VI.

ANATOMY AND PHYSIOLOGY

A. Physiology of Menstruation

MENSTRUATION

Menstruation is the shedding of the upper portion of the endometrium in response to withdrawal
of progesterone following regression of the corpus luteum in the late secretory phase. The initial
signals for the menstrual cycle come from the hypothalamus and anterior pituitary gland.
Menarche, the first menstrual bleed, occurs between the ages of 10 and 16 years in the
developed world.

HYPHOTALAMUS

The release of GnRH also called luteinizing hormone-releasing hormone in the hypothalamus
initiates the menstrual cycle. GnRH then stimulates the pituitary gland to send the
gonadotrophic hormone to the ovaries to produce estrogen.
PITUARY GLAND

Under the influence of GnRH, the anterior lobe of the pituitary gland produces two hormones,
the
FSH (Follicle Stimulating Hormone) and the LH (Luteinizing Hormone). The FSH is responsible
for the maturation of the ovum and the LH is responsible for the release of the mature egg cell
from the ovary.

OVARIES

FSH and LH are called gonadotrophic hormones because they cause growth in the ovaries.
Every month during the fertile period of a woman’s life one of the ovary’s oocytes is activated
by FSH to begin to grow and mature. As the oocyte grows, its cells produce a clear fluid that
contains a high degree estrogen and progesterone. If conception occurs as the ovum proceeds
down a fallopian tube and the fertilized ovum implants on the endometrium of the uterus, the
corpus luteum remains throughout the major portion of pregnancy. If conception does not
occur the unfertilized ovum atrophies after 4 to 5 days.

UTERUS
Uterine changes occur monthly as a result of stimulation from the estrogen and progesterone
produced by the ovaries preparing the endometrium for a possible implantation.

B. Signs of Labor : True vs False Labor

SIGNS OF LABOR

 Your baby drops or moves lower into your pelvis. This is called lightening. It means
that your baby is getting ready to move into position for birth. It can happen a few weeks
or even just a few hours before your labor begins.
 You have an increase in vaginal discharge that’s clear, pink or slightly
bloody. This is called show or bloody show. It can happen a few days before labor starts
or at the beginning of labor. 
 At a prenatal checkup, your health care provider tells you that your cervix has
begun to efface (thin) and dilate (open). Before labor, your cervix is about 3.5 to 4
centimeters long. When it’s fully dilated (open) for labor, it’s 10 centimeters. Once labor
starts, contractions help open your cervix. 
 You have the nesting instinct. This is when you want to get things organized in your
home to get ready for your baby. You may want to do things like cook meals or get the
baby’s clothes and room ready. Doing these things is fine as long as you’re careful not to
overdo it. You need your energy for labor and birth.

TRUE AND FALSE LABOR (CONTRACTIONS)

The timing of the contractions is a big component for recognizing the differences between true
and false labor. Other differences you might notice include the contractions changing when you
change positions, like stopping with movement or rest. The strength of contractions is also
different, and the pain is felt in different places.

True labor False labor (Braxton-Hicks contractions)

 Contractions come and get closer  Contractions don’t come regularly and
together over time, lasting about 30-70 they don’t get closer together
 seconds each
 They continue regardless of movement
or resting
 They progressively get stronger
 Usually they start in the back and
move to the front
 contractions come at regular intervals
and get closer together as time goes
on. (Contractions last about 30 to 70
seconds.).
 contractions continue, despite moving
or changing positions.
 They stop with walking or resting or
with changes in position
 They are usually weak and don’t get
stronger, or start strong and get
weaker
 Usually the pain is only felt in the front
 contractions are often irregular and do
not get closer together.
 contractions might stop when you walk
or rest, or might even stop when you
change position.

C. Mechanisms of Labor/ Cardinal Signs of Labor

STAGES OF LABOR
STAGE l
It is usually the longest part of labor. It begins with regular uterine contractions and ends
with complete cervical dilatation at 10 centimeters. This stage is broken down into three (3)
phases: the Latent phase, where the contractions are mild and short, lasting 20 to 40 seconds.
Cervix dilates from zero to three cm. This phase lasts approximately 4.5 to 6 hours. Active
phase, where contraction lasts 40 to 60 seconds and occurs every 3 to 5 minutes. Cervix dilates
with four to seven cm and initiates a more rapid dilatation. This phase lasts approximately, 2 to
3 hours; and the Transition phase, where it is definitely known as the shortest phase but the
hardest, contraction occurs every two to three minutes with a duration of 60 to 90 seconds,
about approximately eight to ten cm of cervical dilatation. Some women will shake and may
vomit during this stage, and this is regarded as normal. Most of the time, women would find a
comfortable position to acquire complete dilatation.

STAGE ll

This stage lasts for three or more hours. However, the length of this stage depends upon the
mother’s position (e.g.; upright position yields faster delivery). Once the cervix has completely
dilated, the second stage had begun. This stage ends with the expulsion of the fetus.

STAGE lll
This stage focuses on the expulsion of the placenta from the mother. Placenta exclusion is
much easier than the delivery of the baby because it includes no bones, and this is during this
stage that the baby is placed on top of the mother’s womb.

STAGE IV

This stage is the first to four hours after the delivery of the placenta. It is more on close maternal
observation and monitoring.

7 CARDINAL MOVEMENT OF LABOR

1. Engagement – fetal presenting part as its widest diameter reaches the level of the ischial
spine of the pelvis
2. Descent – movement of the bi-parietal diameter of the fetal head downwards until it reaches
the pelvic inlet.
3. Flexion – Fetal head reaches the pelvic floor; head bends forward onto chest, presenting the
smallest anteroposterior diameter.
4. Internal Rotation – fetus enters pelvic inlet to the maternal pelvis, allows longest fetal head
to match the longest maternal pelvic diameter.
5. Extension – Internal rotation is complete, fetal head passes beneath the symphysis pubis
while in flexion.
6. External Rotation - as the head is delivered, it rotates back to its original position prior to
internal rotation. The release of the Passive forces on the fetal head allows it to return to
appropriate position.
7. Expulsion – delivery of the fetus, occurs first as the anterior, then the posterior shoulder
passes under the symphysis pubis.

D. Physiology of Labor

A. Normal labor

Emanuel Friedman in his elegant treatise on labor (1978) stated correctly that "the clinical
features of uterine contractions namely frequency, intensity, and duration cannot be relied
upon as measures of progression in labor nor as indices of normality. Except for cervical
dilatation and fetal decent, none of the clinical features of the parturient patient appears to
be useful in assessing labor progression." Friedman sought to select criteria that would limit
normal labor and thus be able to identify significant abnormalities of labor. These limits,
admittedly arbitrary, appear to be logical and clinically useful. The graphic representation of
labor plotting descent and dilatation against time has become known as the Friedman
curve. It, or a modification of it, is used extensively to evaluate laboring patients.
 Graphic portrayal of the relationship between cervical dilatation and elapsed time in labor
(heavy line) and between fetal station and time (light line). Labor has been divided functionally
into a preparatory division (including latent and acceleration phases of the dilatation curve), a
dilatational division comprising only the linear phase of maximum slope of dilatation, and a
pelvic division encompassing the linear phase of maximum descent.

B. Functional classification of labor

Principal Clinical Features on the Functional Divisions of Labor

Dilatational
Characteristic Preparatory Division Pelvic Division
Division
Functions Contractions Cervix actively Pelvis negotiated; mechanisms
coordinated, polarized, dilated of labor; fetal descent; delivery
oriented; cervix
prepared
Interval Latent and acceleration Phase of Deceleration phase and
phases maximum slope second stage
Measurement Elapsed duration Linear rate of Linear rate of descent
dilatation
Diagnosable Prolonged latent phase Protracted Prolonged deceleration;
disorders dilatation; secondary arrest of dilatation;
protracted arrest of descent; failure of
descent descent
 C. Abnormal labor

Dystocia (literally difficult labor) is characterized by abnormally slow progress in labor. It is the
consequence of four distinct abnormalities that may exist singly or in combination.

1. Uterine forces that are not sufficiently strong or appropriately coordinated to efface and
dilate the cervix.

2. Forces generated by voluntary muscles during the second stage of labor that are
inadequate to overcome the normal resistance of the bony birth canal and maternal soft
parts.

3. Faulty presentation or abnormal development of the fetus of such character that the
fetus cannot be extruded through the birth canal.

4. Abnormalities of the birth canal that form an obstacle to the descent of the fetus.

Labor Disorders
Pattern Diagnostic Criterion
Prolonged latent phase Nulliparas 20 hr or more Multiparas 14 hr or more
Protracted active phase
Nulliparas 1.2 cm/hr or less
dilatation
Protracted descent Nulliparas 1 cm/hr or less Multiparas 2 cm/hr or less

Prolonged deceleration phase Nulliparas 3 hr or more Multiparas 1 hr or more

Secondary arrest of dilatation Arrest 2 hr or more

Arrest of descent Arrest 1 hr or more
Failure of descent No descent in deceleration phase of second stage

Prolonged latent phase of labor

  
Prolonged Latent Phase Pattern (solid line)

Etiologic factors that appear to be responsible for the development of prolonged latent phase
disorders in multiparas most often include excessive sedation administered during the course of
the latent phase and poor prelabor soft-tissue preparation. In addition, false labor and
myometrial dysfunction are found but can be diagnosed only retrospectively.

1. Arrest disorder
 A. Secondary arrest of dilatation pattern with documented cessation of progression in the
active phase

B. Prolonged deceleration phase pattern with deceleration phase duration greater than
normal limits

C. Failure of descent in the deceleration phase and second stage

D. Arrest of descent characterized by halted advancement of fetal station in the second

stage.

These four abnormalities are similar in etiology, response to treatment, and prognosis, being
readily differentiated from the normal dilatation and descent curves (broken lines).

Etiology of arrest disorders are as follows. The striking association with cephalopelvic
disproportion makes these disorders especially ominous; whenever encountered, arrest
patterns should signal the likelihood that a bony impediment exists. Other factors very often
occur in combination with each other and with disproportion as well.
V. PARTS AND FUNCTION OF FEMALE REPRODUCTIVE SYSTEM
EXTERNAL GENITALIA

The external female genitalia structures are referred to collectively as the vulva a latin word for
“covering”. It serves as a protection to the woman/s sexual organs, urinary opening, vestibule
and vagina.

MONS PUBIS
The mons pubis is a rounded mound of fatty tissue that covers the pubic bone. During puberty,
it becomes covered with hair. The mons pubis contains oil-secreting (sebaceous) glands that
release substances that are involved in sexual attraction (pheromones).
LABIA MAJORA

The labia majora (literally, large lips) are relatively large, fleshy folds of tissue that enclose and
protect the other external genital organs. They are comparable to the scrotum in males. The
labia majora contain sweat and sebaceous glands, which produce lubricating secretions. During
puberty, hair appears on the labia majora.

LABIA MINORA
These are the folds of tissue that is fused anteriorly and separated posteriorly positioned lateral
to the labia minora. It’s internal surface is made up of mucous membranes and the external
surface is covered with skin, it is also composed of fine layer of pubic hair and serves as a
protection of external genitalia and acts as a shield to urethra and vaginal opening.

CLITORIS
It is a small rounded organ of erectile tissue at the anterior junction of labia minora. It is usually
1 to 2 cm in size and is the center of sexual arousal and orgasm in woman.

URETHARAL OPENING
Female urethral opening: The external opening of the transport tube that leads from the
bladder to discharge urine outside the body in a female.

HYMEN
A tough elastic semicircle tissue that covers the opening of the vagina during childhood. It is
often
torn during the time of the first sexual intercourse. However, hymen can’t be utilized as a sign
of
“virginity”

VAGINAL ENTRANCE
The opening is where menstrual blood leaves the body. It's also used to birth a baby and for
sexual intercourse.

SKENE AND BARTHOLIN GLANDS

Skene glands (paraurethral glands) are two glands that is located on each side of the urethra
while Bartholin glands (vulvovaginal glands) are located on each side of the vaginal opening.
Both
of these glands produce secretions that lubricate the external genitalia during sexual
intercourse.
The alkaline pH of those secretions also increases the survivability rate of the sperm in the
vagina.

INTERNAL GENITALIA OF FEMALE

OVARY

The ovaries are approximately 3 cm long by 2 cm in diameter and 1.5 cm thick, or the size and
shape of almonds. They are located on both sides of the uterus in the lower abdomen. The
function of the two ovaries is to produce, mature and discharge ova (egg cells). In the process
of producing ova, the ovaries also produces estrogen and progesterone with the help of FSH
(Follicle Stimulating Hormone) and LH (Luteinizing Hormone) produced by the pituitary gland.
Ovaries are not covered by a layer of peritoneum so that the ova can readily escape and enter
the uterus by the fallopian tubes.

UTERINE TUBE

The primary function of the uterine tubes is to transport sperm toward the egg, which is
released by the ovary, and to then allow passage of the fertilized egg back to the uterus for
implantation.

URINARY BLADDER

Bladder. This triangle-shaped, hollow organ is located in the lower abdomen. It is held in place
by ligaments that are attached to other organs and the pelvic bones. The bladder's walls relax
and expand to store urine, and contract and flatten to empty urine through the urethra.

FALLOPIAN TUBE
These are narrow tubes that are attached to the upper part of the uterus and serve as pathways
for the ova (egg cells) to travel from the ovaries to the uterus. Fertilization of an egg by a sperm
normally occurs in the fallopian tubes. The fertilized egg then moves to the uterus, where it
implants to the uterine lining.

UTERUS

Uterus, also called womb, an inverted pear-shaped muscular organ of the female reproductive
system, located between the bladder and the rectum. It functions to nourish and house a
fertilized egg until the fetus, or offspring, is ready to be delivered.

A uterus is about 5 to 7 cm long, 5 cm wide, and 2.5 cm deep. Ina non pregnant state it weighs
about 60 g. The function of the uterus is to receive the ovum from the fallopian tube, provide a
place for implantation and nourishment, serve as a protection to the growing fetus and at the
maturity of the fetus expel it from the body. After pregnancy, uterus never returns to the
nonpregnant size but remains approximately 9 cm long, 6 cm wide, 3 cm thick, and 80 g in
weight. . The fundus (uppermost portion of the uterus) can be palpated abdominally to
determine the amount of uterine growth during pregnancy, to measure the force of uterine
contractions during labor, and to assess that the uterus is returning to its nonpregnant state
after childbirth.

VAGINA

The vagina is a muscular, ridged sheath connecting the external genitals to the uterus, where
the embryo grows into a fetus during pregnancy. In the reproductive process, the vagina
functions as a two-way street, accepting the penis and sperm during intercourse and roughly
nine months later, serving as the avenue of birth through which the new baby enters the world.
The vagina ends at the cervix, the lower portion or neck of the uterus. Like the vagina, the
cervix has dual reproductive functions.
Within 24 hours after fertilization, the egg that will become your baby rapidly divides into many
cells. By the eighth week of pregnancy, the embryo develops into a fetus. There are about 40
weeks to a typical pregnancy. These weeks are divided into three trimesters.

Pre-embryonic - First 2 weeks, beginning with fertilization

Embryonic – weeks 3 through 8

Fetal – from week 8 through birth

Fertilization – also referred to as conception or impregnation. It is the union of

spermatozoon
and ovum (zygote)

Implantation – once fertilization is complete, a zygote migrates over the next 3 to

4 days toward
the body of the uterus. Aided by the muscular contractions of the fallopian tubes.
During this time,
mitotic cell division or cleavage begins. Over the next 3 – 4 days large cells tend to
connect at the
periphery of the ball leaving a fluid space surrounding an inner cell mass. At this
stage, the
structure is termed as the blastocyst. The cells in the outer ring are called
trophoblast cells these
are the structure that will later form the placenta and membranes
EMBRYONIC STAGE AND FETAL STRUCTURE

DECIDUA
- After fertilization, the corpus luteum in the ovary continues to function rather than atrophying
under the influence of human chorionic gonadotrophin hCG secreted by the trophoblast cells.
The endometrium is now typically termed as the decidua (latin word for falling off) because it
will be discarded after birth.

CHORIONIC VILLI

- As early as 11th or 12th day after fertilization, chorionic villi reach out from the trophoblast cells
into the uterine endometrium to begin formation of the placenta

PLACENTA

- Latin for “pancake” grows from few identifiable trophoblastic cells at the beginning of
pregnancy to an organ 15 to 20 cm in diameter covering about the half the surface area of the
internal uterus at term. As early as the 12th day of pregnancy, maternal blood begins to collect
in the intervillous spaces of the uterine endometrium surrounding the chorionic villi. By the third
 week, oxygen and other nutrients such as glucose, amino acids, fatty acids, minerals, vitamins
and water osmose from the maternal blood through the cell layers of the chorionic villi. From
there, nutrients are transported to the developing embryo.
AMNIOTIC MEMBRANES

- The chorionic villi on the medial surface of the trophoblast gradually thin until they become
chorionic membrane the outermost fetal membrane. The amniotic membrane forms beneath
the chorion. It is a dual walled sac with the chorion as the outmost and the amnion as the
innermost part. They have no nerve supply, so when they spontaneously rupture at term the
pregnant woman doesn’t feel any pain.

AMNIOTIC FLUID

- This fluid never becomes stagnant because it is constantly being newly formed and absorbed by
direct contact with the fetal surface of the placenta. At term, the amount of amniotic fluid has
grown so much it ranges from 800 – 1,200 ml. If for any reason the fetus is unable to swallow
excessive fluid may occur or hydramnios may occur (fluid more than 2000 ml). As soon as the
fetal kidneys become active, fetal urine adds to the quantity of the amniotic fluid any
disturbance may cause oligohydramnios or reduced amount of amniotic fluid. The most
important purpose of the amniotic fluid is to shield the fetus against pressure or a blow to a
mother’s abdomen, protects the fetus in changes of temperature and it allows muscular
development on the fetus.

PHYSIOLOGICAL CHANGES IN PREGNANCY

RESPIRATORY CHANGES

- There is a significant increase in oxygen demand during normal pregnancy. This is due to a 15%
increase in the metabolic rate and a 20% increased consumption of oxygen. There is a 40–50%
increase in minute ventilation, mostly due to an increase in tidal volume, rather than in the
respiratory rate.

PITUARY GLAND
 - The pituitary gland enlarges in pregnancy and this is mainly due to proliferation of prolactin-
producing cells in the anterior lobe. Serum prolactin levels increase in the first trimester and are
10 times higher at term.

INTEGUMENTARY CHANGES

- As the uterus increases in size, the abdominal wall must stretch to accommodate it. This
stretching can cause rupture and atrophy of the segment os connective lare of the skin leading
to streaks of lines or “stretch marks” on the sides of the abdominal wall called the Striae
gravidarum. After birth these lines lighten to a silvery color and became barely noticeable. Extra
pigmentation generally appears on the abdominal wall because of the melanocytestimulating
hormone from the pituitary. A narrow brown line called the linea nigra shows from the
umbilicus to the symphysis pubis. Darkened and reddened areas may appear on the face as well,
particularly on the nose and cheeks known as melasma or the “mask of pregnancy”.

BREAST CHANGES

- Typical changes in breasts often show at about 6 weeks of pregnancy. These changes are a
feeling of fullness, tingling, or tenderness that occurs because of the increased stimulation of
breast tissues by the high estrogen level in the body. The areola of the nipple darkens and
increases in diameter from about 3.5 cm to 7.5 cm. This changes also happens because the
breasts begin readying themselves for secretion of milk.

RESPIRATORY CHANGES

- As the uterus enlarges so much during pregnancy, the diaphragm and the lungs receive an
increasing amount of pressure. This can actually displace the diaphragm by as much as 4 cm
upward. Two major changes do occur with pregnancy: a more rapid than usual breathing rate
918 to 20 breaths per min) and a chronic feeling of shortness of breath.

ABDOMINAL CHANGES

- Besides of noticeable changes on the abdomen of the pregnant women during 9 months of
gestation such as an expanding belly, enlargement of the uterus and weight gain, a pregnant
woman also experiences some nausea and vomiting. It is also known as morning sickness; it
begins to be noticed at the same time levels of hCG and progesterone begin to rise.

URINARY CHANGES

- Like other systems, the urinary system undergoes physiologic changes during pregnancy. These
includes alteration in fluid retention and renal, ureter, and bladder function which results from
the effects of high estrogen and progesterone levels, compression of the bladder due to the
growing fetus, increased blood volume that increases urine production by the kidney and
postural influences.
VAGINAL CHANGES
- Pregnancy hormones can cause an increase in vaginal discharge, but this should be clear,
mucous, non-irritant and non-smelly. Not long after delivery, the woman will have a vaginal
secretion made generally of blood and what is left of the uterine coating from pregnancy. This is
called lochia and can keep going for half a month. Changes in vaginal discharge can begin as
early as one to two weeks after conception. As the pregnancy progresses, this discharge usually
becomes more noticeable, and it's heaviest at the end of pregnancy. The vaginal area can feel
painful or sore in the immediate period after childbirth. This usually improves within 6 to 12
weeks after the birth

SKIN CHANGES

- A temporary shift in immunologic, metabolic, and hormonal factors during pregnancy leads to
physiological dermatologic manifestations including hyperpigmentation, hair and nail changes,
vascular changes, and shifts in apocrine and eccrine gland activity.

SIGNS OF PREGNANCY

PRESUMPTIVE PROBABLE POSITIVE

Nausea – with or Increased Fetal heart sounds
without vomiting frequency of
urination
Breast enlargement Braxton hicks Ultrasound
contractions scanning of the
fetus
Fatigue Abdominal Palpation of fetus
enlargement
Poor sleep Goodell`s sign Fetal movements
Constipation Chadwick sign
 PHYSIOLOGY OF POST-PARTUM

A. POST-PARTUM ASSESSMENT AND PHYSIOLOGICAL CHANGES

ASSESSMENT

An assessment on any patient is always considered to be from head to toe. In the

postpartum patient, the assessment EXPANDS to also include the following (starting from top to
bottom):

BREASTS
Palpate each breast for firmness, fullness, tenderness, shininess, and contour. Does the
mom complain of sore nipples, are the nipples red, cracked or bleeding? Is she wearing a support bra?
Encourage all moms to wear a support bra whether nursing or non-nursing.

UTERUS
It is firm or is it boggy? The fundus should be firm; if not, gently massage to obtain firmness
and note if excess bleeding or clots are expelled during the massage. What is the fundal height? It
should decrease in height by one fingerbreadth below the umbilicus each day post delivery. Nursing
mothers may involute a little more quickly due to the release of oxytocin while nursing. It is best to have
the mother void and then have her lie flat in bed before checking fundal height. If the fundus is above
the
uterus or displaced to the right or left, the mom may have a full bladder or retained placenta fragments.

C-SECTION
If the patient had a C-Section, inspect the dressing or incision at this time noting site,
redness, discharge, and approximation of the incision if uncovered. Don't forget to check for bowel
sounds.

LOCHIA
When examining the fundus, check the lochia for color, amount, odor, and the number of pads
used. The first two to three days, lochia is bright red, similar to menses and is known as RUBRA. The
next few days lochia becomes serous and more watery and is known as SEROSA. By 10 to 14 days the
lochia is thin and colorless and is known as ALBA. If the lochia has a foul odor, then be suspicious of an
infection. The doctor should be notified of any unusual odor, excessive bleeding, or clotting.

EPISIOTOMY

Inspect the incision for REEDA. (If you do not know what this is, look it up in your
textbook before giving care) Also check for a hematoma. The patient may need to be medicated for
discomfort. Also check the rectum at this time for hemorrhoids and initiate appropriate measures if
uncomfortable to the patient.

ELIMINATION: BLADDER
Is mom voiding, is so, how often and how much. Is bladder distended?
Does she or did she have a catheter? If the catheter has been discontinued, what time was it? All
postpartum patients should void by six hours after delivery or Foley removal. All postpartum moms
should have their urine measured the first three voiding’s to ensure adequate emptying of the bladder.
These voiding’s should be at least 150 cc's. Remember, the mom's blood volume increased during the
second and third trimester, and diuresis takes place to return to pre-pregnancy status.
Frequent, small voiding’s may be indicative of retention or infection. This is a good time to find out if the
mom is performing peri care with each use of the bathroom. If she is not, then by all means teach her
according to the process of your hospital uses. BOWEL: Daily ask the patient if she has had a bowel
movement. If no bowel movement by the second day, she may need a stool softener or a laxative.
Encourage increase in fluid and juices along with increasing intake of fruits and vegetables. Ambulation
helps too.

LEGS
Check Homan's sign, and chart with cardiovascular status.
TEACHING: Talk with your mom during the assessment, and teach her the things about her care
as you go along. EXAMPLE: Peri care when checking the perineum, rationale for sitz bath and
peri light, use of local analgesics, hemorrhoid treatment, rationale for ambulation especially if a
Csection, etc.

PSYCHOSOCIAL
Note mother/father infant bonding and chart. Is mom stroking the infant,
talking to the infant, calling the infant affectionate names, or just looking affectionately at the
infant. A lack of bonding may be noted by bottle feeding the infant in the crib, or spending time
on the phone when the infant is in the room. Evaluate the mom's emotional status, explain the
hormonal changes that are occurring, and that her emotions may change from high to low quickly.
She may cry easily, but these changes are normal. Informing the family members of these
changes helps too.
POSTURAL HYPOTENSION

Caution the mom to move slowly upon sitting or getting out of

bed. Assist her the first few times she is up. Stay in the bathroom or close by the first time she
showers or when taking a sitz bath. Remind her NOT TO LOCK the bathroom or shower doors.
Be CERTAIN your mom can reach and has been instructed in the use of the call bell in the
bathroom or shower as well as her bed.