NCM07 Module 2022

Southern Luzon State University
College of Allied Medicine
CARE OF THE MOTHER, CHILD, AND

ADOLESCENT (WELL CLIENTS)
NCM07 MODULE
Compiled by:
EVANGELINE BUCTIL- MECIJA RN,RM, PhD
Associate Professor
Southern Luzon State University
Care of Mother, Child and Adolescent
(Well Clients)
Course Description
This course deals with concepts, principles, theories and techniques in the care of individuals
and families during childbearing and childrearing years toward health promotion, disease
prevention, restoration and maintenance, and rehabilitation. The learners are expected to
provide safe, appropriate and holistic nursing care to clients utilizing the nursing process.
Class schedule:
Theory: 4 units (72 hours); RLE: Skills Lab- 2 units (102 hours)
Clinical 5 units (255 hours) Clinical – 3 units (153 hours)
Theory: Sec. A M-T 1:30-3:30 PM Sec. B M-T 7:00-9:00 AM

RLE: Skills Lab. Sec. A & B W-TH-F
Dear students
This module is dedicated to the students of Southern Luzon State

University at College of Allied Medicine in support to distant learning during this
time of pandemic, we hope that the students who read this book will prepare you to
shape your future in health care. Remember this module is for SLSU students use
only.
Southern Luzon State

University Brgy Kulapi,
Lucban Quezon
emecija@slsu.edu.ph
FOREWORD
Maternal Health Nursing is expanding its scope area as a result of the broadening field of
practice within the nursing profession and the recognized need for better preventive and
restorative case in this area. The importance of this need is reflected in the fact that the
Philippines is tasked to reduce the maternal mortality ratio to support the Sustainable
Development Goals.
This instructional material is designed for undergraduate student use. The objective of
this material is to give students simpler discussions of the concepts in Maternity Nursing.
This module discusses concepts from sexuality, pregnancy, labor and delivery, and care
during the postpartum period. It includes the frameworks of maternal and Child Nursing,
Responsible Parenthood, and concepts on genetics. Pictures were used to illuminate the
concepts. At the end of each module is an activity which will be answered by the student.
Thus, they will have a chance to apply and review if they understand each concept. This
material will also be useful for practicing nurse/midwife in reviewing or expanding their
knowledge in this area.
EBM
DEDICATION
This instructional material is dedicated to my late beloved Nanay Tancing,
for her unending love and support to her eight children,
all the Nursing and Midwifery students and
Clinical Instructors of CAM-SLSU,
and to all mothers who are on
their childbearing years.
EBM
TABLE OF CONTENT
Title Page 1
Course Description 2
Foreword 3
Dedication 3
Table of Contents 4
Module 1 Framework for Maternal and Child Health Nursing 6

Goals and Philosophies of Maternal and Child Health Nursing 6
Scope and Standards of Maternal and Child Health Nursing 7
Competencies and Roles of a Maternal Child Nurse 7
Activity 1: Scope and Standards of Nursing Practice 8
Module 2 Reproductive and Sexual Health 9
Concept of Reproductive and Sexual Health 9
Human Sexuality 9
Anatomy of Female and Male Reproductive system 10
Menstruation 14
Activity 2: The Reproductive system and Menstruation 15
Module 3 Human Conception and Reproduction 16

Concept and theories of Human Reproduction 16
Fertilization and Implantation 17
Three germ Layers 18
The Amnion and Chorion 18
Milestone in Fetal Growth and Development 21
Fetal Circulation 22
Activity 3: Human Conception and Reproduction 22
Module 4 Antepartum Care 24

Physiological Changes in Pregnancy 24
Psychological Changes in Pregnancy 29
Prenatal Care and Estimates of Pregnancy 30
Health Teaching 35
Childbirth Preparation Classes 38
Activity 4: Nursing Care During Antepartum Period 39
Module 5 Intrapartum Care 41

Theories of Labor 41
Components of Labor 43
Stages of Labor 51
Essential Intrapartum and Newborn Care (EINC) 52
Partograph 53
Activity 5: Labor and Delivery 57
Module 6 Postpartum Care 59

Physiologic Changes in Postpartal period 60
Psychologic Changes in Postpartal period 62
Nursing Assessment 63
Nursing Care/ Planning and Implementation 63
Family Planning 64
Activity 6: Nursing Care During the Postpartum Period 69
Module 7 Legal Considerations and Issues in Maternal-Child Care 70

Legal considerations of Maternal-Child Practice 70
Ethical issues in Maternal Child Nursing 71
Advances in genetics and genetic technology 73
Reproductive Health Bill 73
Activity 7:Legal and Ethical Considerations in Maternal and 73
Child Care
Module 8 Filipino Culture, Values and Practices in Relation to Maternal 74

and Child Care
Nursing Care Planning to Respect Cultural Diversity 74
Myths and Beliefs related to Pregnancy 75
Birth practices of selected cultural groups 75
Activity 8: Filipino Cultural Beliefs and Practices 75
Module 1
Framework for Maternal and Child

Health Nursing
OVERVIEW
Module 1 presents an overview of maternal and child health nursing. It also includes
the goals, philosophy, scope and standards of nursing practice. The competencies and roles of
nurses in this field are also discussed.
LEARNING OBJECTIVES:
1. Identify the goals and philosophies of maternal and child health nursing
2. Describe the scope and standards of maternal and child health nursing practice
3. Describe the competencies and roles of nurses in maternal and child health nursing
A Framework for Maternal and Child Health Nursing Care

Maternal and child health nursing can be visualized within a framework in which nurses,
using nursing process care for families during childbearing and childrearing years through
four phases of health care: Health promotion, maintenance, restoration, and rehabilitation.
Goal of Maternal and Child Nursing

The primary goal of maternal and child health nursing care is to promote and maintain
optimal family health to ensure cycles of childbearing and childrearing.
Philosophy of Maternal and Child Health Nursing (Pilliteri 2018)
1. Maternal and child health nursing is family-centered
2. Maternal and child health nursing is community-centered
3. Maternal and child health nursing is research oriented
4. Nursing theory and evidence-based practice provide a foundation for nursing care
5. A maternal and child health nurse serves as an advocate to protect the rights of all family
members including the fetus
6. Maternal and child health nursing uses a high degree of independent nursing functions
because teaching and counseling are frequently required
7. Promoting health is an important nursing role because this protects the health of the next
generation
8. Pregnancy or childhood illness can be stressful and can alter family life in both subtle and
extensive ways
9. Personal, cultural, religious attitudes and belief influence the meaning of illness and its
impact on the family.
10. Maternal and child health nursing is a challenging role for the nurse and is a major factor
in promoting high-level wellness in families.
Scope and Standards of Nursing practice

The legal bases for the scope and standards of nursing practice is embedded in Article
3 Sec.4 of Republic Act 9173 known as the “The Philippine Nursing act of 2002”. The Board
of Nursing shall monitor and enforce quality standards of nursing practice necessary to
ensure the maintenance of efficient, technical, moral and professional standards in the
practice of nursing taking into account the health needs of the nation. On the other hand, the
Scope of Nursing practice is embedded in Article 6 Sec. 28. Nursing standards of practice in
the care of childbearing women is described in the National Nursing Core Competency
Standard (NNCCS). Part of the NCCS is to utilize the Nursing Process in the
Interdisciplinary Care of Clients that Empowers the Clients and Promotes Safe Quality Care.
Competencies and Roles of a Maternal and Child Nurse

Below is the list of Competencies using the Nursing Process in the Care of
Childbearing Women
1. Ensures a working relationship with the client and/or support system based on trust, respect
and shared decision making. Establishes rapport with client and/or support system ensuring
adequate information about each other as partners in a working relationship.
2. Assesses with the client (individual, family) one’s health status/competence. Obtains
assessment data utilizing appropriate data gathering methods guided by type of client and
work setting requisites.
3. Implements safe and quality nursing interventions addressing health needs, problems and
issues affecting pregnant woman during the intrapartal phases and newborn from perinatal to
neonatal stage.
a. Provides appropriate physiologic interventions to address needs of women during
the peripartal phases of pregnancy and of the newborn from perinatal to neonatal stages of
care (e.g. IMCI- Integrated Management of Childhood Illness)
b. Performs autonomously a wide range of nursing interventions (actions, treatments
and techniques) that: Promote health covering the areas of health concerns e.g. women’s
health, safe and quality Care for Birthing Mothers antepartal/ intrapartal/ immediate post-
partum and puerperium care and Prevent disease/injury/ complications during the intrapartal
phases.
c. Performs evidence-based nursing procedures safely and effectively in the care of
the mothers along the following areas of concerns: Essential Intrapartal Care practices
following the WHO Essential Intrapartal Care guidelines and Essential neonatal care
practices following WHO guidelines.
Activity 1. Scope and Standards of Nursing Practice
1. Describe the health care focus of each of the following nurses:
a. Perinatal nurse
b. Neonatal nurse
c. Gynecologic Nurse
2. Give at least 2 example of a specific activity that would reflect each of the following
perinatal health nursing roles:
a. caregiver
b. teacher/educator
c. manager
d. researcher
e. advocate
References
Pillitteri, A. Maternal and Child Health Nursing (2018), Lippincott William &
Wilkins 8th Ed. Vol 1 & 2
Venzon L,Venzon R.,Professional Nursing in the Philippines (2016) ,C&E
publishing,Inc.,12th ed.
National Nursing Core Competency Standards Training Modules, Philippines, 2014
Module 2
Reproductive and Sexual

Health
OVERVIEW
Module 2 provides a fundamental concept of human sexuality. Some terms related to
sexuality are defined. It also reviews the anatomy and physiology of the female and male
reproductive system.
LEARNING OBJECTIVES:
1. Discuss the concept of sexuality; biologic gender, gender role, gender identity
2. Identify the structures and functions of the female and male reproductive system.
3. Outline the menstrual cycle according to phases.
HUMAN SEXUALITY
Concept of Sexuality
 It reflects the human character and not solely the genital nature of a person
 It is an integral characteristic of every human being because everyone is born with the
capacity to function as sexual being.
 It includes more than the acts of intercourse and is an integral part of life (Stuart)
 Sexuality is the behavior of being a male or female, it is an entity subject to a lifelong
dynamic change
Components of Sexuality
Biologic Gender is a person’s chromosomal gender, a biologic categorization based

on reproductive function as a male or a female.
Gender Identity is a person’s perception of his or her maleness or femaleness. Sex

a person thinks of him or her which may be the same or different from biologic
gender.
Sexual Anatomy and Physiology
REPRODUCTIVE SYSTEM
FEMALE REPRODUCTIVE SYSTEM
A. External Genitalia- also called “vulva” or “pudenda”
https://nursekey.com/2-reproductive-anatomy-and-physiology/
Parts of external genitalia
1. Mons Pubis or Mons Veneris is a soft rounded, fatty cushion (pad of adipose
tissue) that lies over the symphysis pubis.
2. Labia Majora are two folds of adipose tissue extending downward and backward
from mons pubis
3. Labia Minora are two thin folds of connective tissue within the labia majora
4. Glans Clitoris is a pea-shaped composed of erectile tissues and sensitive nerve

endings which is the “seat” of a women’s sexual arousal and orgasm”. It serves as a
guide to female catheterization
5. Perineum is the muscular structure between vaginal orifice and anus. It consist of
pelvic diaphragm ( consist of levator ani and coccygeal muscle) and Urogenital
diaphragm ( consist of deep transverse perineal muscle)
6. Vestibule is an almond-shaped area bounded anteriorly by the prepuce of the

clitoris, posteriorly by fourchette and on the sides by the labia minora. It contains the
hymen, urethral meatus, vaginal orifice, Bartholin’s glands, and Skene’s glands.
a. Hymen is a thin circular membrane made of elastic tissue that covers the
vaginal opening.
b. Urinary or Urethral Meatus is the urethral opening located just below the
clitoris through which the urine comes out
c. Vaginal Orifice is the external opening of vagina located just below the
urethral meatus. It occupies the posterior 2/3 of the vestibule
d. Bartholin’s Gland is also called “vulvovaginal gland”. These are 2 small
palpable glands situated between the vestibule on either side of vaginal orifice.
Its function is to secrete mucus which acts as lubricant during sexual
intercourse
e. Skene’s Gland are 2 palpable glands that open onto the vestibule on
either side of the urethra. Its function is to lubricate the vestibule especially the
urethra to prevent irritation
B. Internal Genitalia
perimetrium
https://www.britannica.com/science/uterus
https://flexbooks.ck12.org/cbook/ck-12-middle-school-life-science-
2.0/section/11.69/primary/lesson/female-reproductive-structures-ms-ls
Parts of Internal Genitalia
1. Vagina is a dilatable canal containing rugae ( thick folds of membranous stratified

epithelium which permits considerable starching without tearing. It extends from the
https://flexbooks.ck12.org/cbook/ck-12-middle-school-life-
vulva to the uterus. It is 3-4 inches long in between urinary bladder and rectum.
science-2.0/section/11.69/primary/lesson/female-reproductive-
Vagina is pinkish in appearance and protected by hymen, its acidity (ph 4.0-6.0) and
structures-ms-ls
presence of doderleins bacilli that secretes lactic acid. The blood supplies comes from
branches of internal iliac artery, vaginal artery, and descending branch of the uterine
arteries. Vagina serves as the female organ of copulation, soft birth canal in labor, and
passageway for menstrual discharges.
https://flexbooks.ck12.org/cbook/ck-12-middle-school-life-
science-2.0/section/11.69/primary/lesson/female-reproductive-
structures-ms-ls
2. Uterus is a hollow, pear shaped, muscular organ that is posterior to bladder and
anterior to rectum. It measures 3 inches long (9cm), 2 inches wide (6cm), 1 inch thick
(3cm), and weighs 60gms in non-pregnant while, 1000gms in pregnant state.
3 Layers of the Uterus

a. Perimetrium is a thin outer layer of serous membrane that protects the entire
uterus (Parietal peritoneum)
b. Myometrium also called the “living ligature”. The most contractile, thick
middle layer of smooth muscle
c. Endometrium is the inner mucosal lining that undergoes constant changes in
respond to levels of estrogen and progesterone during menstrual cycle. It
becomes decidua in pregnancy
Parts of the uterus

a. Fundus the convex upper part; most contractile portion; very vascular and
active
b. Corpus or Body is the larger triangular portion which houses and nourishes the
growing fetus
c. Cornua is the point from which the fallopian tube emerges
d. Isthmus is the area between corpus and cervix which forms part of the lower
uterine segment
e. Cervix is the lower cylindrical portion of the uterus
Position of the Uterus

a. It is almost horizontal when a non-pregnant woman stands erect
b. If it leans forward it is known as anterversion, while if it bends forward on itself
it is called anteflexion with the fundus resting on the bladder
Functions of the Uterus

a. Organ of menstruation
b. Site of implantation
c. Propels the product of conception into vaginal canal during labor
3. Fallopian Tube or Oviducts are two muscular canals about 8-14cm in length. It
extends from uterine cornua to a site near the ovaries. The blood supplies come from
ovarian and uterine arteries.
Parts of the Oviducts

a. Interstitial Portion is 1.23cm long and lies within the wall of uterus
b. Isthmus a narrow portion adjoining the uterus
c. Ampulla the wider portion, of the tube approximately 5cm long. Ampulla is the
site of fertilization and conception
d. Infundibulum is funnel-shaped part ending in fimbriae attached to the ovaries
Functions of the Oviducts

a. Site of normal fertilization
b. Responsible for transport of mature ovum from the ovary to uterus
4. Ovaries are two almond shaped organs situated in the upper part of the pelvic
cavity. It measures 2.5-5cm length, 1.5-3cm width, and 0.6-1.5cm thickness
Parts of the Ovaries

a. Cortex is the functioning part of the ovary. It is the outer layer that contains the
ova and graafian follicle
b. Medulla the inner or central portion of the ovary that contains blood vessels.
Functions of the Ovaries

a. It is responsible for oogenesis or the process of developing a mature ovum
b. It also responsible for ovulation or the monthly expulsion of a mature ovum
c. It has an endocrine function; it secretes female hormones- estrogen and
progesterone
Mammary Gland or Breast is the accessory organ of reproduction located under the skin
over the pectoralis muscles. Each mature mammary gland is made up of 15-25 lobes
(average 20) each lobe divided into tubules consisting of alveoli and secreting cells the Acini
cells (milk producing cells) excretory dust lead from each lobe to the opening in the nipple.
Mammary gland is for milk secretion or lactation.
Parts of the Mammary Glands
a. Nipple is composed of erectile tissue and muscle fibers which have a sphincter
b. Areola is the pigmented area of the breasts. The size varies depending on the
amount of adipose tissue rather than on the amount of glandular tissue
https://my.clevelandclinic.org/health/articles/8330-breast-anatomy
MALE REPRODUCTIVE SYSTEM

Parts of the Male Genitalia
a. Scrotum a pouch which hangs behind the penis. It is divided into 2 sacs
(contains and support one of the testes)
https://sites.google.com/site/reproductivesystemfacts/home/male-reproductive-system
b. Penis is the male organ for copulation
c. Testes manufacture sperms and secretes male hormone (testosterone)
d. Duct System is the passageway for semen. It has four parts: Epididymis is first
part of the duct system; Ductus Deferens is excretory duct, carries sperm through
inguinal canal and empties into ejaculatory ducts; Ejaculatory Duct is a tube about 1
inch in length penetrating the base of prostate gland and opening into prostatic portion
on urethra; Male Urethra is a tube like organ responsible for transmitting both semen
and urine
e. Accessory Gland consists of : Seminal Vesicle that secretes a thick nutrient
containing fluid that energize the sperm and enhance transport; Prostate is a gland
that secretes a thin, milky, alkaline fluid which aids in maintaining the viability of
sperm cells; and Bulbourethral Gland that secretes a lubricating mucous secretion
prior to ejaculation.
MESTRUAL CYCLE
Is a series of monthly rhythmic changes in the ovaries affecting the tissue structure of
the endometrium governed directly by ovarian hormone, estrogen, and progesterone and
indirectly by the hypothalamus and anterior pituitary gonadotropic hormones. The average
duration is 28 days but it may vary between 20-45 days.
Menstruation is a periodic discharge of blood, mucus and cellular debris from uterine
mucosa and occurs at regular, cyclic and predictable intervals. The amount of menstrual
discharges is about 25-60ml (1/4cup) which is equivalent to about 0.4-1.0mg of iron for every
day of menstruation. It is uncoagulable because the blood is promptly liquefied by
fibrinolytic activity.
Terminologies related to menstruation

1. Menarche means first menstruation, it is usually anovulatory, infertile and
irregular
2. Menopause - permanent cessation of menstruation
3. Amenorrhea -temporary cessation of menstruation
4. Dysmenorrhea - painful menstruation
5. Menorrhagia- excessive menstruation
6. Metrorrhagia-- abnormal bleeding less than 3 weeks interval
7. Oligomenorrhea scanty/ diminished menstrual flow
Phases of Menstrual Cycle

Open the link to view the phases of menstrual cycle
https://www.youtube.com/watch?v=3Lt9I5LrWZw
1. Menstrual Phase
2. Proliferative Phase
3. Secretory Phase
Body Structure and Hormones Involved in Menstrual Cycle

1. Hypothalamus ultimate initiator of menstrual cycle. It secretes Follicle Stimulating
Hormone Releasing Factor ( when triggered by low serum estrogen level, stimulate
APG to release FSH) and Luteinizing Hormone Releasing Factor ( when triggered
by low serum progesterone, stimulate APG to release LH).
2. Anterior Pituitary Gland releases gonadotropin hormones:
➢ FSH (stimulate development of several GF in ovary and production of
estrogen)
➢ LH (stimulate corpus luteum to produce progesterone and some estrogen,
resp. for ovulation)
3. Ovaries the female gonads that produces estrogen on first half of cycle and
progesterone on the second half of the cycle.
Estrogen is the hormone that inhibit FSH, hormone of women, causes mucus to
be thin, transparent, and highly stretchable, stimulates growth of ductile structure of
breast, stimulate proliferation of cells in endometrium resulting in its thickness
Progesterone is the hormone that causes increase in the basal body temperature,
relaxes uterine muscle, promotes growth of acini cell of breast, causes weight gain,
and cause of PMS
OVULATION
Is the discharge of a mature egg cell by the graafian follicle of the ovary repeated
every year from menarche to menopause, except in pregnancy and lactation. Normally only 1
ovary ovulates .each month
 Click here to view the process of ovulation
Signs of Ovulation includes

1. Tenderness of the breast
2. Mittelschmerz
3. Slight rise in body temperature
4. Spinnbarkheit test
Activity 2. The Reproductive System and Menstrual Cycle

1. Create a teaching material to be used in a group of teenage girls covering anatomy
and physiology,
2. Make an outline of the menstrual cycle
References
Flagg. J & Pillitteri A. Maternal and Child Health Nursing (2018), Wolters Kluwer
9th Edition
https://sites.google.com/site/reproductivesystemfacts/home/male-reproductive-system
https://my.clevelandclinic.org/health/articles/8330-breast-anatomy
Module 3
Human Conception and Fetal

Development
OVERVIEW
This module discussed the concept of human reproduction and the stages of fetal
development from fertilization through birth. It also presents the process of sex
differentiation and fetal circulation.
LEARNING OBJECTIVES
1. Discuss the theories and process of human reproduction
2. Summarize significant changes in growth and development of the embryo and fetus.
3. Describe the development, structure, and functions of placenta and amniotic fluid.
4. Identify organs arising from each of the three primary germ layers
5. Explain fetal circulation
Definition and Theories Related To Procreation

Fertilization – refers to impregnation as a result of the union of an ovum (egg) and a
spermatozoan (sperm). It is also called impregnation, conception and fecundation. The best
site for fertilization is the ampulla of the fallopian tube or the outer third of the fallopian tube.
At the time of fertilization, the female gamete or egg cell has 23 chromosomes ( 22
autosomes and a X sex chromosome), the male gamete has 23 chromosomes (22 autosomes
and a sex chromosomes either an X or Y sex chromosomes). A combination of XX sex
chromosomes give rise to a female baby and a combination of XY give rise to a male baby.
Therefore it is the sex chromosomes of the father and not the mother that determines the sex
of the baby.
Concepts on Human Reproduction
➢ During ejaculation, sperms are deposited in the vagina. An average of 3-5ml
containing 50-200 million spermatozoa per milliliter, or an average of 400 million
sperm per ejaculation. At the time of ovulation, there is a reduction in the viscosities
of the cervical mucus, which makes it easier for spermatozoa to penetrate it.
➢ During intercourse (in humans) about 150 to 300 million sperm cells are released and
travel through the vagina into the uterus. Only a few hundred of these actually make it
to the egg. Only a single sperm cell can actually enter the egg cell to fertilize it.
➢ Within a few hours of conception, tiny hair-like structures called cilia (found in the
oviduct) push the zygote towards the uterus. During this journey to the uterus, the
zygote starts the process of cell division.
➢ Cleavage - is the term used for the rapid division of cells that happens in the first 24-
48 hours after fertilization. There is little/no growth in the size of the zygote.
➢ The zygote implants (attaches) to the wall of the endometrium at around 10 days.
After implantation, the zygote is officially known as an embryo.
➢ Rapid growth of the embryo continues and a yolk sac develops beside it.
This sac contains nutrients that help the embryo grow in the early stages before the
umbilical cord. The embryo is called a fetus once bone cells develop.
FERTILIZATION
Fertilization is the union of the mature egg cell and mature sperm cell
Open the link below to view the fertilization process:
https://www.youtube.com/watch?v=_5OvgQW6FG4
https://www.youtube.com/watch?v=-TXkZ_sjyUk
Ovum or “egg cell", is the female sex cell or gamete. It has 2 layers of protective
covering: the Corona radiata (outer) and the Zona pellucida (inner). The lifespan of
the ovum is 24hours
Sperm Cell also called spermatozoa, a male sex cell or gamete. It takes 64 days to
attain its maturity. The parts of the sperm cell: head (contain chromatin), neck (energy
for movement), tail (motility). The lifespan is approximately 48-72 hous or 2-3 days.
The kinds of sperm cell either Gynosperm or andosperm.
IMPLANTATION
Is the embedding of the ovum in the uterus also called “nidation”. Fertilization occurs
6-9 days or 8-10 days after fertilization. The normal site of implantation is in the
uterus, upper third of the uterus/ upper fundal portion.
Two Layers of Blastocsyst:
1. Embryonic Disc or Blastocoele will develop into a baby and give rise to
Three germ layers:
a. Ectoderm (outer covering / layer, give rise to skin, hair, nails, sebaceous glands,
sweat glands and oral passages, salivary glands, and mucus membrane of the mouth
and nose, enamel of teeth and nervous system, mammary gland)
b. Entoderm ( give rise to bladder, lining of GIT and respiratory system, tonsils,
thyroid gland, urethra and the thymus)
c. Mesoderm ( middle layer, give rise to kidney, musculoskeletal system,
reproductive system, cardiovascular system)
2. Trophoblast is the feeding layer, chorionic villi will develop from this layer
Functions of Chorionic Villi:
1. supplies oxygen and nourishment from the mother
2. produce HCG
HCG – hormone that stimulates the corpus luteum to produce progesterone thus
preventing ovulation and menstruation during pregnancy.
3 layers of the trophoblast:

1. Cytotrophoblast (inner layer)
2. Syncitiotrophoblast ( outer containing villi)
3. Primitive mesenchyme ( loose connective tissue into which the blood vessels grow)
I. Amnion (fetal membrane)

a. Umbilical Cord (funis)
- Connect fetus to placenta
- Approximately 400ml of blood flows through the cord each minute
- It is about 50-55cm long and 2cm wide
- It appears to be white, moist and cover by amnion
- It contain 2 arteries, 1 vein, supported by wharton’s jelly
b. Amniotic Fluid (BOW)
- Clear luminous fluid in which baby floats
- begins to form at 11-15 wks. gestation
- Colorless containing little white speaks of vernix caseosa and other solid
particles (near term)
- Its volume ranges from 500-1200ml, averaging 1000ml
Terms related to Amniotic Fluid

1. Polyhydramnios
Term used when the amniotic fluid is more than 1,500ml is being produced. It
stem from the inability of fetus to swallow amniotic fluid rapidly as in
Tracheo-esophageal Fistula
2. Oligohydramnios
It is the term used when the amniotic fluid is less than 500 ml. It results when
kidneys are not functioning normally.
Functions of the Amniotic Fluid

1. Protection
- Fetus against trauma, blows and pressure
- fetus from uterine contraction
- fetus from sudden changes in temperature
- cord from pressure
- against infection
2. It act as excretion and secretion system
3. It provides medium in which fetus can easily move
4. It allow symmetrical development
5. A source of oral fluid for fetus who swallows it
6. Aid in diagnosis ( amniocentesis, meconeum stained means fetal distress)
7. Assist in labor by:
- Intact membrane act in effacement and dilatation of cervix
- once it ruptured the fluid washes the canal and serves as an antiseptic
- act as lubricant making birth canal more slippery for passage of fetus
II. Chorion (placental membrane)

As pregnancy progress, the trophoblast is now termed chorion, together with the
decidua basalis it give rise to placenta, which starts to develop on the 8th weeks of
gestation.
https://www.youtube.com/watch?v=kgwUxHVht_M
Placenta
Is a discoid organ, weighing approximately 500 gm, diameter of 15-20 cm and
about 3 cm thick. It occupies ¼ of uterine cavity.
Functions of the Placenta

1. Exchange of gases takes place in the placenta
2. Waste product are being excreted in the Placenta
3. Nutrient pass to the fetus via the placenta by diffusion through placental tissue
4. It produce hormones like estrogen, progesterone, HCG, HPL
5. Placenta transfer heat
6. It serves as a protective barrier
7. It gives antibodies
Decidua
It is a specialized endometrial lining during pregnancy. Once implantation taken
place, the uterine endothelium is now termed DECIDUA, which means “to cast off”
or to “discard”
3 Types:
1. Decidua basalis (located at base of developing embryo)
2. Decidua capsularis (encapsulated the embryo)
3. Decidua parietalis ( not associated directly with developing ovum)
Stages of Human Pre-natal Development
Zygote
➢ cell that result from fertilization of ovum by the sperm cell, fertilized ovum
from conception to 2 weeks.
• Blastocyst
➢ after morula reaches the uterus
Embryo
➢ from 7th day- 7th week
Fetus
➢ from eight weeks until term
Length of Pregnancy
❑ 10 lunar
month
❑ 3 trimester
❑ 38-42 weeks
❑ 266-280 day
Milestone in Fetal Development
First Lunar Month (4 weeks)

• rudimentary eyes, ears, and nose are discernable
• rudimentary heart appears as a prominent bulge on the anterior surface
• the spinal cord is formed and fused
Second Lunar Month (8 weeks)

• organogenesis is complete
• the heart, is beating rhythmically
• external genitalia is present but is not distinguishable
• resemble a human form
• UTZ shows gestational sac
• all body system present
Third Lunar Month (12 weeks)

• Spontaneous movement is possible, although too faint to be felt by the mother
• sex is distinguishable
• placenta is fully develop
• Kidney secretion has begun but may not yet evident in the amniotic fluid
• FHT audible by doppler
Fourth Lunar Month (16 weeks)
• quickening in multipara
• lanugo is well develop
• FHT audible by stethoscope
• urine in amniotic fluid
• Liver and pancreas are functioning
Fifth Lunar Month (20 weeks)

• quickening in primipara
• vernix caseosa begins to form
• IgG transfer is possible
• Meconium present in the upper intestine
• Fetal heart beat is strong enough to be audible
• Definite sleeping and activity pattern is distinguishable
Six Lunar Month (24 weeks)
• surfactant production begins
• hearing is demonstrated
• pupil react to light
• Hearing can be demonstrated by response to sudden sound
Seven Lunar Month (28 weeks)

• Lung alveoli begin to mature
• testes begin to descend
• blood vessels of retina susceptible to damage from high O2
• The eyes open
Eight Lunar Month (32 weeks)

• Subcutaneous fat begins to be deposited
• birth position assumed
• iron transfer from mother to fetus
• Active Moro reflex
Nine Lunar Month (36 weeks)

• L/S ratio 2:1
• lanugo begin to diminished
Ten Lunar Month (40 weeks)
• fetus kicks actively

• vernix caseosa is fully formed
• wt. 3,000 gms
SEX DIFFERENTIATION
At around 7th weeks of gestation, sex differentiations begins. Human embryo has neutral
gonads with a pairs of duct systems the Mullerian duct (Paramesonephric) and the Wollfian
duct (Mesonephric). If the embryo carries XY sex chromosomes, the gonads will secretes
Mullerian duct Inhibitor ( MDI or MIS) it causes mullerian duct to disappear or self-destruct
(a process called apoptosis) and Testosterone which causes Wolffian ducts to develop into the
sperm transport system (epidydimis, vas deferens and seminal vesicles). The conversion of
testosterone to Dehydrotestosterone causes development of prostate gland and male external
genitalia. If the embryo is XX, no hormones are released. Mullerian ducts develop into
oviducts, uterus and upper vagina. Wolffian ducts disappear without stimulation of
testosterone. Even if the chromosomal sex is XY, if the hormones are not produced or
insufficient, female organs will develop.
FETAL CIRCULATION
Oxygenated blood enter umbilical vein from placenta Enters ductus venosus
Passes through inferior vena cava Enters the right atrium Enters the foramen ovale
Goes to left atrium Passes through left ventricle Flows to ascending aorta to
supply nourishment to brain and upper extremities Enters superior vena cava Goes to
right atrium Enters right ventricle Enters pulmonary artery with some blood
going to the lungs to supply oxygen and nourishment Flows to ductus arteriosus Enters
descending aorta (some blood going back to lower extremities) Enters hypogastric
arteries Goes back to placenta
Open this link to view the fetal circulation https://www.youtube.com/watch?v=EIfCa0OUbPA
Activity 3. Human Conception and Reproduction
1. Describe the 3 phases of the human prenatal development

a. zygote
b. embryo
c. fetus
2. Explain how the placenta function as:

a. An endocrine gland,
b. A metabolic, respiratory, and renal organ
c. An immunologic system
d. A protective barrier
3. Fetal circulation; Identify the structures that are present in the fetal circulation that you
will not found in the adult circulation and discuss the importance of these structures.
References
9th Edition
Fertilizationhttps://www.youtube.com/watch?v=nLmg4wSHdxQ
http://www231.pair.com/fzwester/courses/bis10v/week10/12zygoteembroyo.html
https://www.google.com.ph/url?sa=i&url=https%3A%2F%2Fwebcampus.drexelmed.edu%2F
neurobio%2Fembryology%2Fpage25%2Fpage29%2F&psig=AOvVaw1ACONipCMC-
ITbJw9BzGhC&ust=1597630130529000&source=images&cd=vfe&ved=0CAIQjRxqFwoTCMi1
_5XSnusCFQAAAAAdAAAAABAUhttps://www.britannica.com/science/prenatal-
development/Embryonic-acquisition-of-external-form
https://www.youtube.com/watch?v=_5OvgQW6FG4
https://www.youtube.com/watch?v=-TXkZ_sjyUk
Module 4
Antepartum Care
OVERVIEW
Module 4 presents the physical and psychological changes that a woman experience
during pregnancy. In the discussion of the physiologic changes, the minor discomforts
experiencing by a pregnant women are also given an emphasis. Understanding these changes
can help the students to assess and make the necessary interventions to minimize these
discomforts. This module provides information on the importance of prenatal care, thus
validating the pregnancy and determining the health status can help the students in planning
care for the pregnant woman and her family.
LEARNING OBJECTIVES
1. Explain the expected physiological, physical, and psychological changes during
pregnancy.
2. Describe the various types of pregnancy test, including the timing of tests and
interpretation of results.
3. Determine gravidity and parity using the two-and five-digit systems.
4. Compute Expected date of confinement, estimates the fetal length and weight
5. Differentiate the presumptive, probable, and positive signs of pregnancy.
6. Identify the different danger signs of pregnancy.
7. Plan education needed by pregnant women
8. Describe the available birth setting choices.
9. Use critical thinking to analyze the roles of nurses during antepartum period
PHYSIOLOGICAL CHANGES DURING PREGNANCY

Reproductive System
1. Uterus
a. There is an increases in size
• weight change- from 60-70gm up to 1,000-1,100gm
• shape change- from globular to oval/ovoid
• measurement changes:
Length – from 7.5cm to 32 cm
Width – from 5cm to 24 cm
Depth – from 2.5 cm to 20-22 cm
b. There is hypertrophy of uterine wall in the first 3 months due to estrogen; after 3
months it is due to increase in size of product of conception
c. The enlargement of the uterus is not SYMMETRICAL; it is more marked in the
fundus
d. Uterus changes in position
• first 12 weeks – at pelvic content; fundus at level of symphysis pubis; not
palpable
• week 13 – rising from pelvic cavity; maybe palpable for the first time
• week 16 – halfway between pubis and umbilicus
• week 20 – level of umbilicus
• week 24 – 2 fingers above the umbilicus
• week 30 – midway between umbilicus and xiphoid process
• week 36 - level of xiphoid process
• week 40 – 2 fingers below xiphoid process
Braxton Hicks Contractions

- painless, irregular contractions
Ballotement
- rebounding of fetal head against the
examining fingers; as about 4-5 months
Hegar’s Sign
- softening of the lower uterine
segment
endometrium changes into highly specialized DECIDUA
2. Cervix
The cervix becomes shorter, thicker, more elastic. Goodell’s sign appear.
Goodell’s sign is the softening of the cervix due to an increase in vascularity,
edema and hyperplasia of mucus lining results to increased mucus production
producing MUCUS PLUG
3. Vagina
Chadwick Sign is bluish discoloration of the vagina. There is an increase in the
vaginal discharge, it is termed (leukorrhea). An increase in the vaginal disharges is
estrogen – induced. The characteristics of the discharges can be thick, white, not
itchy, and mucoidal . Douching is not necessary.
4. Perineum
There is an increase vascularity resulting to deeper color
5. Ovaries
Ovum production ceases. Corpus luteum persist; this the reason why there is
amenorrhea during pregnancy. Corpus luteum is functional until 12 weeks
6. Breast
There is a tingling, tenderness of the breast as early as 3-4 weeks. It is firm and
enlarged by 6 weeks. There is a darkening and enlargement of areola by 12 weeks.
Integumentary System
1. Striae Gravidarum
It is also called stretch mark; reddish streaks in skin of the abdomen, upper
thighs and lower breast.
2. Chloasma
Also called melasma gravidarum or mask of pregnancy; these are irregular
brown patches on the face and neck.
3. Linea Nigra
- brownish-black pigmentation in midline of abdomen
https://momlovesbest.com/pregnancy/beauty-care/linea-nigra-appear
4. Fluid of the sweat glands increases

5. Vascular spider nevi appears ; these are prominent capillaries under the skin
Circulatory System
1. The circulating blood volume increases by 30-50%
2. Cardiac rate increases by 10-15 beats per minute
3. Blood pressure remains constant
4. Palpitation may occur maybe due to CNS disturbance at early months of
pregnancy; during end of gestation it is due to intra-abdominal pressure
5. Increase blood coagulation in pregnancy because of increase fibrinogen
6. Physiologic Anemia of Pregnancy may occur if there is no enough iron reserved in
the body
a. Maternal Hgb averages (12.5g); below 11g most likely an indication of Iron
Deficiency Anemia
7. There is poor circulation on the lower extremities because of pressure of the
gravid uterus resulting in:
a. Edema of lower extremities
Management is to raise legs above hip level
b. Varicosities
Managements:
Use of support hose or elastic stockings,
Avoid use of round garter,
Use elastic bandages, and
Sit with feet and legs elevated
Respiratory System
1. There is shortness of breath due to increased consumption of oxygen and
production of CO2 and increase uterine size causes diaphragm to be pushed or
displaced
Management:
Semi-fowler’s position supported by pillows
Lying on back with arms extended above the head to allow lung expansion
Gastrointestinal System
1. There is constipation due to decrease intestinal motility and displacement of
stomach and intestine, thus slowing peristalsis and gastric emptying time
Management:
Increase fluids and roughage in the diet
Have regular exercise
Establish regular elimination time
2. Hemorrhoids may be develop due to venous obstruction by enlarging uterus

Management:
Sitz bath, ice bags or cold compress
Elevate hips on pillows
Avoid constipation
3. Heartburn is the regurgitation of the stomach contents to the esophagus

Management:
Frequent small feedings
Decrease amount of fat consumption
Sips of milk at frequent interval
4. pica/pika – craving for non-food stuff or unusual food stuff

5. ptyalism – increase salivation
6. Morning sickness – nausea and vomiting in pregnancy
Management:
Eat 6 meals a day instead of 3
Eat dry toast or crackers 30 minutes before rising in morning
Increase CHO, decrease fat and spices in the diet
Urinary System
1. There is frequent urination in the first the 3rd trimester due to pressure on bladder
2. Glucosuria is present in normal pregnancy due to decrease renal threshold for
sugar
Musculoskeletal System
1. Lordosis is a characteristic feature of normal pregnancy
2. There softening and relaxation of joints and ligaments resulting to backache and
waddling gait
3. Leg cramps are common due calcium withdrawal from long bones
WEIGHT GAIN
1. The total weight gain throughout pregnancy is 24 lbs (11kg)
2. There is a slight weight gain in 1st trimester usually 1lb/month or 2lbs in first
trimester
3. The average weight gain in second and third trimester is 11lb (5kg) or about 1lb
per week
4. The weight gain is a measure of maternal health:
• fetus= 7.5lbs
• placenta and membrane= 1.5lbs
• BOW= 2lbs
• uterus= 2.5lbs
• increase blood volume= 2-4lbs
• extravascular fluid and fat= 4-9lbs
PSYCHOLOGICAL CHANGES DURING PREGNANCY
First trimester- Developmental Task is to accept the pregnancy
1. Normal denial
2. Ambivalence
3. Mood swings
4. Focus on self/ narcissism
Second Trimester-Developmental the task is accepting the baby
1. Mother identifies fetus as a separate entity due to quickening
2. Mother begins to fantasize the appearance of the baby
3. Most comfortable stage
Third Trimester- Developmental task is preparing for the baby and end of
pregnancy
1. Mother dreams about labor, pain
2. The couple begins nesting behavior, prepared for coming of baby like knitting
mittens, buying baby things
Pre-Natal Care
It is the supervision and management of women’s pregnancy. It is the single
most important factor in the prevention of problems and complication of pregnancy,
labor and puerperium.
Aims/Goals of Prenatal Care

1. Promotion and maintenance of maternal health
2. Supervision of pregnancy and fetal development focusing on prevention of
congenital anomalies/ malformations
3. Early detection, prompt and appropriate management of high risk conditions
4. Preparation of woman and family for the task of labor and puerperium, primarily
initiation of continued BF.
5. Enhancement of quality of life of mother, child and family through planned
parenthood
Pre-Natal Visit
The first prenatal visit of the mother must be as soon as she misses a menstrual
period when pregnancy is suspected. Inform women that early and regular prenatal
visit is important to safeguard the pregnancy.
Pregnancy Test
1. Urine Pregnancy Test maybe positive within days of the first missed menstrual period.
HCG in urine is basis for pregnancy test
a. HCG present from 40th-100th day and reaching a peak from the 60th day
b. HCG is most correct 6 weeks after the LMP
2. Women taking psychotropic drug or contraceptive pills may have a false-positive
pregnancy test result
Obstetrical Scoring
1. Gravidity refers to the total number of pregnancies
2. Parity is the total number of pregnancies that reached the age of viability
3. Viability is the ability of the fetus to live outside the uterus at the earliest possible
gestational age; 0-24 weeks or 5-6 months of gestation.
4. Obstetrical scoring can be a two or five-digit scoring
a. In two- digit scoring, the nurse gets only the gravidity and parity of a pregnant
woman (GP). Ex. G2P1 – The woman is pregnant for the second time and has 1 viable
delivery.
b. In a five-digit scoring, the nurse gets the GTPAL score
G- gravida: Number of pregnancy
T- term : number of baby born between 38-42 weeks
P- Preterm: number of baby born more than 20 weeks but less than 38 weeks
A- Abortion: number of pregnancy ending in an abortion
L- Living children
Example:
Mrs. Lee, 3 months pregnant visited the clinic for prenatal check-up. History reveals
that it is her 3rd pregnancy. She had a daughter who is now three years old. She had
an abortion during her second pregnancy. Her obstetrical scoring reveals:
a. Two-digit G3P1
b. Five-digit G3, T1,P0,A1,L1 recorded as (3-1-0-1-1) or G3(1-0-1-1)
General Rule in getting GTPAL:

1. Multiple gestation (Twins, triplets, etc) is counted as one (1) in the number of
pregnancy (Gravida) and is counted as one (1) in the number of viable deliveries
(Para)
2. Stillbirth/Intrauterine Fetal Death(IUFD) is counted as one(1) Para
a. if it falls between 38-42 weeks it is counted under term pregnancy
b. if it falls less than 38 weeks but more than 20 weeks it is counted in preterm
3. If the product of conception was delivered before the 20th week, it is considered
abortion
Terms related to obstetrics:

Primigravida – pregnant for the 1st time regardless of outcome
Multigravida- a woman who has been pregnant more than once
Nulligravida – not or never been pregnant
Primipara – completed one pregnancy beyond the age of viability (>500 g, dead or
alive)
Multipara – has completed 2 or more pregnancy
Nullipara – has never completed a pregnancy beyond the age of viability
Estimates in Pregnancy
1. Nagele’s Rule – calculation of expected date of birth or EDC.

Count back 3 days from 1st day of LMP, then add 7 days. Substitute number for
months for easy computation.
2. Date of Quickening- estimate EDC using date of quickening

- primi (date of quickening plus 4 months and 20 days = EDC)
- multi (date of quickening plus 5 months and four days = EDC)
3. McDonalds method – determine AOG by measuring the height of the fundus to the
symphysis pubis (in cm.)
• Height of fundus in cm x 2/7 = duration of pregnancy in lunar months
• Height of fundus in cm x 8/7 = duration of pregnancy in weeks
4. Bartholomew’s Rule – estimate AOG by the relative position of the uterus in the
abdominal cavity
- By the 3rd lunar month (12-14 weeks) = fundus is palpable slightly above the
symphysis pubis
- On the 5th lunar month,(20 -22 weeks) fundus is at the level of the umbilicus
- On the 9th lunar month, (36-38 week), the fundus is below the xiphoid process
Estimate of Fetal Length
1. Hasse’s Rule – determines the length of the fetus in centimeter

- 1st half of pregnancy, square the number of months
Ex; 3rd month x 3 = 9 cms.
- 2nd half of pregnancy, multiply the month by 5
Ex: 6th month x 5 = 30 cms.
Estimate of Fetal Weight
1. Johnson’s Rule – estimates the weight of the fetus in grams.

Formula: height in cm – n x k
k = is constant, it is always 155
n = is 12 if fetus is engaged
= 11 if fetus is not yet engaged
Signs of pregnancy
The signs of pregnancy are categorized into presumptive, probable, and positive. The
signs are enumerated in the table below.
Trimester Presumptive Probable Positive

Signs and Signs that can be Undeniable signs;
symptoms are felt documented by the confirmed by the
and observed by the examiner use of instruments
mother; least
indicative of
pregnancy
First Trimester Breast changes Goodell’s Ultrasound
Urinary frequency Chadwick’s evidence of fetal
Amenorrhea Hegar’s outline
Nausea and Elevated BBT
Vomiting Positive HCG
Enlarged Uterus
Second Trimester Chloasma Ballotement FHT audible
Linea Nigra Enlarged Abdomen Fetal movement
Striae Gravidarum Braxton-Hick’s felt by examiner
Quickening contraction Fetal outline on
palpation
Danger Signs of Pregnancy
1. Chills and fever

2. Escape of fluid from vagina
3. Abdominal pain
4. Board-like abdomen
5. Vaginal bleeding- no matter how slight
7. Severe, persistent headache with vomiting
8. Swelling of hands and face
9. Dimness, blurring and doubling of vision,
10. Marked change in intensity & frequency of fetal movement or absence of
movement (6-8 hours) after quickening
Prenatal Examination
1. Vital Signs
a. temp slight high due to high progesterone; reading 38 is abnormal and must be
reported
b. pulse – increase by 10-15 bpm
c. RR – does not change
d. BP – not much change
ROLL OVER TEST
1. It is a screening test to assess hypertension in pregnancy or if women is likely to
develop hypertension
Procedure
a. position woman on left side lying position
b. check BP until stable (may take 10-15 min)
c. roll to supine
d. check BP right away
e. wait for 5 minutes then check BP again
f. compare the first with the second diastolic reading
Interpretation of Roll Over Test
• Positive result
- an increase in the diastolic pressure than 20mmHg means the women is at risk of
developing PIH
• Negative Result
- an increase in diastolic pressure less than 20mmHg means woman is not likely to
develop PIH
2. Weight
- should be evaluated in the initial visit and all subsequent visit
- total wt. gain of 10-12kg is desirable
- she should have equal amount of clothes during weighing
3. Height
- short stature of a petite woman is less likely to be significant than short stature
because of malnutrition or disease
4. Urine testing
- done every visit
a. benedict’s test – test for sugar
b. heat and acetic acid test – albumin
5. Physical Assessment
- done in cephalocaudal manner
- teeth and gums (pale, bleeding, swelling, dental carries)
- throat (enlargement of thyroid)
- breast
- abdomen
6. Measure the fundic height
7. Perform Leopold's maneuver
Preparation
• explain the procedure to the women
• position in dorsal recumbent with knees slightly flexed to better relax abdominal
muscle
• drape properly to provide privacy
• warming hands
Procedure
• First Maneuver
- palpate fundus; identify parts occupying the fundus
• Second Maneuver
- palpate sides of abdomen; locate fetal back and small parts
• Third maneuver
- grasp the area above the symphysis pubis to determine presentation
• Fourth maneuver
- facing the mother lower extremities, palpate parts above symphysis ; determine
degree of engagement
• consideration applied gentle, firm palpation using palm of the hands
• the side of the fetal back is the best place for locating the fetal heart beat
8. Vulvar examination
- assess for presence of varicosities, leukorrhea, look for any abnormalities in vaginal
discharges
a. purulent yellowish discharge (gonorrhea)
b. whitish cheese like consistency (moniliasis)
c. greenish frothy or foamy (trichomoniasis)
9.Extremities
- assess for presence of varicose veins and edema.
10. Pelvic Examination

- cardinal rule (empty bladder)
- internal exam ( to determine Hegar’s, chadwick’s, goodell’s)
- ballottement
-Papanicolaou smear (cytological examination to dx cervical carcinoma
- pelvic measurement
10. Laboratory Examination

a. Blood test (hgb, blood typing and RH determination)
b. Urine test (to determine presence not only of albumin but also bacteria)
HEALTH TEACHING
Nutrition
1. Good nutrition is important in the maintenance of maternal health during
pregnancy and in the provision of adequate nutrients for embryonic and fetal
development
1. All pregnant women should be encouraged to eat a well- balanced diet, must
include foods high in iron and limit intake of caffeine.
2. Folic acid is recommended in the pre conceptional and early prenatal period to
prevent neural tube defects (NTDs). A standard prenatal multivitamins satisfies the
requirements of most pregnant women.
3. Conduct nutritional assessment and emphasize knowledge on the food pyramid
especially on the following high risk mothers:
a. Pregnant Teenagers
b. Extremes in weight, underweight and overweight
c. Mothers with low socio-economic status
d. Vegetarian mothers
4. Nurses can refer the woman to a dietician if a need is identified during the nursing
assessment
Smoking
1. It is contraindicated in pregnancy because it causes vasoconstriction of the uterine
vessels which can cause small for gestational age babies
Drinking alcohol
1. Alcohol is a known teratogen that can have a devastating effect on the fetus
2. Pregnant women should not take alcohol, even the so called “social drinking”.
Studies show that alcohol is the most commonly identifiable cause of mental
retardation
Intake of Drugs
1. Drugs can cause severe malformation when taken in early pregnancy especially
during the first trimester when the placental barrier is still incomplete and the
different body organs are developing
2. Drugs are teratogenic and therefore, contraindicated unless prescribed
Marital relations/Sexual Activity

1. Generally no contraindication to coitus except in the presence of the following
conditions
• Premature rupture of membrane
• Premature labor
• History of abortion, bleeding in present pregnancy
• Incompetent cervix
• Deeply engaged head
2. In healthy women, coitus does no harm before the last 4-6 weeks of pregnancy
• alteration of position maybe necessary
• like any tasks avoid fatigue, exercise moderation and observe hygienic
measures
Employment
1. The pregnant woman may continue working provided the work, work area and
work conditions do not pose hazards to mother and fetus
2. Safety and rest are the two most important considerations in deciding whether or
not the mother should continue working, must have every 2 hours rest and alter the
position she has at work
Rest and Sleep
1. Assess maternal activities to identify need for rest
a. Must have night sleep of at least 8 hours and afternoon nap of 1-2 hours
b. When at work, every 2 hours break to stand and walk around or can sit with
legs elevated
Bathing
1. Daily bath is encouraged but it is advised to avoid soap on nipples because it has a
drying effect
Clothing
1. Advise to use loose comfortable of cotton material; no constrictions on breast,
abdomen, legs and thigh and use of support hose, flat shoes
Dental Care
1. Dental carries require prompt treatment however, major dental surgeries should
be delayed
2. Assess for gum swelling because of estrogen. Advise the mother to use soft
toothbrushes and gentle brushing
Travelling
1. Long distance travel by land need stop-over every 2 hours so woman can stand and
walk
2. Best time for travelling is during the 2nd trimester
3. Journeys close to term is contraindicated
Exercises
Exercise is necessary during pregnancy to strengthen muscles that will be used during
the delivery process; done in moderation and must be individualized.
1. Walking is the best form of exercise
2. Pelvic Rocking
- These activities can strengthen the muscles that will be used for labor processes
- Increase flexibility of lower back
- To shift center of gravity toward the spine
-To improve posture, relieve backache, enhance appearance in late pregnancy
3. Squatting
- To strengthen perineal muscles and increase circulation to perineum (feet flat on
the floor)
4. Tailor sitting
- strengthens perineal muscles
- makes pelvic joint more fliable
5. Kegel‘s exercise
- improves pubococcygeal muscles, perineal muscles
- improves vaginal and pelvic floor muscle tone
6.Abdominal Exercise
- strengthen muscle of the abdomen
7. Shoulder circling
- strengthen muscle of the chest
8. Panting
- best for crowning period and actual delivery of the head, promotes gradual
extension of the fetal head
Childbirth Preparation Classes

The overall goal of the childbirth preparation is to prepare parents physically and
psychologically while promoting wellness behaviour that can be used by parents and
family thus, helping them achieve a satisfying and enjoying childbirth experience.
1. Psychophysical
a. Grantly Dick Read Method by Dr. Grantly Dick Read
Principle: fear causes emotional tension and tension causes pain, and lack of
knowledge about what happen in labor often is the cause of fear.
Feature: abdominal breathing and relaxation techniques are essential to
minimize maternal discomfort.
b. Bradley Method by Dr. Robert Bradley

Principle: this method is based on “imitations of nature”. Advocates active
participation of husband during delivery and encourages him to serve as a “coach”.
Requirements: Must be in a darkly lighted room and quiet environment
2. Psychosexual
a. Kitzenger Method by Dr. Shiela Kitzenger
Principle: Pregnancy, labor, birth and the care of the newborn is an important
turning point in a woman’s life cycle
Feature: Mother should go with the flow of contraction rather than struggle
with it.
3. Psychoprophylaxis (prevention of pain through the mind)

a. Lamaze Method - by Dr. Ferdinand Lamaze
Principle: conditioned response
In this method the woman is conditioned (through education) to respond
neuromuscularly to specific verbal cues. In psychoprophylaxis, the client is
made to focus her attention on something else, thus inhibiting the reception of
stimuli- the unpleasant and painful stimuli.
Requirements: Conscious relaxation; Cleansing breath (inhaling through the
nose and exhaling through the mouth); effleurage ( a gentle circular massage
over the abdomen to relieve pain; and Imaging “Sensate focus”
All childbirth method require prenatal preparation/ instructions. They are advised
only for those undergoing a normal labor and delivery. In this method of natural childbirth
the woman is fully awake.
Activity 4. Estimates of Pregnancy
1. Using Nagele’s rule, calculate the expected date of delivery (EDD) for each of the
following pregnant women: Show your computation.
a. Janet’s last menses began on May 20, and its last day occurred on May 25.
b. Karen has intercourse on February 12. She has not has a menstrual period since the
one that began on January 24, and ended 5 days later.
c. Rosanna has a regular 32-regular cycles. Her last period began on December 4, and
ended on December 8.
2. Using McDonald’s rule, estimate the gestational age in weeks and lunar months for each of
the following fundal heights:’
a. 16 cm
b. 20 cm
c. 24 cm
3. Using the 2-digit and 5-digit system, describe the obstetric score for each of the following
women.
1. Janet is pregnant for the second time. Her first pregnancy resulted in a stillbirth at
36 weeks’ gestation
2. Amie is 6 weeks pregnant. Her previous two pregnancies resulted in the live birth
of a daughter at 40 weeks and a son at 41 weeks.
3. Catherine is experiencing her fourth pregnancy. Her first pregnancy ended in a
spontaneous abortion at 8 weeks, the second resulted in the live birth of twin boys at
38 weeks, and the third resulted in the liven birth of a daughter at 34 weeks.
4. Explain/ Discuss the Diagnosis of pregnancy

5. List some cardiovascular changes in pregnancy caused by the marked increase in
circulating blood volume.
6. Describe the expected changes in the bladder and bowel elimination that occur during
pregnancy. Include in your answer the basis for the changes.
7. Identify the steps a nurse can take to ensure more accurate fundal measurements.
8. Ellen is a primigravida at 34 weeks’ gestation. For each of the signs/symptoms listed,
explain its physiological basis
SIGNS/SYMPTOMS PHYSIOLOGICAL BASIS
1. Urinary frequency
2. Infrequent, irregular uterine contractions
3. Occasional heartburn
5. Nonpitting ankle edema
5. Constipation
References
9th Edition
Linea nigra https://momlovesbest.com/pregnancy/beauty-care/linea-nigra-appear
Module 5
Intrapartum Care
OVERVIEW
This module introduces the theories of labor onset. It also includes the discussion of
the four major components that affect the labor process and the difference between the true
and false labor. The discussion of the stages of labor emphasizes the nursing care of the
woman during each stage.
LEARNING OBJECTIVES
1. Describe the theories of labor onset.
2. Compare true from false labor
2. Explain the 4 major factor that affect the labor process.
3. Explain the significance of the size of the fetal head, fetal positions and
measurements/diameters of the pelvis on labor and delivery.
4. Discuss the four stages of labor process
5. Summarize the cardinal movements of the mechanisms of labor
6. Use critical thinking to analyze the roles of nurses during each stage of labor process
Intrapartum is the period from the beginning of contractions that cause cervical
dilation to the first 1-4 hours after the delivery of the baby and placenta while Intrapartum
Care refers to the care given to the pregnant woman during labor and delivery.
Labor is a series of physiologic and mechanical processes by which all the products
of conception are expelled from the birth canal.
Theories of Labor Onset
1. Uterine Stretch Theory explains that any hollow organ when stretched to its maximum
capacity will contract and expel its content. As uterus gets stretched, the contractibility of
muscle increases.
2. Progesterone Deprivation Theory. During pregnancy there is a balance between the

effect of estrogen and the relaxing effect of progesterone on uterus. A decrease in amount of
the hormone progesterone therefore results in uterine contraction
3. Oxytocin Theory. Oxytocin is known to stimulate uterine contraction. It is secreted by

the posterior lobe of pituitary gland.
4. Prostaglandin Theory. Prostaglandin like oxytocin are known to stimulate uterine
contractions. The relative progesterone deprivation, estrogen predominance set off
production of cortical steroids which act as lipid precursor to release “arachidonic acid” thus,
prostaglandin is produce.
5. Theory of Aging Placenta. As the placenta begins to degenerate by 36 weeks, a decrease

nutrients and blood supply in aging placenta causes uterine contraction
Preliminary signs of labor
1. Lightening is the descent of presenting part into the pelvis or sinking of the uterus in the
pelvis while Engagement is the settling of presenting into the pelvic inlet. It gives the woman
relief from dyspnea and abdominal tightness. Lightening may cause increase frequency of
urination from pressure on the bladder, increased amount of vaginal discharges, increase
pedal edema and leg varicosities, and may experience shooting pain down the leg from
pressure on the sciatic nerve. In primigravida, lightening occurs 10-14 days or about 2 weeks
prior to onset of labor. In multigravida, it is not dramatic and it may occur on the day of
labor or a day before labor onset.
2. Increase level of Activity is due to an increase in epinephrine release initiated that is

initiated by a decrease in progesterone produced by placenta. Additional epinephrine prepares
the woman for the work of labor ahead.
3. Increase Braxton Hicks Contraction. A woman may experience strong Braxton Hicks
Contraction in the last week or days before labor begins which she may interpret as true labor
contractions. These painless irregular and intermittent uterine contractions can be relieved by
walking and enema and not likely to dilate cervix.
4. Ripening of the Cervix is an internal sign and seen only on pelvic exam, the cervix
becomes even softer, described as “butter soft”.
5. Rupture of BOW(Bag of Water) maybe seen as sudden gush or scanty slow seeping of
amniotic fluid from the vagina. The fluid must be clear or colorless. In most instances,if
labor has not occurred in 24 hours after the rupture of membranes and the pregnancy is at
term, labor will be induced. Once membranes have ruptured there is a risk of intrauterine
infection and umbilical cord compression. Remember that the amniotic flid is produced by
the amniotic membrane, and its production does not stop until placental delivery; hence there
is no dry labor.
6. Show is a pinkish vaginal discharge, blood-tinged mucus discharge from the cervix
shortly before or during labor.
Difference Between False and True Labor
Criteria False Labor True Labor

Frequency of Contractions Irregular/not increasing Regular/increasing
Pain Confined on abdomen, can Starts from lower back
be relieved by walking sweeping around the
abdomen; cannot be
relieved by walking
Show Absent Present
Cervix Closed Open/Effaced
Physiologic Alteration in Labor
1. Dilation is the process by which the cervix opens, “opening” or “widening” or

“increased in diameter” of the cervix or cervical os. It is expressed in centimeters. A
10 cm is fully dilated cervix, and is the end of 1st stage of labor.
2. Effacement is the thinning and obliteration of the cervix or cervical canal or may
also be defined as “narrowing”, “thinning” or “shortening” of cervical canal. It is
expressed in percentage. A 100% effaced cervix is a fully effaced cervix.
3. Physiologic Retraction Ring is the separation of the active shorter upper uterine
segment from the passive longer thinner lower uterine segment. A Bandl’s ring occur
when the upper and lower uterine segment are both active. This is a pathologic
retraction seen as abdominal indentation signifying an impending uterine rupture if
not managed. Uterine contraction is the one responsible for the physiologic alteration
in labor.
COMPONENTS OF LABOR
A successful labor depends on four integrated concepts, the four P’s of the labor
process. The power (uterine factors), the passenger (the fetus), the passage ( the woman’s
pelvis), and psyche (the woman’s psychological state or feelings).
POWER
The power of labor are implemented by uterine contractions which are involuntary,
intermittent, regular activity of uterine musculature. A process that causes effacement and
dilation of the cervix and expel the fetus and placenta from the uterus. Contractions can
increase maternal blood pressure and decreased blood flow to the uterus,
Phases of Uterine Contraction
a. Increment (cresendo) is the phase of increasing intensity of the contraction
b. Acme is the height of a contraction; apex of contraction
c. Decrement (decresendo) is the phase of decreasing contraction
Interval
https://www.slideshare.net/aymanshehata2010/normal-uterine-action
Monitoring the Uterine Contractions

a. Duration is from the beginning of the contraction to the end of the same
contraction.
b. Interval is from the end of one contraction to the beginning of next contraction.
c. Frequency is from the beginning of one contraction to the beginning of next
contraction
d. Intensity refers to the strength of uterine contraction
PASSENGER
FETAL HEAD
The fetal head is the largest part of the newborn’s body, representing ¼ of the
newborn’s length.
Fetal Bones
Bones of the fetal head comprises the cranium the uppermost portion of the skull, and
eight bones. The frontal (two fused bones), two parietal, and the occipital bone. Other four
bones are the sphenoid, ethmoid and two temporal bones. Sinciput is the area over the frontal
bone and occiput is the area over the occipital bone
Suture Lines
Suture lines are membranous interspace in between bones. The sagittal suture joins the 2
parietal bone. The coronal suture is the line of junction of the frontal and the 2parietal bones.
The lambdoidal suture joins the parietal and occipital bones. Suture lines are important in
birth because they allow the cranial bones to move and overlap, it is called molding. It
diminishes the size of the skull so it can pass through the birth canal more readily.
Fontanelles
Fontanel is a point of intersection of cranial bones, membranous space between cranial bones
during feta life and infancy. Types of fontanelle:
1. Anterior Fontanelle sometimes called Bregma. Lies at the junction of the coronal and
sagittal suture. It is diamond shaped measures 2.5cm x 2.5cm. Closes or ossifies by
12-18 months.
2. Posterior Fontanelle lies at the junction of he lambdoidal and sagittal suture because the
two parietal bones and the occipital bone are involved in this junction, the posterior
fontanelle is triangular in shape. It ossifies around 6-8 weeks or 2 months of life.
https://www.pinterest.ph/pin/679058450043961558/
FETAL HEAD DIAMETER

Antero-posterior diameter
a. occipitomental
- 12.5 to 13.5 cm; widest AP diameter
- from occiput to mentum
b. occipitofrontal
- 12cm; from occiput to midfrontal bones
-
c. suboccipitobregmatic
- 9.5cm; narrowest A-P diameter of the head
Transverse diameter
a. Biparietal diameter
- 9.5cm; widest transverse diameter of the head
b. Bitemporal diameter
- 8cm
c. Bimastoid diameter
- 7.0 cm; narrowest transverse diameter
FETAL LIE
Fetal lie is the relationship of the long axis of the fetal body to the long axis of
the woman’s body. Longitudinal lie is when the long axis of the fetus parallel to the
long axis of the mother’s body. Transverse lie when the long axis of fetus at right
angle to the long axis of the mother’s body. While oblique lie is neither longitudinal
nor transverse.
FETAL ATTITUDE
Describes the degree of flexion the fetus assumes during labor or the relationship
of fetal parts to the trunk or to one another: Either flexion or extension (can be full
flexion, moderate flexion, poor flexion/partial extension, very poor flexion/extension).
FETAL PRESENTATION
Fetal presentation denotes the lowest most part of the fetus or the part of
fetus that lies nearest the pelvic inlet or pelvic brim. Presentation can be cephalic,
breech, or shoulder.
Types of cephalic presentation

1. Vertex is when the head is sharply flexed, making the parietal bones or the space
between the fontanelles (the vertex) the presenting part. The most common
presentation
2. Brow presentation occurs when the head is only ,moderately flexed, the brow or
sinciput becomes the presenting part.
3. Face when the fetus has extended the head to make the face the presenting part.
The presenting diameter (occipitomental) is so wide birth may be impossible.
4. Mentum is when the fetus has completely hyperextended the head to present the
chin. The widest diameter (occipitomental) is presenting. As a rule, the fetus cannot
enter the pelvis in this presentation
https://www.jaypeedigital.com/book/9789350258026/chapter/ch2
Types of breech presentation

1. Complete or full breech when feet and legs are flexed on thighs, fetus squatting,
buttocks and feet presenting.
2. Incomplete or Frank Breech when thighs flexed against the abdomen, legs extend
up to shoulder as they lie on anterior chest buttocks present.
3. Footling may be single or double footling (when one or two feet present)
4. Shoulder Presentation when the shoulder is the lowest most part and occupies the
lowest pole of the uterus
https://nursekey.com/labor-and-birth-processes-2/
FETAL POSITION
Fetal position is the relationship of the denominator of the presenting part to the 4
quadrants of the mother’s pelvis or the relation of the denominator of representing
part to the 6 areas of the pelvic brim.
Denominator is the part of the presentation that determines position of the fetus.
The denominator can be occiput (denominator in vertex presentation), mentum
(denominator in face presentation), sacrum (denominator in breech presentation), or
acromion (denominator in shoulder presentation process)
Six Areas of the Pelvic Brim

The six areas of the pelvic brim are: Right anterior, Right posterior, Right
transverse, Left anterior, Left posterior, and Left transverse
Varieties of Fetal Position
FETAL STATION
It is the relationship of presenting part to the ischial spine it measure how far
presenting part has descended into the pelvis.
1. Floating or high means unengaged presenting part
2. Station O when the presenting part is at level of ischial spine
3. Minus (-) station when the presenting part is above ischial spine (e.g -1 means
the presenting part is 1 cm above the ischial spine)
4. Plus (+) station when the presenting part is below the ischial spine ( e.g +2
means the presenting part is 2 cm below the ischial spine)
5.+3 to +4 means the presenting is 3-4 cm below the ischial spine. At these levels,
crowning occurs and signals the 2nd stage of labor
https://obgyn.onlinelibrary.wiley.com/doi/10.1002/uog.6336
PASSAGES
PELVIS OR PELVIC BONE is a part of skeletal system and is very important to
pregnant mother. It is a bony structure through which the fetus must pass during the
process of birth.
Structure
1. Innominate Bones
a. Ilium. Upper large flared out, with concave anterior surface known as Iliac
Fossa, the upper curved border known as Iliac Crest, and posterior superior is Iliac
Spines
b. Ischium. Lowest part of the innominate bone with large prominences the
tuberosities, upon which the body rest when in sitting position; the ischial spine is a
projection which is useful landmark in making vaginal examination. It indicate degree
of descent
c. OS pubis is the front portion that join to form an articulation of 2 pubic bones
known as symphysis pubis.
2. Sacrum is the wedge-shaped, back part of the pelvis with 5 fused sacral vertebrae. The
upper prominent margin is called sacral promontory. It articulates with the ilium known as
sacroiliac joint
3. Coccyx is the lowest part of spine, small bone consisting of 4 coccygeal vertebrae. A
degree of movement between sacrum and coccyx is made possible by the sacro-coccygeal
joint.
Three Parts of the Pelvis
a. Inlet – entrance way to true pelvis; its transverse diameter is widen than AP diameter
b. cavity – space between the inlet and outlet
c. outlet – inferior portion of pelvis, bounded in the back by coccyx on the sides by
ischial tuberosities and in front by inferior aspect of symphysis pubis.
Types of Pelvis
1. Gynecoid – circular, ideal for child-bearing, rounded inlet normal for “female pelvis”
2. Anthropoid – oval brim, transverse diameter is narrow that AP diameter larger than
normal
3. Android – male pelvis, heart in shape
4. Platypelloid – simple type of pelvis, with a short AP and wide transverse diameter.
Pelvic diameter
For the fetus to pass through the pelvis, the pelvis must be of adequate size. Two
pelvic measurements are important to determine the adequacy of the pelvic size; the
diagonal conjugate and the transverse diameter of the outlet.
1. INLET (pelvic brim)

a. Diagonal conjugate is the shortest AP diameter of the inlet through which the
head must pass. It is the distance between the inferior surface of symphysis pubis to
sacral promontory; measures 12.5-13 cm
b. Obstetric conjugate measurement that determine whether presenting part can
engage or enter superior strait. It is from the posterior surface of symphysis pubis to
sacral promontory; 1.5-2 cm less than the diagonal
c. true conjugate (AP diameter) also called conjugate vera. It is the distance
between upper or superior border of symphysis pubis to sacral promontory
- size 11-12 .5 cm or more
d. Oblique diameter measured from sacroiliac joint to the iliopectineal eminences on
the opposite sides of pelvis either right or left; measures 12.75 cm
e. Transverse diameter is the widest diameter at inlet ;measures 13 cm
2. OUTLET
a. Transverse diameter ( tuberischial diameter)is the narrowest diameter of the
outlet; distance between the ischial tuberosities; less than or equal to 8 cm
b. Anteroposterior diameter distance from the lower or inferior border of the
symphysis pubis to tip of sacrum; 11.9 cm
c. Posterior sagittal extends from the tip of the sacrum to a right-angled intersection
with a line between the ischial tuberosities; 9 cm
https://www.orthobullets.com/recon/12768/pelvis-anatomy
PSYCHE/POSITION
The fourth “P” of the labor process is the “Psyche”, refers to the psychological
state or feelings that women bring into labor with them. Maternal behavior in labor is
influenced by a lot of factors: perceptions about labor, cultural influences, previous
experiences, support system, responses to uterine contraction, ability to communicate
feelings to SO, pain, attendance to childbirth preparation classes. Position also affects
the woman’s anatomic and physiologic adaptation to labor. Frequent changes of
position relieve fatigue, increase comfort and improve circulation. Relaxation,
awareness and participation in labor result to less intense and shorter labor.
DURATION OF LABOR
The duration of labor for primigravida is 12-14 hours, while that of the multigravida is 6-8
hours. Danger sign of difficult labor (Dystocia) is when labor extends beyond 18 hours in
primigravida and it extends beyond 14 hours in multigravida.
Stage of Labor Primigravida Multigravida
First stage 12 ½ hours 7-8 hours
a. Latent phase 8 ½ hours 5 1/2 hours
b. Active 4 hours 2 hours
c. Transitional 1 hour 10-15 minutes
Second stage 50-60 minutes 10-15 minutes
Third stage 5-30
Fourth stage First hour following placental delivery
STAGES OF LABOR
Labor is divided into four stages; stage of dilation; delivery stage; placental
stage; recovery stage.
FIRST STAGE- STAGE OF CERVICAL DILATATION AND EFFACEMENT

It starts with the true labor contractions and ends with fully dilated cervix. This
stage is divided into three phases; the latent, active, and transition phase.
THREE PHASES
Latent Active Transition
Cervical Dilatation 0-3 cm 4-7 cm 8-10
Frequency of Every 5-10 Every 3-5 Every 2-3 minutes
contraction minutes minutes
Duration of 20-40 seconds 40-60 seconds 60-90 seconds
Contraction
Intensity of Mild Moderate Strong contraction
contraction contraction contraction
Mother’s behavior Apprehensive, Fear of losing Increased perspiration,
excited but can control of herself irritability, anxious, trembling
communicate legs, white ring around the
mouth, increased show, may
have amnesia in between
contraction, out of control
Cervical Effacement and Dilatation
https://www.dreamstime.com/vector-cervical-effacement-dilatation-labor-image166859980
Essential Care during the first stage of labor
1. Encourage upright position or walking

2. Encourage to void every 2-3 hours because a full bladder inhibits uterine contractions
3. Monitor progress of labor using partograph: Vital signs, progress of cervical dilatation and
effacement, fetal monitor etc.
4. Inform mother on progress of labor; encourage and praise the effort of the mother
5. Apply sacral pressure to suppress pain transmission to the brain
6. Encourage to do proper breathing technique during contractions; chest breathing, or
abdominal breathing
7. Medications readied; Pain relief during labor and delivery may employ analgesia and
anesthesia. These drugs are not without risk. Therefore, the benefits should always out weigh
the risk.
a. Pain relief should have 3 essentials: simplicity, safety, and preservation of fetal
homeostasis
b. The fetus of a woman who received analgesia and anesthesia in labor likely to have
depression of the respiratory center especially when administered close to delivery. Therefore
the best time for giving this drug to women in labor is during the active phase of the first
stage when the cervix is about 4-6cm.
c. A women who received pain relief drugs in labor needs close supervision. Side rails
and not leaving her alone can prevent falls, putting on NPO can prevent vomiting and
aspiration of gastric contents.
d. The BP should be monitored, analgesics and anesthetic drug can cause hypertension.
Essential Intrapartum and Newborn Care (EINC)

Essential Intrapartum and Newborn Care Known also as “The First Embrace” (Unang Yakap),
EINC is designed to promote evidence-based care eliminating stereotyped newborn care practices
such as unnecessary suctioning and bathing instead of carrying out a step-by-step time bound
interventions.
Four core steps of EINC: immediate and thorough drying of a newborn, early skin to skin
contact with the mother, properly timed cord clamping and non-separation of the baby from the
mother promoting exclusive breast feeding.
This program also ameliorates maternal support and discontinues harmful and fallacy practices
such as fundal push, routine episiotomy, routine enemas, restriction of oral intake during labor,
routine intravenous fluid insertion and perineal shaving. The protocol allows the child-bearing mother
a companion of her choice during labor and delivery, mobility and ambulation during labor, position
of comfort during labor and delivery and spontaneous pushing in a gravity-neutral position. The birth
attendant is encouraged to use partograph and active management of the third stage of labor.
Conversely, non-routine episiotomy are discouraged.
Open this link to view the “Unang Yakap”

https://www.youtube.com/watch?v=AjcoR2tozyQ
The Partograph
Is a tool to assess & interpret the progress of labour. The partograph is a means of
graphic presentation of labour: It shows the:
a. Progress of labour; Cervical dilatation ; Fetal head descent; and Uterine
contractions
b. Fetal status
c. Maternal status
Recording the findings in the Partograph

• Start doing the partograph when the cervix is 4-7 cm dilated
• Start by labeling the record with the pertinent patient identifying data
Plotting the cervical dilatation

• Plot the CERVICAL DILATATION using the symbol “X”. Connect the X’s to
demonstrate the pattern
• Start when the woman is in Active Phase of labor (4cm or more) and is contracting
adequately (3-4 contractions per minute)
• Progress of labor is normal if plotting stays on or to the left of the alert line
If plotting passes the alert line
• Reassess woman
• Alert the transport services
• Empty the bladder
• Ensure adequate hydration
• Ensure upright position
• Monitor intensively
If plotting passes the action line

REFER ungently to the nearest hospital/facility
Symbols used in plotting the data

1. Amniotic Fluid: I- Intact, C-Clear, M-Meconium, A-Absent, B- Bloody
2. Moulding: 0- bones are separated and the sutures can be felt, +- bones are just touching
each other, ++-bones are overlapping, +++- severe overlapping
3. Descent use symbol 0
4. Contractions: dots- mild (duration of contraction is 0-20 seconds), slanting lines- moderate
(contractions last for about 21-40 seconds), shade- strong (duration of contraction is more
than 40 seconds
SECOND STAGE DELIVERY STAGE or Fetal Stage

It starts with full cervical dilatation and ends with the delivery or expulsion of
the baby. Contractions are strong: duration is 60-90 seconds, frequency is 2-3
minutes. Mother: with eagerness, excitement, perineum bulges, with spontaneous
pushing during contraction, with increase bloody show, bow ruptures. Crowning (the
encirclement of the presenting part by the vulvar ring)is the hallmark of the second
stage of labor.
Essential care during the second stage

1. Coach mother on proper pushing/ bearing down during contraction
2. Monitor: contraction, maternal BP, FHT
3. Provide psychological support, inform mother of progress of labor
4. Transfer to the delivery room (DR) for primigravida is when cervix is fully dilated
with bulging of the perineum and for multigravida is when cervix is 8-9cm dilated.
When placing the woman on the DR table; pad stirrups, equal height of legs,
simultaneous placing legs on stirrups
5. Practice strict asepsis to prevent sepsis
6. An episiotomy can be performed to prevent tearing of perineum, to shorten 2nd
stage of labor. Episiotomy is the surgical incision to the perineum. It can be
mediolateral episiotomy (Incision starts at the midline but is deviated laterally from
the rectum) or medial episiotomy (incision goes down midline).
7. During crowning apply Ritgen’s Maneuver; placing a sterile towel over the
rectum, pressing forward to the fetal chin while the other hand presses forward on the
occiput to facilitate extension of fetal head.
https://slideplayer.com/slide/11713219/
8. With extension of the fetal head: clear the mouth and nose of secretion using bath
syringe; wipe face
9. With expulsion of the fetus: delay clamping of the cord until cord pulsation
disappear to transfuse placental blood to the baby ( approximately additional 50-
100ml of blood will be transfused)
10. The women's BP should be monitored as the analgesic and anesthetic drugs are
likely to cause hypotension that can cause fetal bradycardia or fetal distress.
MECHANISM OF LABOR
The mechanisms of labor are called the cardinal movements of labor. The
mechanisms of labor occur dependently on each other. The first four mechanisms
(engagement, descent, flexion, and internal rotation) are not necessarily in order. In
some cases, flexion may be present before descent. The mechanisms of labor are;
1. ENGAGEMENT is the mechanism by which the greatest diameter of fetal head

(biparietal diameter) passes through the pelvic inlet.
2. DESCENT refers to the progress of presenting part through the pelvis. Descent is
the first requisite for the birth of the baby. It may occur earlier in a nulliparous
woman, descent usually begins with engagement. The forces to descent are amniotic
fluid pressure, direct fundal pressure upon breech, abdominal muscle contraction,
fetal body extension and straightening
3. FLEXION occurs when descending head meets resistance from cervix, pelvic wall
or floor. In flexion, the chin brought in contact with the chest. In flexion, the
smallest anteroposterior diameter of fetal head presents.
4. INTERNAL ROTATION is the turning of the head so that occiput moves

anteriorly towards symphysis pubis. Internal rotation allows long axis of fetal head to
change from transverse diameter to an anteroposterior diameter
5. EXTENSION: is the delivery of head in vertex presentation, emergence of the

occiput under symphysis pubis, of head leaves the outlet. In extension the occiput is
out first, then face and finally the chin. Breaking of BOW can be done, if it has not
broken
There should be gradual extension of fetal head, to accomplish this, the mother should
not push in crowning, she should pant, instead to effect gradual extension.
RITGENS MANEUVER should be applied to allow gradual extension of fetal head.
As soon as the head extends, quickly wipe the face, mouth and nose of the baby to
prevent aspiration of the amniotic fluid. After clearing the nasopharynx, should feel
the nape for any cord col. If present and if loose enough, the cord should be drawn
down between the fingers and slipped over the infant’s head. But if this action is
impossible for the cord is too tight around the neck, it should be double-clamped, then
cut between two clamps followed by the delivery of the baby.
6. RESTITUTION is when the head rotates briefly to the position that it occupied
when it was engaged in the inlet. This restitution is followed by completion of
external rotation to the transverse position which corresponds to the rotation of the
fetal body. It is also called EXTERNAL ROTATION
7. EXPULSION is the final birth of the infant
 Open the links below to view the Mechanisms of labor

https://www.youtube.com/watch?v=ruIa1bC4tsw&t=11s
https://www.youtube.com/watch?v=duPxBXN4qMg
THIRD STAGE PLACENTAL DELIVERY

It is the stage of placental separation and delivery which start with the delivery of
the baby and ends with expulsion of the placenta.
Signs of placental separation

1. Calkin’s sign: uterus changes in shape and consistency becomes globular and firm
2. Uterus becomes mobile and it rises up in the uterus. Immediately after placental
separation, the fundus is midway between the symphysis pubis and umbilicus, then
rises to the level of the umbilicus, midline and firm.
3. Sudden gush of blood
4. Slight lengthening of the cord
TYPES OF PLACENTAL DELIVERY/ PRESENTATION

 SCHULTZ MECHANISM is more common, present in 80% of cases. The
separation is from center to edges and presents the fetal surface which is shiny. This
type has less external bleeding because blood is usually concealed behind the placenta
 DUNCAN’S MECHANISM is less common, present 20% of cases. The separation
from edges to center and presents the maternal surface which is red beefy and dirty.
More external bleeding so it appears bloody.
https://www.waybuilder.net/sweethaven/MedTech/FraPkr02.asp?iCode=020211_020212_020213
BRANDT-ANDREW TECHNIQUE
Is the technique used to deliver the placenta by winding the cord around the
clamp until placenta is borne, the placenta Is then held and rotated gradually to ensure
that no membranes are retained.
ESSENTIAL CARE:
1. Do not hurry expulsion of placenta
2. Apply Brandt-Andrew Maneuver; tract the cord slowly
3. Apply Cord traction with counter traction
4. Note the time of placental delivery should be 20 minutes after delivery of the baby
5. Inspect for completeness of cotyledons
6. Palpate uterus to determine degree of contraction
7. Inspect perineum for laceration
Categories of laceration
1st degree: involves vaginal mucus membrane and skin
2nd stage: involves not only vaginal mucus membrane and skin, but also
muscles
3rd stage: involve external sphincter of the rectum
4th stage: involves mucus membrane of the rectum
Open this link to view the degree of perineal lacerations
https://www.youtube.com/watch?v=vj47fo7kgrg&t=228s
8. Make mother comfortable by perineal are and applying clean sanitary napkin
9. Provide additional blanket for mother who are complaining of chills
FOURTH STAGE RECOVERY STAGE
This is the period of 1-2 hours after the delivery of placenta. This is considered
dangerous for the mother as she can have hemorrhage and uterine atony.
ESSENTIAL CARE:
1. Monitor v/s every 15 minutes until stable
2. Palpate fundus every 15 minutes, check fundal height and position in relation to
umbilicus, check consistency if relaxed massage until firm but do not over massage as
this can tire the uterine muscles causing relaxation; if displace to side, feel lower
abdomen for distended bladder and make sure bladder is empty before fundic height
determination
3. Assess the lochia
4. Check for bladder distention
5. Check the perineum: note general appearance, redness, swelling, bruising, vaginal
bleeding
6. Count vaginal pads, lochia is excessive if it can reduce edema and swelling
7. Promote comfort
8. Provide fluid and foods as tolerated
9. Promote bonding
Activity No.5 Labor and Delivery
1. Discuss four factors that may influence the beginning of labor.

2. Discuss the physiologic retraction ring. How does this ring facilitate the birth of
the fetus.
3. Outline the nursing procedure in handling delivery of the baby

4. Rose gave birth 4 hours ago. On palpation her fundus was found to be 1 cm
above the umbilicus and deviated to the right. It was also found to be less firm.
a. What is the most likely cause of these findings?
b. On the basis of these findings, what actions should be taken by the nurse?
References
9th Edition
.
Perry, Hochenberry, Lowdermilk, & Wilson.Maternal Child Nursing Care
(2014),Elsevier,5th Ed.
Unang Yakap https://www.youtube.com/watch?v=AjcoR2tozyQ

Fetal skull https://www.pinterest.ph/pin/679058450043961558/
Types of pelvis https://www.pinterest.ph/pin/505388389410117004/
Pelvic brim https://www.orthobullets.com/recon/12768/pelvis-anatomy
Types of cephalic & breech https://nursekey.com/labor-and-birth-processes-2/
Cervical dilatation https://www.dreamstime.com/vector-cervical-effacement-dilatation-
labor-image166859980
Fetal station https://obgyn.onlinelibrary.wiley.com/doi/10.1002/uog.6336
cephalic presentation https://www.jaypeedigital.com/book/9789350258026/chapter/ch2
fetal position https://www.pinterest.ph/pin/276971445810769277/
Uterine contraction https://www.slideshare.net/aymanshehata2010/normal-uterine-action
ritgens maneuver https://slideplayer.com/slide/11713219/
fetal station https://www.youtube.com/watch?v=ze53Ep-gwBQ
mechanism of labourhttps://www.youtube.com/watch?v=ruIa1bC4tsw&t=11s
https://www.youtube.com/watch?v=duPxBXN4qMg
Placental delivery https://www.waybuilder.net/sweethaven/MedTech/FraPkr02.asp?
iCode=020211_020212_020213
lochia https://www.slideshare.net/ishamagar/postnatal-mother-examination-bubblehe
Uterine Involution https://www.pinterest.com.mx/pin/110619734572477521/
Module 6
Postpartum Care
OVERVIEW
This module presents the physiologic and psychologic changes that occur after
childbirth. It also discussed the nursing care for the postpartum mother. Discussions of the
different family planning methods are also included in this module.
LEARNING OBJECTIVES
1. Define terms related to puerperium.

2. Describe the anatomic and physiologic, and psychologic changes that occur during the
postpartum period.
3. Discuss characteristics of uterine involution and lochial flow and describe ways to
measure them.
4. Discuss the necessary nursing care for a postpartum mothers.
5. Discuss the different family planning methods
Puerperium
This refers to six week period after delivery of the baby during which reproductive
organs undergo involution.
Involution
Is the return of the reproductive organs to their nonpregnant states.
Postpartum Care
Is the nursing care given to the mother and baby during her reparative process.
PHYSIOLOGIC CHANGES IN POST PARTAL PERIOD
1. Reproductive System
a. Uterus. By essence of its contraction, the uterus begins involution from the
level of umbilicus, decreasing 1 cm a day. Uterine involution is assessed by
measuring the fundus by fingerbreadths (FB). On postpartum day 1(PPD 1) the
fundus must be 1 FB below the umbilicus; On postpartum day 2(PPD 2) the fundus
must be 2 FB below the umbilicus; and so on and so forth until on the on the 10th day
the fundus can be no longer palpated. Ensure that the bladder is emptied before
palpating for the uterine fundus, or else deviations from its expected alignment occur.
Prone knee-chest position should be advised- this position promote return of uterus to
its normal position
https://www.pinterest.com.mx/pin/110619734572477521/
b. After birth pains occur , these are strong uterine contraction felt more particularly
by multiparous mother, those who delivered large babies or twins because more force
is needed to return the uterus into prepregnant state, and those who breastfed because
of the release of oxytocin. Management: never apply hot on abdomen, give
analgesics, as ordered and explain that it is normal and rarely last more than 3 days
c. Lochia – uterine discharge consisting of blood, deciduas, WBC, mucus and some
bacteria. The pattern of lochia should not reverse and the amount is approximate menstrual
flow. It should not have offensive odor and should not contain large clots. Lochia should
never be absent regardless of method of delivery.
Types of Lochia
Rubra Serosa Alba
Color Reddish Brownish Pinkish
Amount Moderate Scanty Light
Time present 1-3 days 4-10 days 10-14 days
Amount of Lochia
https://www.slideshare.net/ishamagar/postnatal-mother-examination-bubblehe
d. Pain in perineal region may occur and may be relieved by: sim’s position to
minimize strain on the suture line, use of perineal heat lamp or warm sitz bath 2x a
day, and application of topical analgesics or administration of mild oral analgesics, as
ordered.
e. Sexual activity may be resumed by third or fourth week PP if bleeding has

stopped and episiorrhapy has healed. Decrease physiologic reactions to sexual
stimulation are expected for the first 3 months because of hormonal changes and
emotional factors.
f. Menstruation or menstrual flow is expected within 8 weeks after delivery if the

woman is not breastfeeding. If the woman is breastfeeding, menstrual flow return is
expected in 3-4 months, in some women no menstruation occurs during the entire
lactation period
2. Vascular Changes
a. The 30-50% increase in total cardiac volume during pregnancy will be re-absorbed
into general circulation within 5-10 minutes after placental delivery. Implication: first
5-10 minutes after placental delivery is crucial to gravidocardiacs because the weak
heart may not be able to handle such workload.
b. WBC increases to 20,000-30,000/mm3; Implication: the WBC count, therefore
cannot be used as an indicator for postpartum infection.
c. There is extensive activation of clotting factors, which encourages
thromboembolization. To prevent complication brought by this change the
postpartum mother must ambulate as early after 4-8 hours, perform exercise such as
kegal and abdominal breathing on PPD 1; chin-to-chest on PPD 2; knee-to-abdomen
when perineum has healed; massage is contraindicated
d. All blood values are back to prenatal level on the third or fourth week PP
3. Urinary changes
a. There is marked diuresis within 12 hours PP to eliminate excess tissue fluid
accumulation during pregnancy. Some may complain frequent urination in small
amount – explain that it is due to urinary retention with overflow, on the other hand
they may have difficulty voiding due to decrease adnominal pressure or trauma to the
trigone of bladder. Management: pour warm and cold water over the vulva,
encourage to go to the CR and listen to the sound of running water, catheterization is
done gently, instruct mother to breath through the mouth during the insertion
4. Gastrointestinal changes
1. Digestive system is active but defecation maybe difficult because of relaxin effect.
There is a delay in the bowel evacuation because of decrease muscle tone, lack of
food during labor, dehydration, and fear of pain from perineal tenderness due to
laceration, hemorrhoids and episiotomy
5. Vital signs
1. Temperature may increase because of dehydrating effects of labor: any increase in
body temperature during the first 24 hours PP is not necessarily a sign of PP infection
2. Bradycardia (heart rate 50-70 bpm) is common for 6-8 days PP
3. There is no change in RR and BP
6. Weight
1. There is an immediate weight loss of 10-12 lbs representing the weight of the
fetus, placenta, amniotic fluid and blood. Further weight loss will occur during the
next days due to diaphoresis.
Psychological Changes in Postpartal Period

1. Taking in Phase
The first 2-3 days PP when mother is passive and relies on others to care for her and
her newborn. She keeps on verbalizing her feelings regarding the recent delivery for
her to be able to integrate the experience into herself.
2. Taking- Hold Phase

The mother expresses independence concerning child care. Assist the mother in
providing care to the newborn, providing positive reinforcement as she performs the tasks
successfully. The mother may experience Postpartum blues; an overwhelming feelings of
sadness could be due to hormonal changes, dependency, fatigue or feelings of inadequacy in
taking care of a new baby as manifested by moodiness, tearfulness, sleep and nutritional
disturbance. Explain to the mother that it is normal and that crying is therapeutic.
3. Letting Go Phase
The mother lets go of her ideal image of the child and accepts the reality of their
situation, taking the reins of caring for the child and accepting the adjustments they have to
undertake with the new member of their family.
Nursing Assessment during the Postpartal Period
1. Assess the postpartum mother; use the acronym BUBBLESHE
B- Breast. Assess breasts for firmness, tenderness, and warmth, and nipples for cracks,
fissures, and bleeding. Determine if the mother is breastfeeding or bottle feeding and palpate
for engorgement or tenderness. Engorgement usually occur on the 3rd day postpartum period
U- Uterus Assess the fundus daily for firmness and location; make sure the client empties
her bladder before palpating. Look for indications of subinvolution: uterus not progressively
decreasing in size or returning to the lower pelvis, uterus remains flabby and poorly
contracted, persistent backache or pelvic pain, and heavy vaginal bleeding
B- Bladder Assess degree of bladder distension often in the first 8 hours after delivery.
Monitor urine output; voiding small amounts on frequent consecutive voiding indicates
residual urine and possible need for catheterization. Assess for frequency, burning, and
urgency and the ability to empty bladder.
B- Bowel Assess status of bowel elimination and the return to predelivery patterns. Assess
bowel sounds if normal, hyperactive, hypoactive, or absent
L- Lochia Assess the amount and character of lochia daily to provide an essential index of
endometrial healing. Report any abnormal findings such as; fresh bleeding, heavy, persistent,
and malodorous lochia rubra.
E- Episiotomy Inspect the perineum, noting the status of sutures (if present), tenderness,
swelling, bruising and hematoma. Assess the episiotomy using the acronym REEDA-
redness, edema, ecchymosis, discharge, approximation.
S- Skin Assess the skin
H- Homan’s Sign Assess peripheral circulation, temperature, color. Assess presence of
Homan’s sign by dorsiflexing the foot. It is negative when there is no pain in the calf
E- Emotional Assess psychosocial adaptation, including signs and symptoms of postpartum
“blues”; crying, loss of appetite, poor concentration, difficulty sleeping, anxiety. Observe
interactions of the new mother with the newborn. Observe the new mother providing care for
her newborn
Nursing Care/Planning and Implementation
1. Teach the new mother aspects of self-care and newborn care
2. Report and record increased pulse rate, decreased blood pressure, and elevated temperature
3. Gently massage the fundus if boggy; express clots from the fundus as indicated
4. Apply ice or cold therapy to the episiotomy or lacerations immediately after delivery to
decrease edema and provide anesthesia; thereafter, apply moist or dry heat therapy to
promote comfort and healing
5. Apply anesthetic sprays, ointments, or witch hazel pads to the perineum to promote
comfort; administer analgesia as ordered and indicated; provide sitz baths as needed
6.Instruct the patient on sitting properly to relieve pain; squeeze buttocks together and
contract pelvic floor muscles before sitting. Also instruct her to wear perineal pads loosely
and to lie in Sim’s position
7. Teach the patient to cleanse her breast daily, with clean water if breast-feeding , do not use
soap as it has a dying effect, and to wear a well-fitting brassiere
8. Assist with breast-feeding, as needed; explain mechanisms involved in lactation, breast
care, positioning of self and infant, and nursing techniques
9. Encourage the patient to void within first 4 to 8 hours after delivery and every 2 to 4 hours
thereafter. If necessary, help stimulate urination by running water, placing her hands in warm
water, giving warm beverage, providing privacy and support, pouring warm water over the
vulva
10. Teach the patient to cleanse the perineum after each voiding and defecation, wiping from
front to back
11. Provide adequate dietary fiber and fluids to promote bowel movements. Teach the
importance of good fluid intake, exercise, proper diet, and establishing a regular defecation
time
12. Ensure good nutrition and fluid intake
13. Support the patient’s attempts at ambulation and exercise; explain the advantages of
early ambulation and regular exercise in preventing complications and strengthening muscles
of the back, pelvic floor, and abdomen
14. Permit the patient to shower as soon as she can ambulate. Recommend a daily shower to
promote comfort and sense of well-being
15. Provide emotional and psychological support during the transition to parenthood,
including: Encouraging the mother to hold and explore her new infant, and providing time for
patient-infant contact, as indicated by the mother’s and infant’s condition.
16. Encourage use of family planning method
Family Planning
Responsible Parenthood
In essence, the concept of family planning is responsible parenthood. Married couples
are responsible for the outcome of their sexual union. They are rational being capable of
making an intelligent decision about family size and family life.
-If pregnancy is planned and children are desired, the child is therefore born not by chance
but by choice
Family Planning
As defined by WHO FP is the use of a range of methods of fertility regulation to help
individuals or couples attain certain objectives: avoid unwanted births, bring about wanted
births, produce a change in the number of children born, regulate the intervals between
pregnancies, and the time of which births occur.
3 Elements of Family Planning

1. Proper spacing
2. Proper timing of pregnancy
3. Number of pregnancies
Health Benefits to the Mother

1. Helps reduce the risks by helping women bear their children in their healthiest years
2. Helps mothers to fully recover from the physical strain of childbearing
3. Offers safe alternatives to women, and can help reduce the number of maternal deaths
due to abortion
4. Offers non-contraceptive health benefits
Health Benefits to the Children

1. Helps insure better chance of survival at birth
2. Helps promote better childhood nutrition
3. Helps physical growth and development
4. Helps prevent birth defects
Health Benefits to the Father

1. Allows father to keep a constant balance between their physical, mental, and social
well-being
Roles & Functions of The Nurse in Family Planning

1. Identifying, counseling, and when appropriate, making referral for clients who are in
need of information about family planning and its services.
2. Providing and interpreting family planning instructions, information and resources
3. Contributing to the development of new method, services and programs as well as
evaluating existing ones.
Counseling
It is one of the most important tasks of a family planning provider. It aimed at ensuring
the clients freedom to choose and use a method based on complete, accurate, and unbiased
information
The Counseling Process
G- greet client
A- ask the client about herself
T- tell clients about family planning methods
H- helps clients choose a method
E- explain how to use the method
R-return for follow up
Terms related to Family Planning

1. Voluntarism the client chooses the method out of free will after considering all
information given
2. Informed Choice is the right to choose the family planning method based on a clear
understanding of the risks and benefits of the different FP methods
3. Informed Consent is a written consent signifying the clients voluntary decision to use a
surgical contraceptive after he/she has undergone counseling with full understanding of the
method
Elements of Informed Consent
It implies that the client knows the following:
B- benefits of the method
R- risk of the method
A- alternatives to the method
I- inquiries about the method are the client’s rights
D- decision to withdraw from using the method is alright
E- explanation of the method, what to expect
D- documentation of the above
Suggestions to Counteract Rumors

1. Investigate how the client learned about the rumor
2. Explain facts
3. Present support arguments by using comparisons
4. Clarify information with the use of demonstrations and visual aids
5. Reassure the client by giving her a check up
6. Refer the client to a doctor for more information if client is still unconvinced
Methods of Family Planning

1. Natural Family Planning Method:
a. Cervical mucus (billings) Method
b. Basal body temperature
c. Symptothermal Method
d. Lactational Amenorrhea Method
e. Cycle Beads Method
2. Artificial Family Planning Method:

A. Temporary
1. Hormonal Contraceptives
a. oral contraceptives
b. injectables
2. Intrauterine Device (IUD)
3. Barriers
a. condoms
b. vaginal spermicides
B. Permanent (Voluntary Surgical Sterilization)
1. Bilateral Tubal Ligation
2. Vasectomy
Advantages of Natural Family Planning Method

1. Safe, no physical side effects
2. Free or inexpensive
3. Acceptable to many religious groups
4. Helpful for planning or avoiding pregnancy
5. Promotes involvement of the man-cooperation on shared responsibility of the couple
for FP
Disadvantages of Natural Family Planning Method
1. Requires high degree motivation by both partners
2. Tedious- needs daily attention
3. Need several months of practice and training
4. Less effective than other methods
Contraindications of Natural Family Planning; couple who are not willing to follow the
instructions correctly and diligently
Natural Methods of Family Planning

1. Cervical Mucus Method
Involves the ability of woman to recognize the characteristics changes of the cervical
mucus discharge throughout the menstrual cycle. The characteristics of a fertile mucus is
clear, abundant, elastic, thin, slippery, and can be stretched into a thin strand (spinnbarkeit)
How to Check The Mucus

Begin checking the mucus when; the menstrual bleeding ends, if there is no prior
sexual intercourse , and if a woman is not sexually stimulated. With the middle index
finger and the thumb test for the consistency, slipperiness, stretchiness of the mucus.
Record the finding
2. Basal Body Temperature

Is the determination of the lowest body temperature of a person at rest. The woman
takes and records her BBT daily upon waking up in the morning before doing any
activity. It is recommended that the temperature be taken and recorded at the same
time, consistently using same thermometer and route of the temperature
determination. An increase of 0.2 ºC- 0.5 ºC signals ovulation. Consider fertile until
the temperature has remained elevated for three consecutive days.
3. Symptothermal Method
A combined measurement of BBT of observation of the cervical mucus and other
fertility symptoms like mitteslchmerz pain, breast tenderness, pelvic heaviness,
irritability, and others
4. Lactational Amenorrhea Method
LAM delays the return of ovulation and menstruation in post partum mothers
It is considered to be 98% effective when all of the following conditions are present;
fully breastfeeding, amenorrhea, and within the 6 month post partum
Artificial Family Planning Method
1. Hormonal Contraceptives
a. Oral Contraceptives
Oral contraceptives can be Combined pills ( 21 or 28 day pill) with fixed estrogen
and progestin or a Triphasic pills- all tablets have both estrogen and progestin but in
different amount depending on the phase of the cycle
Warning Signs that must be observed; use the acronym ACHES

A- abdominal pain
C- chest pain or shortness of breath
H- headaches that are severe
E- eye problems or blurring/doubling vision, blindness
S- swelling or leg pain
b. Injectable
It is a long acting progestin that is used as a method of contraception, it inhibits
ovulation.
Injectables can be Depo provera injection/ DMPA- 3 month injectable and can be used even
by breastfeeding or Net-en- 2 month injectable
When can DMPA be given?
a. Within the first 7 days of the menstrual period
b. Within the first 14 days after an abortion
c. Within the first 28 days after delivery if the client is not breastfeeding
2. IUD prevents fertilization through biochemical changes. Interfere with the transport of
sperm in the genital tract due to the production of prostaglandins and enzymes, and it cause
inflammatory reactions in the genital tract thereby increasing WBC which phagocytose the
sperm
Warning Signs that must be observed by woman with IUD using the acronym PAINS
P- period late (pregnancy)
A- abdominal pain or pain with intercourse
I- infection
N- not feeling well, fever and chills
S- string missing, shorter and longer
3. Condom- acts as a barrier that blocks the sperm from entering the vagina in order to
prevent pregnancy
4. Spermicide consist of a sperm killing chemical
5. Diaphragm fits over the cervical opening, preventing sperm from entering the uterus.
The diaphragm is a flexible rubber cup that is filled with spermicide and self-inserted over
the cervix prior to intercourse
Permanent Family Planning Method

1. Bilateral Tubal Ligation is a surgical procedures that involves cutting, or removing
sections of the fallopian tubes. It involves blocking the fallopian tubes to prevent the ovum
from being fertilized.
2. Vasectomy is a surgical procedure for male sterilization. During the procedure, the vas
deferens are cut and tied so as to prevent sperm from entering into the urethra. Remember,
that men are not sterile immediately after vasectomy. Submit sperm examination after 20
ejaculations
Activity No. 6 Nursing Care During the Postpartum period
1. Describe the physiologic changes that occur in the fundus, cervix, and cardiovascular
system during the postpartum period.
2. Create a teaching material to be used in a group of mothers covering family planning
methods
References
9th Edition
lochia https://www.slideshare.net/ishamagar/postnatal-mother-examination-bubblehe
Uterine Involution https://www.pinterest.com.mx/pin/110619734572477521/
Module 7
Legal Consideration and Issues in

Maternal and Child Care
OVERVIEW
Module 7 presents an overview of the basic legal and ethical issues in perinatal. The
content is organized and divided into two : legal considerations and ethical issues in Maternal
and Child Nursing.
LEARNING OBJECTIVE
1. Discuss the importance of meeting the standards of care in the delivery of nursing care.
2. Appreciate the importance of maintaining accurate records and the right of clients to
privacy
3. Explore the ethical dillemmas in relation to maternal and child care
LEGAL CONSIDERATIONS IN MATERNAL CHILD NURSING

1.Scope of practice is defined as the limits of nursing practice set forth in state statues. Most
state practice acts cover expanded practice roles that include collaboration with other health
professionals in planning and providing care, physician-delegated diagnosis and prescriptive
privilege, and the delegation of direct care tasks to other specified licensed and unlicensed
personnel.
2. Standards of Nursing Career established minimum criteria for competent, proficient
delivery of nursing care. Such standards are designed to protect the public and are used to
judge the quality of care provided. Agency policies, procedures, and protocols also provide
appropriate guidelines for care standards. Some standards carry the force of law; others,
although not legally binding, carry important legal significance. Any nurse who fails to meet
appropriate standards of care invites allegations of negligence or malpractice. However, any
nurse who practices within the guidelines established by an agency, or follows local or
national standards, is assured that clients are provided with competent nursing care, which
decreases the potential for litigation.
3. Informed Consent is legal concept that protects a person’s right to autonomy and self-
determination by specifying that no action may be taken without that individual’s prior
understanding and freely given consent. The person, usually the physician, who is ultimately
responsible for the treatment or procedure should provide the information necessary to obtain
informed consent. In such cases the nurses role is to witness the client’s signature (or parent
signature of a child) giving consent. If the nurse determines that the individual does not
understand the procedure or risks, the nurse must notify the physician, who must then provide
additional information to ensure that the consent is informed. Anxiety, fear, pain and
medications that alter consciousness may influence and individual’s ability to give informed
consent. An oral consent is legal, but written consent is easier to defend in a court of law.
Children under 18 or 21 years of age, depending on state law, can legally give informed
consent in the following circumstances. When they are minor parents of the child client.
When they are emancipated minors (self-supporting adolescents under 18 years of age, not
subject to parental control). In most states, a pregnant teen is considered emancipated. When
they are adolescent between 16 and 18 years of age seeking birth control, mental health
counseling, or substance abuse treatment. Mature minors (14 and 15 year-old adolescents
who are able to understand treatment risks) can give some consent for treatment or refuse
treatment in some states. Refusal of a treatment, medication, or procedure after appropriate
information is provided also requires that the individual sign a form releasing the doctor the
clinical facility from liability resulting from the transfusion is an example of such refusal.
Parents or guardians have absolute authority to make choices about their child’s healthcare
except in specific cases. When the child and parents do not agree on major treatment options.
When the parent’s choice of treatment does not permit lifesaving treatment for the child.
When there is a potential conflict of interest between the child and parents, such as with
suspected child abuse or neglect. When the parents are incapacitated and cannot make a
decision (e.g. critically injured in the same motor vehicle cash).
4. Right to privacy is the right of a person to keep his or her person and properly free from
public scrutiny. To protect this right for clients and families, only those responsible for their
care should conduct an examination or discuss their case. The right to privacy is protected by
state constitutions, statues, and common law. Healthcare agencies should also have written
policies dealing with client privacy. Laws and standards, and policies about privacy specify
that information about client’s treatment, condition, and prognosis can be shared only by
health professionals responsible for their care. Information considered vital statistics (name,
age, occupation, and so on) may be revealed legally, but is often withheld because of ethical
considerations. The client should be consulted as to what information may be released to
whom. Children and confidentiality are concern about privacy and the fear of disclosure of
sensitive information to parents is a major reason why adolescents do not seek healthcare.
When the child is an emancipated or mature minor, many states permit healthcare providers
to provide birth control and treatment for sexually transmitted infections including
HIV/AIDS, pregnancy, and substance, and substance abuse without informing the child’s
parents. Patient Self-Determination Act directs healthcare institutions to inform hospitalized
patients about their right, which include expressing a preference for treatment options and
making advance directive (writing a living will or authorizing a durable power of attorney
for healthcare decisions on the individual’s behalf).
ETHICAL ISSUES IN MATERNAL-CHILD NURSING
For Nursing Practice are the complex ethical issues facing maternal-child nurses have
many social, cultural, legal, and professional ramifications. Ethical decisions in maternal
child nursing are often complicated by moral obligations to more than one client. Nurses
must learn to anticipate ethical dilemmas, clarify their own positions related to the issues,
understand the legal implications of the issues, and develop appropriate strategies for ethical
decision making. Below are some of the ethical issues:
1. Maternal-Fetal Conflict recently the fetus was viewed legally as a non-person, Mother and
fetus were viewed as one complex client-the pregnant woman- of which the fetus was an
essential part. The fetus is increasingly viewed as a client separate from the mother, although
treatment of the fetus necessarily involves the mother.
2. Abortion can be performed until the period of viability. After that time, abortion is
permissible only when the life or health of the mother is threatened. Before viability the
rights of the mother are paramount: after viability the rights of the fetus take precedence.
3. Intrauterine Fetal Surgery is an example of therapeutic research, is a therapy for anatomic

lesions that can be corrected surgically and are incompatible with life if not treated. The
procedure involves opening the uterus during the second trimester (before viability),
performing the planned surgery, and replacing the fetus in the uterus. The parents must be
informed of the experimental nature of the treatment, the risk of the surgery, the commitment
to cesarean birth, and alternatives to the treatment.
4. Reproductive Assistance-Assisted Reproductive Technology (ART) is the Term used to

describe highly technologic approaches used to produce pregnancy. In Vitro Fertilization and
Embryo Transfer (IVFET), a therapy offered to selected infertile couples, is perhaps the best
known ART technique
5. Surrogating childbearing is another approach to infertility. Surrogate childbearing occurs

when a woman agrees to become pregnant for a childless couple. She may be artificially
inseminated with the male partner’s sperm or a donor’s sperm or may receive a gamete
transfer, depending on the infertile couple’s needs. If fertilization occurs, the woman carries
the fetus to term and release the infant to the couple after birth.
6. Embryonic Stem Cell Research can be found in the human stem cell in embryonic tissue
and in the primordial germ cells of a fetus. Research has demonstrated that in tissue cultures
these cells can be made to differentiate onto other types of cells such as blood, nerve, or heart
cells, which might then be used to treat problems such as diabetes, Parkinson and Alzheimer
diseases, spinal cord injury, or metabolic disorders. The availability of specialized tissue or
even organs grown from stem cells might also decrease society’s dependence on donated
organs for organ transplants.
7. Cord Blood Banking is used when cord blood, taken from a newborn’s umbilical cord at
birth and stored or “banked”, may play a role in combating leukemia, certain other cancers,
and immune and blood system disorders. This is possible because cord blood, like bone
marrow and embryonic tissue, contains regenerative stem cells, which can replace diseased
cells in the affected individual.
8. Making Treatment Decisions For Children-Technology makes it possible to sustain the

lives of the children who previously would have died, thus creating many ethical issues.
Problems may develop because physicians, nurses, and parents have differing opinions about
treatments for an infant or child with a serious or fatal condition. Nurses often ethical
dilemmas when providing care to such a child, especially as they witness parents struggling
to decide among treatment options. Ethical issues in pediatrics are often more complex
because most children lack the capacity to make or to participate in medical decisions that
directly affect them.
9. Terminating Life-Sustaining Treatment-Federal “Baby Doe” regulations were developed to

protect the rights of infants with severe defects. Parents of such infants are usually the
ultimate decision makers about the child’s care. They may want to terminate the treatment
because of the tremendous social, emotional, and financial burden they face. Physicians may
believe treatment will help the child and improve the quality of life (sometimes defined as a
meaningful existence or an ability to develop human relationship).
Justifications for withholding, withdrawing, or limiting therapy include the following:
1. The treatment in question has a poor rate of success.

2. The burdens of the treatment outweigh the benefits, or the quality of life is poor
after treatment.
3. The burdens of the disease outweigh the benefits of continued survival, or the
quality of life is poor before the treatment.
Advances in genetics and genetic technology

The Human Genome Project is an international multidisciplinary effort to Explore and
map all human genetic material. It revealed that there are between 30,000 and 40,000 human
genes, a significantly lower number than previously estimated. As more genetic information
becomes available, questions arise about the ethical use and protection of such information.
Other emerging issues include the question of payment for genetic testing; appropriate
counseling following testing; confidentiality; qualifications of individuals engaged in testing,
counseling, and interventions; mandated testing; and the right to refuse to receive information
about genetic findings.
Reproductive Health Bill

The Responsible Parenthood and Reproductive Health Act of 2012, also known as
the Reproductive Health Law or RH Law, and officially designated as Republic Act No.
10354, is a law in the Philippines, which guarantees universal access to methods on
contraception, fertility control, sexual education, and maternal care.
Activity No. 7 Legal and Ethical Considerations in Maternal and Child Care
1. Identify or give example of situations that may put a nurse into litigation.
2. What is your opinion regarding termination of pregnancy when the woman is at risk from
the pregnancy and the fetus is healthy.
References
9th Edition
Module 8
Filipino Culture, Values and Practices

in Relation to Maternal and Child Care
OVERVIEW
This module presents a transcultural approach of nursing care related to Maternal and
Child Nursing practices.
LEARNING OBJECTIVES
1. Analyze the influence of cultural, and religious beliefs and practices in relation to
maternal care from pregnancy to labor and delivery.
Sociocultural differences and their implications for maternal and Child Nursing
Respecting sociocultural values is important in maternal and child health because
childbearing and childrearing are both times in life surrounded by many cultural traditions.
Nurses can better provide multicultural care by understanding cultural concepts and
sociocultural influence on families (Pilliteri 2018). It is essential that nurses become
culturally competent. Nurses must examine their own beliefs so that they have a better
appreciation and understanding of the beliefs of their patients. Understanding the concepts of
ethnocentrism and cultural relativism may help nurses care for families in a multicultural
society (Perry 2014).
Filipino Beliefs and Practices During Pregnancy, Labor and Delivery and
Postpartum
In the Philippines part of the culture are myths or misconceptions regarding pregnancy, birth,
postpartum and infant care. These myths are usually from old folks and passed on to family members
and relatives that are then put into practice. These often mislead pregnant women making them
hesitant to follow advice from professional health workers (Bermio 2017).
According to Siojo (2016), the Philippines is a country full of superstitions and

beliefs regarding childbearing that is practiced mainly because Filipinos believe that there is nothing
to lose if they abide with these beliefs that were derived from their traditions, customs and culture.
They emphasized that when a woman is pregnant her one foot is confined to a hospital while the other
foot is bound ‘six-feet below the ground.
Myths and Beliefs related to Pregnancy
Here are some of the beliefs and practices of the Filipinos related to pregnancy. According to
some Filipino beliefs, cravings for food during pregnancy should be satisfied. Some pregnant
women may avoid eating black foods to avoid the birth of an infant with a dark skin tone.
Some pregnant women may place great emphasis on being tidy and beautiful, believing that
these practices will influence the beauty of their child. Unpleasant emotions experienced by
pregnant women may be blamed for causing birthmarks.
Birth practices of selected cultural groups
In some regions of the Philippines, it is believed that putting squash leaves on the
abdomen of a laboring woman can facilitate labor. Some women believe that drinking
coconut water can facilitate a fast labor. Some fathers may prefer to be close to their laboring
wife, so they can bury the placenta. Traditional custom in the Philippines dictates that women
should not bathe for about ten days after giving birth and during menstruation. Bathing
during these times is seen as a cause of ill health and rheumatism in old age. Sponge baths
and steam baths could be used as alternatives. Women may object to having a shower
immediately after giving birth. Traditionally, after labor, women wear heavy clothes or wrap
themselves in blankets to prevent exposure to ‘cold’ and ‘wind’. Some Filipinas bind their
abdomen tightly, believing that this practice helps to prevent bleeding and helps the uterus to
retract. Women fear what is referred to as a ‘relapse’ if they become active too soon. This
involves extreme tiredness, weakness and chronic headache. Postpartum women may be
massaged with coconut oil, with the aim of restoring their lost health, expelling blood clots
from the uterus, returning the uterus into a normal position, and promoting lactation.
Colostrum is usually considered ‘dirty milk’ and discarded. Some women may be reluctant to
feed colostrum to their newborn, despite encouragement by health professionals. Some
mothers believe that a mother’s mood can be transmitted through breast milk and therefore do
not feed if the mother is not in good mood (Cabigon 2006).
Activity No.8 Filipino Cultural Beliefs and Practices
1. Identify the Filipino beliefs and health care practices that may have a significant impact
during pregnancy, labor and delivery, and postpartum period. Discussed whether these beliefs
and practices promote health or whether these brings risks to the mother and the fetus/infant.
References
9th Edition
Bermio J, Reotutar L, Beliefs and Practices During Pregnancy, Labor and Delivery,
Postpartum and Infant Care of Women in the Second District of Ilocos Sur,
Philippines International Journal of Scientific & Engineering Research Volume 8,
Issue 9, September-2017

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Southern Luzon State University

College of Allied Medicine

CARE OF THE MOTHER, CHILD, AND

Theory: Sec. A M-T 1:30-3:30 PM Sec. B M-T 7:00-9:00 AM

This module is dedicated to the students of Southern Luzon State

Southern Luzon State

This instructional material is dedicated to my late beloved Nanay Tancing,

for her unending love and support to her eight children,

all the Nursing and Midwifery students and

Clinical Instructors of CAM-SLSU,

and to all mothers who are on

their childbearing years.

Module 1 Framework for Maternal and Child Health Nursing 6

Module 3 Human Conception and Reproduction 16

Module 4 Antepartum Care 24

Module 5 Intrapartum Care 41

Module 6 Postpartum Care 59

Module 7 Legal Considerations and Issues in Maternal-Child Care 70

Module 8 Filipino Culture, Values and Practices in Relation to Maternal 74

Framework for Maternal and Child

A Framework for Maternal and Child Health Nursing Care

Goal of Maternal and Child Nursing

Scope and Standards of Nursing practice

Competencies and Roles of a Maternal and Child Nurse

Reproductive and Sexual

Biologic Gender is a person’s chromosomal gender, a biologic categorization based

Gender Identity is a person’s perception of his or her maleness or femaleness. Sex

FEMALE REPRODUCTIVE SYSTEM

A. External Genitalia- also called “vulva” or “pudenda”

Parts of external genitalia

4. Glans Clitoris is a pea-shaped composed of erectile tissues and sensitive nerve

6. Vestibule is an almond-shaped area bounded anteriorly by the prepuce of the

Parts of Internal Genitalia

1. Vagina is a dilatable canal containing rugae ( thick folds of membranous stratified

3 Layers of the Uterus

Parts of the uterus

Position of the Uterus

Functions of the Uterus

Parts of the Oviducts

Functions of the Oviducts

Parts of the Ovaries

Functions of the Ovaries

MALE REPRODUCTIVE SYSTEM

Terminologies related to menstruation

Phases of Menstrual Cycle

Body Structure and Hormones Involved in Menstrual Cycle

Signs of Ovulation includes

Activity 2. The Reproductive System and Menstrual Cycle

Human Conception and Fetal

Definition and Theories Related To Procreation

3 layers of the trophoblast:

I. Amnion (fetal membrane)

Terms related to Amniotic Fluid

Functions of the Amniotic Fluid

II. Chorion (placental membrane)

Functions of the Placenta

Stages of Human Pre-natal Development

First Lunar Month (4 weeks)