUSTAINABLE DEV’T GOALS

 MATERNAL & CHILD NURSING Estrogen- Inhibits FSH; cause hypertrophy of myometrium; growth of breasts ducts
- ↑ ph of cervical mucus, making it thin & watery (Spinnbarkheit test)
- Principles/techniques of caring for normal mothers, infants, children & family;
- Proliferates the endometrium; ↑ production (cervix)
application of principles/concepts on family & family health nursing process.
Progesterone- inhibits LH; ↑ endometrial tortuosity & endometrial secretion
Anatomy & Physiology - Inhibits uterine motility; transport of fertilized ovum through fallopian tube
GONAD - ↑ body temperature after ovulation; ↑ production (endometrium)
- produce reproductive cells
- ovary, testes

Graafian follicle (ovum about to be discharged) - unruptured, glistening, clear, fluid-filled

Corpus Luteum (left behind after ovum has been discharged) – small, yellow

MENSTRUAL CYCLE
a. 4 LEVELS
Semen: 60%- prostate gland 5%- epididymis 1. CNS Response- hypothalamic-pituitary gland action (FSH & LH)
30%- seminal vesicle 2. Ovarian Response- 2 phases: Proliferative (1-14 days), Secretory (15-22 days)
5%- bulbourethral gland 3. Endometrial Response:
 3-5 cc (1 tsp) per ejaculation MENSTRUATION- beginning & end; ↓E ↓P
- as corpus luteum regresses, it’s gradually replaced by white
Spermatozoa- by testicles fibrous tissue corpus albicans
40-80 mil/cc of semen 12-20 days travel PROFILERATIVE/ESTROGENIC/PREOVULATORY/FOLLICULAR (6-14 days)
300-500 mil/ejaculation mature after 64 days - in 28-day cycle: ↑E ↓P
- ↓ hypothalamus senses, stimulating APG to secrete GnRH, releasing FSH to
stimulate ovaries to produce follicles (10-20)
- follicles ripen but only 1 matures (Graafian follicle)
OVULATORY (14-15 days)  PEAK
- Graafian follicle ruptures & release mature ovum near fallopian tube
- 2 ova fertilized (fraternal); 1 fertilized ovum divides in 2 dif zygote (identical)
- ↑ hypothalamus senses; estrogen trigger APG to release LH 9act w/FSH) to
cause ovulation & enhance corpus luteum formation
SECRETORY/LUTEAL/PROGESTERONIC (16-28 days)
- corpus luteum secrete progesterone to maintain endometrial vascularity
- ↓È & ↑P cause endometrium gland to secrete nutrient to sustain fertilized
ovum implanted in uterine wall
- no implantation: hypothalamus signal pituitary gland to stop making FSH & LH
- ↓FSH ↓LH: corpus luteum decompose in ovary & endometrium nourish stop
ZONA PELLUCIDA
- ring of mucopolysaccharide fluid HYPOTHALAMUS
CORONA RADIATA
- circle of cells ANTERIOR PG PITUITARY GLAND POSTERIOR PG
FSH MSH Oxytocin
LH Prolactin ADH/Vasopressin
TSH ACTH
GH
Uterus Layers
a. ENDOMETRIUM- INNER OF MUCOUS MEMBRANE PREGNANCY
- for menstrual fx; grows thick & responsive each month bc of estrogen & • Normal # semen/ejaculation: 3.5 cc  # sperm/cc: 40-80 mil; # sperm/ejac: 300-500 mil
progesterone that it is capable of supporting a pregnancy. • Mature ovum fertilize for 12-24 hrs after ovulation; Sperm fertilize 3-4 days after ejac
- If pregnancy does not occur, it sheds as menstrual flow. • Normal lifespan of sperm is 7 days; reach ovum in 1 – 5 mins.
b. MYOMETRIUM- MIDDLE OF MUSCLE FIBERS; fetus expulsion; smooth muscle layer • Fallopian tube will contract due to estrogen
c. PERIMETRIUM- OUTER OF CONNNECTIVE TISSUE • Sperm remain in female genital tract 4 – 6 hrs before fertilizing the ovum
• Sperm (22 autosomes & 1 X /Y sex chromosomes), Ova (22 autosomes & 1 X sex chromo)
MENSTRUATION
- menarche, menopause; 300k-400k oocytes per ovary Stages
- avg cycle: 28 days/25-35 days; duration: 3-5 days 1. Fertilization - sperm penetrates outer layer of ovum.
- Anovulation 1-2 yrs after menarche; flow is 3-80 ml blood 2. Implantation- blastocyst attaches endometrium (7 -9 days after fertilization)
- involves hypothalamus, APG, ovary, uterus, vagina, 3. Pre-placental- endometrium becomes highly vascular (week 2).
- hormones: FSH-estrogen, LH-progesterone 4. Placental & fetal development
- Mittelschmerz; first 14 days variable, last 14 days is fixed
 UMBILICAL CORD- 21 inches long; 2 arteries & 1 vein; Wharton’s jelly (bulk of cord)
- Transport oxygen, nutrients, minerals, waste products
AMNIOTIC FLUID- 500 – 1000 ml inside amniotic sac (BOW); made by amniotic membrane
- Shields fetus from pressure & temp change ; aid in muscular dev’t & descent
- Protects umbilical cord from pressure & fetus from infection
PLACENTA
1. Respiratory system 2. Renal system 3. Gastrointestinal system
4. Endocrine system: Human chorionic gonadotropin
Human placental lactogen
Estrogen and Progesterone
5. Protective fx: IgG – 20th week & 24th week for temporary passive immunity

Fetal Development

focus:  First Trimester – organogenesis

IMPLANTATION  Second Trimester- continued growth & development
- 50% of zygote never achieve implantation; Small # vaginal spotting is occasionally present  Third Trimester- most rapid “ “ “
- Endometrium turned to decidua: decidua basalis, decidua capsularis, decidua vera
- 3 processes: apposition, adhesion, invasion

Human Development
Late Blastocyst- cell turn to: inner cell mass (embryo) & trophoblast cell (attach to uterus)
- trophoblast cell erode uterus endometrium so blastocyst burrow into uterine wall
- endometrium cover embryo & blood supply establishes
Primary Germ Layers

Fetal Circulation

- during implantation, blastocyst differentiate where 2 cavities appear in inner structure: Normal Adaptation in Pregnancy
(1) amniotic cavity (large): lined w/distinctive layer of cells, ectoderm A. REPRODUCTIVE SYSTEM
(2) yolk sac (small): lined w/ endoderm cells; supply nourishment until implantation, after,Uterus- uterine growth & enlargement  length: 6.5 cms - 32 cms
source of RBC until embryo’s hematopoietic sys is mature enough width: 4 - 24 cms
 Between these 2, mesoderm (third layer of primary cells) forms. depth : 2.5 - 22 cms
weight: 50 - 1000 gms
 Chorion – outermost membrane surrounding the embryo
volume: 1–2 - 1000 ml
 Amnion – innermost membrane enclosing the embryo
- Braxton Hicks contraction; becomes globular (4th month)
 Yolk Sac - atrophies & remains only as a thin white streak discernible in cord at birth.
- Goodell’s sign (4th wk); Hegar’s sign (8th wk), Chadwick’s sign (8th-10th wk)
 Allantois – future umbilical cord; fetal membrane below chorion in vertebrates formed
as outgrowth of embryo’s gut Ovaries - no ovulation Vagina- more acidic (ph 3.5 to 6) Breasts – enlarged
- help embryo exchange gases & handle liquid waste B. MUSCULOSKELETEAL SYS- waddling walk, symphysis pubis separate slightly
C. CIRCULATORY SYS- ↑ blood volume 40%-50%; physiologic anemia
- heart is displaced upward; ↑ cardiac output to 30%
- supine hypotension; ↑WBC; ↑CR & PR to 10 -15 bpm; varicosities
D. INTEGUMENTARY SYS- ↑pigmentation; chloasma/melasma; striae gravidarum
- linea nigra; ↑ perspiration
E. GASTROINTESTINAL SYS- morning sickness, heartburn, constipation
F. RESPIRATORY SYS- ↑RR, dyspnea, ↑tidal volume, ↑vital lung capacity, ↓ residual vol
G. URINARY SYS- ↑urinary frequency, ↑GFR
H. ENDOCRINE SYS- ↑CHON & CHO metabolism, ↑insulin production abruptio placenta:

placenta previa:

WEIGHT GAIN- distribution: fetus – 7 lbs placenta – 1 lb amniotic fluid – 1.5 lbs
uterus- 2 lbs bld volume- 1 lb breasts – 1.5 3 lbs
fluid – 2 lbs fats – 4 -6 lbs TOTAL: 20-25 lbs
Signs • PRESUMPTIVE- least indicative; can mean other conditions; largely subjective b. Persistent vomiting: > hyperemesis gravidarum > persistent infection
• PROBABLE- documented by examiner (lab tests, pregnancy test) c. Chills & fever –infection, dehydration, gastroenteritis
• POSITIVE- Fetal Heartbeat & movement felt by examiner, USD visualization of fetusd. Sudden escape of fluid from vagina
1ST TRIMESTER: Presumptive- amenorrhea, morning sickness, breast changes, fatigue, e. Abdominal/chest pain- > ectopic pregnancy > appendicitis >abruptio placenta
urinary frequency, enlarging of uterus > ulcer > uterine rupture > pancreatitis
Probable- Chadwick’s sign, Goodell’s, Hegar’s, (+)hCG > pulmonary embolism
Positive: ultrasound result f. Pregnancy-induced hypertension: face-finger swell, fast wt gain, light flash/dot on eyes
2ND “ : Pre- – quickening, skin pigmentation, Chloasma, linea nigra, striae gravidarum dimness/blurring of vision, severe headache, ↓ urine output
Pro- enlarged abdomen, Braxton Hick’s, Ballottement g. ↑ / ↓ Fetal Movement- fetus may need O2; for further testing
Pos- FHT, fetal movements, fetal X-ray
PELVIC EXAM: 1. Internal Exam 3. Transvaginal Ultrasound
Prenatal Care: Data Gathering (Demographic, Obstetrical, Medical Health History data) 2. Vaginal Speculum 4. Papanicolaou (Pap smear)
Physical Assessment Fetal Heart Tone Monitoring
LEOPOLD’S MANEUVER- non-invasive; know fetal presentation, position, attitude
Pelvic Exam Lab Exam Leopold’s Maneuver
- locate fetal back before applying fetal monitor
Pregnancy Status - equipment: Warm, clean hands
PARA- # pregnancies reaching viability, regardless if it’s born alive Fundal Grip- know presentation Pelvic Grip – for presentation
GRAVIDA- woman who is/has been pregnant Umbilical Grip – “ position Pawlick’s Grip – for attitude/engagement
st
PRIMIGRAVIDA- pregnant for 1 time
PRIMIPARA- has given birth to 1 child past age of viability
MULTIGRAVIDA- has been pregnant previously
MULTIPARA-carried 2 or more pregnancies to viability
NULLIGRAVIDA- never been/not currently pregnant
Obstetrical Data
 Last Menstrual Period (LMP)
 Age of Gestation (AOG)- by weeks; Mc Donald’s Method; Bartholomew’s rule
 Gravida Para Abortion (GPA)
 Term Preterm Abortion Living (TPAL)
 Expected Date of Confinement (EDC)- Naegel’s rule
 Obstetrical History
a. MCDONALD’S RULE- measure from fundus to symphysis

b. BARTHOLOMEW’S RULE OF FOURTHS- use landmarks to instead of numerical height

- fundus is at symphysis pubis: AOG = 12 weeks.
-“ “ midway between symphysis pubis & umbilicus: AOG = 16 wks
- “ “ umbilicus: AOG = 20 weeks.
- “ “ xiphoid process: AOG = 36 wks
c. GPA- # pregnancies
Gravida- # times one is/has been pregnant regardless of outcome
Parity/Para- # pregnancies reaching viable gestational age (28 wks); live/stillbirth
Abortus/Abortion- # pregnancy lost by abortion/miscarriage
- dropped when no pregnancies were lost; exclude stillbirth
FETAL HEART MONITORING- Stethoscope, doppler, fetoscope, ex/int electronic machine
d. TPAL- # infants/babies; exclude UNBORN - every 30 min during beginning labor, every 15 min during active
Term- # full term infants born (38-40 wks) Post Term (>42 wks) labor, every 5 min during 2nd stage of labor
Preterm- # preterm infants born (28-37 wks)
Abortion- # spontaneous miscarriages/therapeutic abortion (<28 wks) Discomforts during Pregnancy
Living- # living children 1st Tri:
NAUSEA & VOMITING- a. Eat dry cracker c. low fat meals e. Avoid antiemetics
e. NAEGEL’S RULE- +1 YEAR -3 MONTHS +7 DAYS b. Small frequent feeding d. Avoid fried foods
or +9 MONTHS +7DAYS  if LMP is around January to March
SYNCOPE- a. sit w/feet elevated b. change pos slowly c. left lateral pos

Physical Assessment 1st – 3rd Tri:

BREAST TENDERNESS- a. supportive bra w/elastic strap b. avoid soap in nipples, areola
• Void (MSCC) • Baseline ht & wt • VS (sudden ↑ BP & wt gain are danger signs)
• Cephalocaudal PA (Sudden ↓pulse/respirations = bleeding) ↑ VAGINAL DISCHARGE- a. hygiene b. cotton underwear c. avoid douching
• Observe for danger signs of pregnancy: d. consult physician if infection
1st & 3rd Tri
a. Vaginal bleeding > placenta previa (painless, bright red blood) > premature labor FATIGUE- a. Frequent rest periods b. Regular exercise c. Avoid stimulants
> abruptio placenta (painful, dark red “) > threatened abortion
URINARY FREQUENCY & URGENCY b. Cervix- dilatation: cervical os opening; 1-10 cm (fully dilated); due to uterine
a. ↑ oral fluid intake c. Void at regular intervals e. Perineal pads contraction & amniotic fluid
b. Limit fluid intake at night d. Sleep on side - effacement: gradual thinning, shortening, drawing up of cervix (0-100%)
cervical canal thinning; (100% is fully dilated cervix)
2nd & 3rd Tri
more dilated = thinner cervix
HEARTBURN- a. Small frequent feeding d. Avoid fatty and spicy foods
b. Sit upright for 30 min after meal e. Avoid antacid unless prescribed
c. Drink milk between meals
ANKLE EDEMA- a. Elevate legs at least 2x/day c. Avoid 1 pos for long time
b. Wear support stockings d. Avoid diuretics
VARICOSE VEINS- a. support stockings e. Avoid pressure on lower legs
b. Elevate feet when sitting f. Avoid leg crossing
c. Lie w/feet & hips elevated g. Avoid stand/sit in long time
d. Move out while standing h. Avoid constricting clothing
HEADACHE- a. Change pos slowly c. Eat small snack
b. Apply cool cloth at forehead d. Use pain relievers when prescribed
HEMORRHOIDS- a. Warm sitz bath b. High fiber diet c. Increase oral fluid intake
d. Exercise e. Apply ointments/suppositories as prescribed
c. Vagina- vaginal canal: w/rugae & stretch but can lacerate:
CONSTIPATION- a. High fiber diet b.↑ oral fluid intake c. exercise d. no laxatives a. 1st degree – skin c. 3rd– external sphincter of rectum
SHORTNESS OF BREATH- a. rest period b. elevate head at sleep c. avoid overexertion b. 2nd – skin & muscles d. 4th– mucus membrane of rectum
BACKACHE- a. Encourage rest b. body mechanics c. Wear low-heeled shoes - perineum: site of episiotomy (median, right mediolateral, left mediolateral)
d. Exercises e. Sleep on firm mattress
LEG CRAMPS- a. Exercise c. Increase calcium intake
b. Elevate & dorsiflex the feet while resting
Recommended Exercise
• Tailor Sitting • Kegel’s (Pelvic Floor Contraction) • Pelvic Rocking
• Squatting • Abdominal Muscle Contraction

LABOR- fetus expelled out from woman’s body; begin when fetus is mature
- regular uterine contractions cause progressive dilatation of cervix & sufficient
muscular force for baby to be pushed outside.
Theories
1. Uterine Stretch Theory- any hollow organ when stretched to its capacity will inevitably
contract to expel its contents 2. PASSENGER (fetus, umbilical cord, amniotic sac, placenta)
2. Oxytocin T- its presence initiates contraction of smooth muscles (uterine) a. Fetus
3. Progesterone Deprivation T- ↓ progesterone results in ↑prostaglandin  Fetal Skull- membrane space: suture line- skull connect for to move & overlap
4. Prostaglandin T-↓progesterone amount elevates prostaglandin level fontanelle- posterior (close at 2 mos/8 wks)
- its synthesis of prostaglandin cause uterine contraction, labor is initiated. - ant (close at 12-18 mos)
5. Placental Aging T- advance placental age decrease blood supply to uterus, triggering anteroposterior diameter
uterine contractions thereby, starting labor.
components
1. PASSAGEWAY
a. Pelvis- shapes: gynecoid- normal female (optimal) android- normal male
anthropoid- pelvic brim longer anteroposteriorly than transversely
platypelloid- “ wider transversely & foreshortened anteroposteriorly
 Fetal Attitude- defined by degree of flexion of fetus head (more flex = better)
- lightening: nestling of fetal presenting part into pelvis good – Suboccipitobregmatic, Vertex Presentation (well-flexed)
- engagement: settling of fetal presenting part into ischial spine military – Occipitofrontal, no flexion, no extension
when largest diameter of fetal head enters pelvic brim at level poor-Occipitomentum, Partial Extension, Brow Presentation
of the ischial spine poor - Submentobregmatic, Full Extension, Face presentation
- station: relationship of fetal presenting part (head edge) to level of ischial spine
degree of descent

 Fetal Lie- relationship of long axis of fetus to mother’s long axis

  Fetal Presentation- Body parts that will first contact cervix b. Placenta- Placental Separation: a. Calkin sign/ globular sign of fundus
- Vertical Cephalic Presentation Vertical Breech: Frank, Footling, Complete Breeches b. Sudden gush of blood c. Lengthening of cord
- Placental Delivery: a. Duncan delivery (“dirty Duncan”) (maternal side)
b. Schultz delivery (“shiny Schultz”) (fetal side)
3. POWER
a. Uterine Contraction (Phases)

left to right: moderate, poor, good attitudes

- Transverse Presentation: presenting part is shoulders (acromion process), b. Uterine Contraction (Contour Changes)
an iliac crest, a hand, elbow c. Cervical Changes- Effacement & Dilatation

CEPHALIC-CEPHALIC CEPHALIC-BREECH BREECH-BREECH 4. PSYCHE- woman’s psychological outlook; psychological state/ feelings brought in labor
- feeling of apprehension/fright. a sense of excitement/awe

CEPHALIC-TRANSVERSE BREECH-TRANSVERSE TRANSVERSE-TRANSVERSE

 Fetal Position- 3-letter abbreviation (ex: Left Occiput Anterior (LOA)
- abbreviation: 1st letter - L (left) or R (right) or D (direct)
2nd - fetal landmarks
3rd - A (anterior), P (posterior), T (transverse)
landmark: Occiput: vertex/cephalic presentation (O)
Mentum: chin/ face presentation (M)
Sacrum: in breech presentation (Sa)
Acromion: scapula/shoulder presentation (A)
Stages of Labor
I. DILATATION- onset of true labor up to expulsion of the fetus.
phases: Latent- on regular perceived uterus contractions until rapid cervical dilatation
- measuring its length monitors for cephalopelvic disproportion (between
fetal head & pelvis) (cause prolonged latent phase) requiring cesarean birth.
Active- cervical dilatation occurs more rapidly
- Show (↑ vaginal secretions) & spontaneous rupture of membranes
- contractions grow strong, last longer, cause true discomfort
Transitional- contractions at peak of intensity; max cervical dilatation 8-10 cm
- membranes ruptured at full dilatation (rule), if not, AMNIOTOMY
- FULL DILATION, COMPLETE EFFACEMENT

 ammiotome/allis forceps- for artificial rupture of membrane

nsg interv: 1. Admission care 2.Data gathering 3. Assisting IE
4. Leopold’s maneuver 5. Fetal Heart Tone (FHT) Monitoring
6. Uterine Contraction Monitoring 7. Promote change in position
8. Empty the bladder 9. Hygiene 10. Enema administration
11.Perineal preparation 12. Analgesic administration as ordered
13. Assist in the administration of regional anesthesia
14. Start IVF as ordered 15. Assist in Amniotomy
16. Watch out for SUBIRBA: Severe uterine contraction Urge to defecate
Bearing down sensation Increased Bloody Show
RBOW Bulging of Perineum
Anal Dilatation
17. Emotional Support
II. EXPULSION- cervix full dilatation until delivery; perineal & vaginal laceration 9. Inspect perineum lacerations 10. Assist episiorrhaphy/laceration repair
- labor mechanism: 11. Do perineal care 12. Apply contoured brief/adult diaper
13. Make patient comfortable 14.Monitor vital signs every 5 minutes
Placenta detachment & delivery
after fetal delivery, uterine wall behind placenta
contract. Uterine wall surface area decreases; but
placenta can’t, so it pulls away from uterine wall

blood vessels
supplying placenta bleed into small space opened behind
it. As blood accumulates, pressure in space increase,
forcing placenta to separate from wall, triggering blood
vessel detachment from placenta, causing more bleeding
into space. Bleeding doesn’t stop until placenta is
completely removed & uterus contract firmly, closing off
blood vessels
Schultz- fetal surface, shiny & glistening, detach from center to edges
Duncan- maternal surface; raw, red, irregular; cotyledons show; detach from edges to center
IV. RECOVERY PERIOD- placenta delivery up to 2 hours postpartum; most critical period
- continue skin to skin contact for at least 90 minutes.
nsg interv: 1. Assess fundus 2.Check for bleeding 3. Check the bladder
4. Check perineum 6. Promote rest
5.Take VS every 5 min for 15 min, 15 min for 30 min, every 30 min for 1 hr
6. Promote rest

NEONATAL PERIOD
1. Airway- wipe mouth-nose; suction; let it cry; administer O2; hook respiratory machine
2. Temp- dry baby; wrap w/towel; goose neck lamp; avoid unnecessary exposure;
- place inside incubator; skin to skin contact
3. Proper identification- name band 4. Care of cord- keep cord dry
5. Care of eyes- Crede’s prophylaxis (prevwsents ophthalmia neonatorum) - Teramycin
neonatal conjunctivitis – lead to blindness (1st week of life)
6. Vitamin K injection – prevent bleeding
7. Newborn assessment- APGAR scoring (after 1 min & 5mins of life)

nsg interv: 1. Lithotomy position 2. Perineal flushing 3. Drape aseptically

4.breathing technique during uterine relaxation
5. Teach pushing technique during uterine contraction
6. Assist episiotomy 7. Ritgen’s maneuver 8. Ease head out, wipe face
9. Assist for external rotation
10. Pull head downward & upward to deliver shoulders
11. Deliver body 12. Note time of delivery & sex
13. Place baby on mother’s abdomen 14. Dry thoroughly the baby 0-4= Poor (danger, need resuscitation) 5-6= guarded (may need airway clearing & O2)
15. Palpate for cord pulsation 7-10 = good (newborn is doing well)
16. Clamp cord 1 in from base once pulsation stops
17. Milk cord from cord clamp up to 2 in towards mother 8. Anthropometric measurements: Birth weight= 2.35-4 kgs Length= 48-53 cms
18. Clamp 1 inch apart from initial clamping using forceps Head circumference= 33-35 cms
19. Cut the cord. Chest circumference= 31-33 cms
abdominal circumference = 28-30 cms
III. PLACENTAL DELIVERY- birth until placenta delivery 9. Vital signs: HR= 110-160 bpm RR= 30-60bpm Temp (rectal)= 36-37.6
Signs: a. Calkin’s sign (change of uterus shape from discoid to ovoid, indicating placental 10. Head to toe assessment
separation from uterine wall) a. Head: moldings- elongated due to pressure against cervix before birth fontanelles
b. Sudden gush of blood c. Lengthening of the cord caput succedaneum- scalp edema at head presenting part bc of scalp presenting
part against dilating cervix (absorbed & disappears on 3rd day of life)
delivery: Schultz Delivery- Fetal surface presentation; Shiny & glistening cephalhematoma – blood collection between skull periosteum & bone itself
- Detaches from center to edges - bc of periosteal capillary rupture due to birth suture line pressure
Duncan Delivery- Maternal surface; raw, red, irregular anencephaly (absence of cranium)
- 15-25 Cotyledons showing; detaches from edges to center
b. Face- blink reflex; nystagmus/strabismus; ears even/above outer eye canthus
nsg interv: 1. Perform Crede’s maneuver: Apply pressure on hypogastric area c. Chest- witch milk
Gentle traction of the cord d. Abdomen- check umbilical cord; gastroschisis (absence of abdominal wall)
(done only when UTERUS IS CONTRACTED) e. Genitals- void within 1st 24 hours; pseudomenses
2. Do Brandt Andrew’s Manuever (coiling & pulling of cord) - testes descended (cryptorchidism- undescended testes)
3. Gently pull the placenta downward - preterm male has less rugae in scrotum; labia minora is prominent
4. Take note for the time of placental delivery f. Extremities- Flexed; creases on palm (Simian crease- only 1 crease)
5. Check placental delivery type: 6. Take BP (methergine- keep uterus contract - polydactyly (extra toes/fingers), syndactyly (webbing of fingers)
7. Check for completeness of cotyledons - amelia (absence of upper extremities), tocophilia (absence of lower ext)
8. Promote uterine contraction: massage hypogastric area - clubfoot
Apply ice pack on hypogastric area g. Skin- color, mongolian spots, vernix caseosa, lanugo, milia
Administer meds: Oxytocin/Maleate
Empty the bladder PUERPERIUM- 6 wks after childbirth where mother's reproductive organs return to normal
 (steps 1-8): prevent postpartum bleeding
 - labor termination to involution
Involution- labor termination; reproductive organs return to nonpregnant state
1. Maintain infection-free environment 5.Provide comfort and rest Health Teachings for Breast Beefing
2. Promote healing 6. Provide emotional support 1. Hand washing before & after 2. Clean nipple with water 3. Expose nipple to air
3. Watch for bleeding 7. Establish successful lactation 4. Feed baby in short frequent intervals & lengthen gradually 5. Alternate the breasts
4. Encourage early ambulation 6. Proper positioning 7. Adequate maternal nutrition & increase OFI
8. Wear well-fitted bra
Physiologic changes in Post Partal Period Proper Attachment
A. REPRODUCTIVE a. Baby should grasp not only the nipple but also the areola
• Uterus- size reduced: immediately after delivery=1000 gm; after end of 1st wK = 500 gm b. Lower lip turned outward c. Chin of baby touches mother’s breast
after 6 weeks = 50 gm Proper Positioning
- placental site sealed; cervical os narrowed; painful during contraction; contracted
a. Head & lower body part aligned b. Baby is facing mother c. Tummy to tummy
 1 hr after birth is most dangerous time: If uterus relaxes during this time (uterine
st

atony), lose blood very rapidly, bc no permanent thrombi have formed at placental site. Postpartum Assessment (AV BUBBLEHER)
Subinvolution – after childbirth, uterus does not return to its normal size Appearance Bowel Rhesus
uterine atony- uterus doesn’t contract Vital Signs Lochia
Breasts Episiotomy/Episiorrhaphy
• Lochia – uterus discharge; pattern shouldn’t reverse; ↑ activity; ↓in breastfeeding Uterus Homan’s sign
- not offensive in odor; w/o large clots; present in CS` Bladder Emotion
Emotional Phases of Puerperium
1. Taking-in Phase- passive & dependent; talk about pregnancy, labor, delivery
- uncertain in caring for newborn
2. Taking-hold Phase- begin to action; interested in caring newborn; assert independence
3. Letting-go Phase- gives up old role; ready for her new role

• Vagina- soft, swollen; hymen permanently torn Family Planning Methods

• Perineum- edematous; laceration/episioarrhaphy; labia minora & majora stay atrophic 1. Natural: Fertility Awareness Method (FAB) Lactation Amenorrhea Method (LAM)
- ecchymosis from ruptured capillaries may show on the surface Billing’s Method Basal Body Temperature (BBT) Symptothermal Method
• Abdomen- soft & flabby; striae gravidarum lightens; linea negra disappears in 6th week 2. Artificial: Intrauterine Device (IUD) Oral Contraceptive Pills Depo Provera Injectables
• Breasts- ↓estrogen & progesterone; Lactating; colostrum is present; Let-down reflex Implant Condom cervical cap spermicidal gel
- warm & tender; engorged; milk produced by 3rd – 4th day; veins are apparent 3. Surgical: a. Tubal Ligation b. Vasectomy

B. SYSTEMIC Legal Implications of Maternal & Newborn Health

• Hormonal- after 1 week (prepregnant state)
1. human chorionic gonadotropin (hCG) & human placental lactogen (hPL) are almost
negligible by 24 hours
2. progestin, estrone, estriol go back to prepregnancy levels after 1week
3. FSH – remains low for 12 days & rise as a new menstrual cycle is initiated.
• Urinary Sys- during pregnancy, 2000-3000 mL excess fluid accumulates in body =
DIURESIS (2ND & 5TH day)
- voiding hard immediately after birth; urinary retention; diuresis after 12 hrs
- voiding time should be after 4-6 hours postpartum
• Circulatory system
- ↓ blood volume (blood loss + diuresis) but returns to normal at 1st – 2nd week)
- return to normal at 1st-2nd wk; blood loss: NSVD (300-500 ml), CS (500-1000 ml)
- ↑ plasma fibrinogen (Plasma Fibrinogen: protect from hemorrhage; high level
increases risk of thrombus formation)
- ↑ WBC (against infection & aid to healing)
• Gastrointestinal sys- hungry & thirsty; slow stool passage in bowel bc of relaxin
- positive bowel sounds; difficult bowel evacuation
• Integumentary sys- linea negra & chloasma barely detectable in 6th week
C. VITAL SIGNS
• Temp-↑ on 1st 24 hrs (dehydration); after 24 hrs (infection); after 3-4 days - milk produ)- legal framework for establishing what nsg actions in care of patients are legal
• Pulse - ↓due to decrease cardiac output • Blood pressure - slightly decrease
• Respiratory rate - no changes
D. RETROGRESSIVE
• Exhaustion: Sleeplessness, fetal movements, labor pains, energy expenditures, NPO
• Weight Loss- diuresis, diaphoresis, return to prepregnant weight at 6th week
E. PROGRESSIVE
• Return of menses
• Lactation- primary engorgement (tension in breasts on 3rd/4th day after birth)
- Breast milk forms bc ↓estrogen & progesterone after placenta delivery (which
stimulates prolactin production & milk production)
1. EXPANDED BREASTFEEDING PROMOTION ACT OF 2009 (RA 10028)
- Availability of Lactation stations - Deductible expenses - Milk banks/storage
- Lactation period for breastfeeding employees
- Inclusion of breastfeeding in the curriculum
2. NEWBORN SCREENING ACT OF 2004 (RA 9288)
- Nat’l Newborn Screening System ensures every baby born in Philippines can undergo
newborn screening & spared from heritable conditions leading to mental retardation &
death if undetected and untreated.
3. MILK CODE OF THE PHILIPPINES (EO 51)
- adequate & safe nutrition by promoting breastfeeding & regulation of promotion,
distribution, selling, advertising, product public relations, information services artificial
milk formulas & other covered products
4. ESSENTIAL NEWBORN CARE: UNANG YAKAP CAMPAIGN OF THE DOH (AO 2009-0025)
- Immediate drying of newborn - Uninterrupted skin to skin contact
- Proper cord clamping and cutting
- Non-separation from mother for breastfeeding initiation & rooming-in
5. THE PHILIPPINE NURSING LAW (The Philippine Nursing Act of 2002 – RA 9173)
- institute reforms to protect & develop nsg profession, amending for Republic Act (RA)
No. 9173/Philippine Nursing Act of 2002 enacted in 2002 to provide comprehensive
definition & understanding of the nursing profession.
- Delineates nurse’s responsibilities from other professionals
- establish boundaries of independent nursing actions
- Assists in maintaining standard of nsg practice by making nurses accountable to law
NAT’L SAFE MOTHERHOOD PROGRAM
Vision: for Filipino women to have full access to health services towards making their
pregnancy and delivery safer
Mission: Guided by DOH FOURmula One Plus thrust & Universal Health Care Frame, the
National Safe Motherhood Program is committed to provide rational &
responsive policy direction to its local government partners in delivery of quality
maternal & newborn health services with integrity & accountability using proven
& innovative approaches
objectives
- contributes to national goal of improving women’s health & well-being by:
- Collaborate w/Local Government Units for sustainable, cost-effective approach of
delivering health services for disadvantages women access to acceptable & high quality
maternal & newborn health services & safely give birth in health facilities near homes
- Establish core knowledge base & support systems that facilitate delivery of quality
maternal & newborn health services in the country
THE RESPONSIBLE PARENTHOOD AND REPRODUCTIVE HEALTH ACT OF 2012 (RA 10354) ER - EXTERNAL ROTATION
- aka Reproductive Health Law/RH Law E - EXPULSION
- guarantees universal access to contraception, fertility control, sex ed, maternal care
- principles based on 4 pillars of: Responsible Parenthood Respect for Life
Birth Spacing Informed Choice
- Reproductive Health services devolved by Local Gov’t Code to local government units

THE MATERNAL, NEWBORN, CHILD HEALTH and NUTRITION (MNCHN) STRATEGY

- DOH issued Administrative Order 2008-0029 “Implementing Health Reforms for Rapid
Reduction of Maternal and Neonatal Mortality”
- give strategy for rapidly reducing maternal & neonatal deaths by provision of a package
of maternal, newborn, child health, nutrition (MNCHN) services
- goal of rapidly reducing maternal & neonatal mortality achieved by effective
population-wide provision & use integrated MNCHN services appropriate to any locality

LBOW- leaking bag of water

RBOW- ruptured bag of water

Rh Incompatibility- mother & father doesn’t have same Rh factor

RhoGAM
Vaginal bleeding- normal in 1st trimester
fundal height measurement
- empty bladder first

DOPPLER TRANSDUCER-
FTH- on fetal back; determined during leopold’s maneuver
event maker- tell mother: “kindly press the button/event marker whenever you feel the
baby moving”
Doppler & Ultrasound Transducer require KY jelly before using
Toco- for contractions

Mechanism of Labor
D – DESCENT
F - FLEXION
IR- INTERNAL ROTATION
E - EXTENSION