MODULE 3 CARE OF THE
uterine contractions resulting in effacement and
MOTHER AND FETUS DURING
THE PERINATAL PERIOD:
Terminology:
Amniotic fluid- Fluid that surrounds and protects
the fetus and consisting of 800 and 1200 ml by
the end of pregnancy. The fetus floats in the
amniotic fluid, which serves as a cushion
against injury from sudden blows or
movements and helps maintain a constant body
temperature for the fetus. The fetus voids into
the amniotic fluid and also drinks and breathes
the fluid.
Ballottement – Rebounding of the fetus against
the examiner’s finger on palpitation. When the
examiner taps the cervix, the fetus floats
upward in the amniotic fluid. The examiner
feels a rebound when the fetus falls back.
Chadwick’s sign – Bluish coloration of the
mucuous membranes of the cervix, vagina , and
vulva that occurs at about 6 weeks of pregnancy
and is a probable sign of pregnancy.
Delivery – is Actual event of birth; the expulsion
or extraction of the neonate.
Fertilization – Uniting of the sperm and ovum,
which occurs within 12 hours of ovulation and
within 2 to 3 days of insemination, the average
duration of viability for the ovum and sperm.
Goodell’s sign – Softening of the cervix that
occurs at the beginning of the second month of
gestation and is a probable sign of pregnancy
Gravida – A pregnant woman; called gravida I
(primagravida) during the first pregnancy,
gravida II during the second, and so on.
Hegar’s sign – Compressibility and softening of
the lower uterine segment that occurs at about
week 6 of gestation; a probable sign of
pregnancy
Implantation – Attachment of the zygote to the
uterine wall 6 to 8 days after ovulation
Infant – A baby born alive; also from 28 days of
age until the first birthday
Labor – Coordinated sequence of involuntary
dilation of cervix, followed by expulsion of the
products of conception.
Lochia – Discharge from the uterus that consists
of blood from the vessels of the placental site
and debris from the decidua; lasts for 2 to 3
weeks after delivery
Nägele’s rule - Determines the estimated date of
confinement and works on the premise that the
woman has a 28-day-menstrual cycle. Add 7
days to the first days of the last menstrual
period. Subtract 3 months and add 1 year.
Alternatively, add 7 days to the last menstrual
period and count forward 9 months.
Neonate – A human offspring from the time of
birth to the twenty-eight day of life; also called
newborn
Newborn – A human offspring from the time of
birth to the twenty-eighth day of life; also
called neonate
Parity – the number of pregnancies that have been
carried to viability
Placenta – the organ that provides for the
exchange of nutrients and waste products
between the fetus and the mother, produces
hormones to maintain pregnancy, and develops
by the third month of gestation; also called
afterbirth.
Quickening – First perception of fetal movement,
appearing usually in the sixteenth to eighteenth
week of pregnancy.
FEMALE REPRODUCTIVE SYSTEM
REPRODUCTIVE STRUCTURES
A. Ovaries
B. Fallopian tubes
C. Uterus
D. Cervix
E. Vagina
Ovaries - formation and expulsion of ova and
secretion of estrogen and progesterone.
Fallopian tubes - muscular tubes(oviducts)
approximate to the ovaries and connected to the
uterus. The tubes propel the ova from the
ovaries to the uterus.
 Uterus - A muscular pear-shaped cavity in which
the fetus develops. The cavity from which
menstruation occurs.
Cervix - is the internal os that opens into the body
of the uterine cavity. Cervical canal is located
between the internal os and the external os.
External cervical os opens into the vagina.
Vagina - mucous membrane-lined channel through
the muscles of the pelvic floor, known as the
Birth canal. It is the passageway between the
cervical os and the external environment
(passageway for menstrual blood flow and
passageway for fetus).
Menstrual Cycle
A. Ovarian hormones
Includes the follicle-stimulating hormone and
the luteinizing hormone and are released by the
anterior pituitary gland. The hormones produce
changes in the ovaries and the secretion of
ovarian hormones leads to changes in the
endometrium known as the menstrual cycle.
The menstrual cycle, the regularly recurring
physical changes in the endometrium that
culminate in its shedding, may vary in length,
with the average length of about 28 days.
B. Ovarian changes
1. Preovulatory phase
2. Luteal phase
C. Uterine changes
1. Menstrual phase
2. Proliferative phase
3. Secretory phase
MENSTRUAL CYCLE- includes the ovarian
changes and the uterine changes.
Ovarian changes:
1. Preovulatory Phase
2. Luteal Phase
1. Preovulatory phase
- The hypothalamus releases gonadotropin-
releasing hormone through the portal system to
the anterior pituitary system.
- Secretion of the follicle-stimulating
hormone(FSH) by the anterior pituitary lobe of
the pituitary gland stimulates growth of follicles.
- Most follicles die, leaving one to mature into a
large GRAAFIAN FOLLICLE.
- Estrogen produced by the follicle stimulates
increased secretions of luteinizing
hormone(LH) by the anterior lobe of the
pituitary gland.
2. Luteal phase
- The luteal phase begins with ovulation.
(ovulation typically occurs at mid- point of the
menstrual cycle).
- Body temperature drops and then rises around
the time of ovulation.
- Corpus luteum is formed from follicle cells that
remain in the ovary following ovulation.
- Corpus luteum secretes estrogen and
progesterone during the remaining 14 days of
the cycle.
- Corpus luteum degenerates if the ovum is not
fertilized, and secretion of estrogen and
progesterone declines.
- The decline of estrogen and progesterone
stimulates the anterior pituitary to secrete more
FSH and LH, initiating a new reproductive
cycle.
Uterine changes
1. Menstrual Phase
2. Proliferative Phase
3. Secretory Phase
1. Menstrual phase
- The menstrual phase consists of 4 to 6 days of
bleeding as the endometrium breaks down
because of the decreased amount of estrogen and
progesterone.
- The amount of FSH rises, enabling the
beginning of a new cycle.
2. Proliferative phase
- The proliferative phase lasts about 9 days.
- Estrogen stimulates proliferation and growth of
the endometrium.
- As estrogen increases, it suppresses secretion of
FSH and increases secretion of LH.
 - Secretion of LH stimulates ovulation and the
development of the corpus luteum.
- Ovulation occurs between day 12 and 16 of the
menstrual cycle.
- Estrogen is high and progesterone is low.
3. Secretory phase
- The secretory phase lasts about 12 days.
- The secretory phase follows ovulation.
- This phase is initiated in response to the increase
in LH.
- Graafian follicle is replaced by corpus luteum.
- Corpus luteum secretes progesterone and
estrogen.
- Progesterone prepares the endometrium for
pregnancy, should a fertilized ovum is
implanted.
MENOPAUSE- is the cessation of menstrual
cycle.
What is dysmenorrhea?
Dysmenorrhea causes severe and frequent cramps and
pain during your period. It may be either primary or
secondary.
 Primary dysmenorrhea. This occurs when you
first start your period and continues throughout
your life. It is usually life-long. It can cause
severe and frequent menstrual cramping
from severe and abnormal uterine contractions.
 Secondary dysmenorrhea. This type is due to
some physical cause. It usually starts later in
life. It may be caused by another medical
condition, such as pelvic inflammatory disease
or endometriosis.
What causes dysmenorrhea?
Women with primary dysmenorrhea have abnormal
contractions of the uterus due to a chemical imbalance in
the body. For example, the chemical prostaglandin
control the contractions of the uterus.
Secondary dysmenorrhea is caused by other medical
conditions, most often endometriosis. This is a condition
in which endometrial tissue implants outside the uterus.
Endometriosis often causes internal bleeding, infection,
and pelvic pain.
Other causes of secondary dysmenorrhea include the
following:
 Pelvic inflammatory disease (PID)
 Uterine fibroids
 Abnormal pregnancy (miscarriage, ectopic)
 Infection, tumors, or polyps in the pelvic cavity
What are the symptoms of dysmenorrhea?
The following are the most common symptoms of
dysmenorrhea. However, each person may experience
symptoms differently. Symptoms may include:
 Cramping in the lower abdomen
 Pain in the lower abdomen
 Low back pain
 Pain radiating down the legs
 Nausea
 Vomiting
 Diarrhea
 Fatigue
 Weakness
 Fainting
 Headaches
What are the risk factors for dysmenorrhea?
While any woman can develop dysmenorrhea, the
following women may be at an increased risk for the
condition:
 Women who smoke
 Women who drink alcohol during their period
(alcohol tends to prolong menstrual pain)
 Women who are overweight
 Women who started their periods before the age
of 11
 Women who have never been pregnant
Consult your health care provider for more information.
How is dysmenorrhea diagnosed?
 Ultrasoud
 Magnetic resonance imaging (MRI)
 Laparoscopy
 Hysteroscopy
To diagnose dysmenorrhea, your health care provider
will evaluate your medical history and do a complete
physical and pelvic exam. Other tests may include:
 Ultrasound. This test uses high-frequency
sound waves to create an image of the internal
organs.
 Magnetic resonance imaging (MRI). This test
uses large magnets, radiofrequencies, and a
computer to make detailed images of organs and
structures within the body.
 Laparoscopy. This minor procedure uses a
laparoscope. This is a thin tube with a lens and a
light. It is inserted into an incision in the
abdominal wall. Using the laparoscope to see
into the pelvic and abdomen area, the doctor can
often detect abnormal growths.
  Hysteroscopy. This is the visual exam of the Female Pelvis and Measurement
canal of the cervix and the inside of the uterus. It
uses a viewing instrument (hysteroscope) A. True Pelvis E. Pelvic midlane diameters
inserted through the vagina.
B. False Pelvis F. F. Pelvic outlet diameter
How is dysmenorrhea treated?
C. Types of pelvis

Specific treatment for dysmenorrhea will be determined D. Pelvic inlet diameter

by your health care provider based on:

 Your age, overall health, and medical history

 Extent of the condition
 Cause of the condition (primary or secondary)
 Your tolerance for specific medications,
procedures, or therapies
 Expectations for the course of the condition
 Your opinion or preference

Treatment to manage dysmenorrhea symptoms may

include:

 Prostaglandin inhibitors, such as nonsteroidal

anti-inflammatory medications, or NSAIDs,
such as aspirin and ibuprofen (to reduce pain)
 Acetaminophen
 Oral contraceptives (ovulation inhibitors)
 Progesterone (hormone treatment) A. True pelvis
 Diet changes (to increase protein and decrease
sugar and caffeine intake) - Lies below the pelvic brim.
 Vitamin supplements
 Regular exercise - Consists of the pelvic inlet, midpelvis, and pelvic
 Heating pad across the abdomen outlet.
 Hot bath or shower
 Abdominal massage B. False pelvis
 Endometrial ablation (a procedure to destroy the
lining of the uterus) - The shallow portion above the pelvic brim.
 Endometrial resection (a procedure to remove
the lining of the uterus). - Supports the abdominal viscera.
 Hysterectomy ( the surgical removal of the
uterus) C. Types of pelvis
Key points 1. Gynecoid 3. Android

 Dysmenorrhea is characterized by severe and 2. Anthropoid 4. Platypelloid

frequent menstrual cramps and pain during your
period.
 Dysmenorrhea may be primary, existing from
the beginning of periods, or secondary, due to an 1. Gynecoid
underlying condition.
 Symptoms may include cramping or pain in the a. normal female pelvis
lower abdomen, low back pain, pain spreading
down the legs, nausea, vomiting, diarrhea, b. transversely rounded or blunt
fatigue, weakness, fainting, or headaches.
c. most favorable for successful labor and birth
 Treatments may include NSAIDS,
acetaminophen, birth control pills, hormone
treatment, dietary changes, vitamins, exercise,
2. Anthropoid
heat, or massage.
a. oval shaped
 In extreme conditions, surgery may be needed.
b. adequate outlet, with a normal or moderately
narrow pelvic arch.

3. Android

a. wedge-shaped or angulated

b. seen in males
 c. not favorable for labor

d. narrow pelvic planes can cause slow descent FERTILIZATION and IMPLANTATION
and midpelvis arrest.
A. Fertilization
4. Platypelloid
1. occurs in the upper region of the fallopian
a. flat with an oval inlet. tubes.
b. wide transverse diameter but short 2. occurs within 12 hours after ovulation and
anteroposterior diameter, making the outlet within 2 to 3 days of insemination, the average
inadequate. duration of viability for the ovum and the
sperm.

3. takes place when the sperm and ovum unites.

D. Pelvic inlet diameter
1. Anteroposterior diameter
2. Transverse diameter
4. once fertilized, the membrane of the ovum
3. Oblique (diagonal) undergoes the changes that prevents the entry of
the other sperm.
4. Posterior sagittal diameter
5. each reproductive cell carries 23 chromosomes.

6. sperm carry an X and a Y chromosome; XY:

1. Anteroposterior diameter
male, XX: female.
a. diagonal conjugate- distance from the lower
B. Implantation
margin of the symphysis pubis to the sacral
promontory. 1. zygote is propelled toward the uterus
b. true conjugate or conjugate vera- distance 2. zygote implants 6 to 8 days after ovulation
from the upper margin of the symphysis pubis
to the sacral promontory. 3. blastocyst secretes chorionic gonadotropin to
ensure that the corpus luteum remains viable
c. obstetric conjugate- the smallest back-to-front and secretes estrogen and progesterone for the
distance through which the fetal head must pass first 2 to 3 months of gestation.
in the moving through the pelvic inlet.
CORPUS LUTEUM- although it’s inside the
2. Transverse diameter- the largest of the pelvic ovaries, the corpus luteum’s job is to make the
inlet diameters. Located at the right angles to uterus a healthy place for a fetus to grow. It
the true conjugate. releases a hormone called progesterone to that
prepares the uterus for pregnancy. Once it is no
3. Oblique (diagonal)- not clinically measurable
longer needed to make progesterone, the corpus
4. Posterior sagittal diameter- distance from luteum goes
the point where the anteroposterior and
transverse diameters cross each other to the
middle of the sacral promontory.

E. Pelvic midlane diameters

1. transverse diameter(interspinous diameter)

2. midplane normally is the largest plane and the

one of greatest diameter.

F. Pelvic outlet diameter

1. transverse ( intertuberous diameter)

2. outlet presents the smallest plane of the pelvic

canal.
BLASTOCYST- is a cluster of dividing cells made
by a fertilized egg. it is made up of an inner
group cells within an outer shell. The inner
 group of cells will become the EMBRYO. The C. Fetal period; beginning of the ninth week after
embryo is what will develop into a baby. conception and ending with birth.

What is the difference between a zygote FETAL DEVELOPMENT

and a blastocyst?
Embryonic Period (Weeks 3 to 8)
During fertilization, the sperm and egg unite in
one of the fallopian tubes to form a zygote. Week 1
Then the zygote travels down the fallopian
tube, where it becomes a morula. Once it Blastocyst is free-floating.
reaches the uterus, the morula becomes a
blastocyst. The blastocyst then burrows into
the uterine lining — a process called
implantation. Week 2 to 4

To form identical or monozygotic twins, one

fertilized egg (ovum) splits and develops
into two babies with exactly the same
genetic information. To form fraternal or
dizygotic twins, two eggs (ova) are fertilized
by two sperm and produce two genetically
unique children.

What causes an egg to split into twins? >Embryo is 2 mm in length.

This type of twin formation begins >Groove forms along middle of back.
when one sperm fertilizes one
>Blood circulation begins.
egg (oocyte). 1 As the fertilized egg
(called a zygote) travels to the uterus, >Heart is tubular
the cells divide and grow into a
blastocyst. In the case of monozygotic
twins, the blastocyst then splits and
develops into two embryos. Week 5-8

All pregnancies start when a sperm fertilizes

an egg. This fertilized egg is called a zygote.

Sometimes a woman’s ovaries release two

eggs, and two separate sperm fertilize each
egg. This forms twins. These twins are called
fraternal twins, dizygotic twins (meaning two
zygotes) or non-identical twins.
>Embryo is 4 to 6 mm in length and weighs 0.4g.
Three or more babies are known as 'higher
order multiples'. This sort of multiple pregnancy >Double heart chambers are visible.
can occur because a single fertilised egg
>Heart begins to beat.
splits, more than one egg is fertilised, or
both things happen at the same time. Higher >Limb buds form.
order multiples rarely happen naturally, and are
usually the result of fertility treatments. Week 8

> Embryo is 3 cm length.

FETAL DEVELOPMENT: > Embryo is 2 g.

A. Preembryonic period: the first 2 weeks after > Eyelids begins to fuse.
conception. > Circulatory system through umbilical cord is well
B. Embryonic period; beginning of the third week established.
through the eighth week after conception.
 After the eight week the baby is called a fetus The reproductive organs and genitalia are now fully
instead of an embryo. developed,

and your doctor can see on ultrasound if you are

having a boy or a girl.
FETAL PERIOD (Weeks 9 to birth)
Active movements are present.
Week 9-12
Fetal skin is transparent.

Lanugo hair begins to develop.

Skeletal ossification occurs.

Week 17-20

>Fetus is 8 cm in length.

>Fetus is 45 g.

>Face is well formed. > Fetus is 19 cm in length and weighs 465g.

>Limbs are long and slender. >Lanugo covers the entire body.

>Kidneys begin to form urine. >Fetus has nails.

>Spontaneous movements occur. >Muscles are developed.

>Heartbeat is detected by Doppler transducer >Enamel and dentin are depositing.

between 10 and 12 weeks.
>Heartbeat is detected by regular (nonelectronic)
>Sex is visually recognizable. fetoscope.

Week 13-16 Week 21-24

 Fetus is 28 cm in length.
Fetus 780 g.
• Your baby's heartbeat may now be audible
through an instrument called a doppler.  Hair on head well formed.
Skin is reddish and wrinkled.
• The fingers and toes are well-defined.
 Reflex hand grasp functions.
• Eyelids, eyebrows, eyelashes, nails and hair are Vernix caseosa covers entire body.
formed.
 Fetus has ability to hear.
• Teeth and bones become denser. • Baby's finger and toe prints are visible.

• Your baby can even suck his or her thumb, • In this stage, the eyelids begin to part and the
yawn, stretch and make faces. eyes open.

The nervous system is starting to function.

• Baby responds to sounds by moving or
increasing the pulse.

• You may notice jerking motions if baby hiccups.

Week 25-28
 Fetus is 38 cm length.
Fetus is 1200 g.

 Limbs are well flexed.  The fetus is 42 to 48 cm length.

Brain is developing rapidly. The fetus is 2500 g.

 Eyelids open and close.
 Lungs are developed sufficiently to provide
gas exchange (lecithin forming) lecithin
forming for lung development components
are phosphatidylcholine and
phosphatidylglycerol, capable of gas
exchange in the last trimester. Exchanging
portion of the lungs is formed and
vascularized.
 If born, neonate can breathe at this time.
Week 29-32
 The skin is pink and the body is rounded.
The skin is less wrinkled.
 Lanugo is disappearing.
• During this stage, your baby will continue to
grow and mature.
• The lungs are close to being fully developed at
this point.
• Your baby's reflexes are coordinated so he or
she can blink, close the eyes, turn the head,
grasp firmly, and respond to sounds, light, and
touch.

 The L/S ratio is greater than 2:1.

Week 37-40

 fetus is 40 cm in length.
Fetus is 2000 g.

 Bones are fully developed.

Subcutaneous fat has collected.

 The L/S (lecithin/sphingomyelin) ratio is

1.2:1.
 The lecithin–sphingomyelin ratio (a.k.a.
>The fetus is 48 to 52 cm in length.
L-S or L/S ratio) is a test of fetal
amniotic fluid to assess for fetal lung >The fetus is 3000 to 3600 g.
immaturity. Lungs require surfactant, a
soap-like substance, to lower the >The skin is pinkish and smooth.
surface pressure of the alveoli in the
lungs. ... Lecithin makes the surfactant >Lanugo is present on upper arms and shoulders.
mixture more effective.
 The normal L/S ratio is 2.0 to 2.5 and is >Vernix caseosa decreases.
significant for appropriate fetal lung >Fingernails extend beyond fingertips.
development. An L/S ratio of less than
2.0 is significant for immature fetal lung >Sole (plantar) creases run down to the heel.
development.
>The testes are in the scrotum.

Week 33-36 >The labia majora are well developed.

• In this final month, you could go into labor at

any time.
 • You may notice that your baby moves less due
to tight space.
• At this point, your baby’s position may have
changed to prepare for birth. Ideally, the baby is
head down in in your uterus.
• You may feel very uncomfortable in this final
stretch of time as the baby drops down into your
pelvis and prepares for birth.
FETAL DEVELOPMENT: AMNION AND
CHORION TOGETHER FORM THE
AMNIOTIC SAC.
A. Amnion C. Amniotic Fluid
B. Chorion D. Placenta
a. Amnion
1. the amnion encloses the amniotic cavity.
2. the amnion is the inner membrane that forms
about the second week of embryonic
development.
3. the amnion forms a fluid-filled sac that
surrounds the embryo and later the fetus.
b. Chorion
1. The chorion is the outer membrane.
2. The chorion becomes vascularized and forms
the fetal of the placenta.
c. Amniotic Fluid
1. The amniotic fluid consists of 800 to 1200 mL
by the end of pregnancy.
2. the amniotic fluid surrounds, cushions, and
protects the fetus and allows for fetal
movement.
3. The amniotic fluid maintains the body
temperature of the fetus.
4. the amniotic fluid consists largely of the fetal
urine and is therefore a measure of fetal kidney
function.
5. The fetus drinks, swallows, and urinates the
amniotic fluid and breathes the amniotic fluid
into its lungs.
d. Placenta
1. The placenta provides for exchange of
nutrients and waste products between the fetus
and mother.
2. The placenta develops by the third month.
3. The placenta depends on maternal circulation.
4. The placenta produces hormones to maintain
pregnancy and assumes full responsibility for
the production of these hormones by the
twelfth week of gestation.
5. Large particle such as bacteria cannot pass
through the placenta.
6. Nutrients, drugs, antibodies, and viruses can
pass through the placenta.
7. in the third trimester, transfer of maternal
immunoglobulin provides the fetus passive
immunity to certain diseases for the first few
months after birth.
8. by week 8, genetic testing can be done.
FETAL CIRCULATION:
A. Umbilical Cord C. Fetal circulation bypass
B. Fetal heart rate
A. Umbilical Cord
1. The umbilical cord contains two arteries and
one vein.
2. Arteries carries deoxygenated blood and waste
products from the fetus.
3. The veins carries oxygenated blood and
provides oxygen and nutrients to the fetus.
B. Fetal heart rate
1. the fetal heart rate depends on gestational age;
160 to 170 beats per minute in the first trimester
but slows with fetal growth to 120 to 160 beats
per minute near or at term.
2. the fetal heart rate is about twice the maternal
heart rate.
C. Fetal circulation bypass
1. is present because of nonfunctioning lungs.
2. bypasses must close following birth to allow
blood to flow through the lungs and the liver.
3. ductus arteriosus connects the pulmonary
artery to the oarta, bypassing the lungs.
 4. ductus venosus connects the umbilical veins
and the inferior vena cava, bypassing the liver.
5. foramen ovale in the opening between the right
and left atriums of heart, bypassing the lungs.
OBSTETRICAL ASSESSMENT:
 GESTATION
a. Time until the estimated date of confinement or
estimated date of delivery.
b. About 280 days.
c. Nagele’s rule for estimating the date of
confinement. For Nagele’s rule to be accurate
requires that the woman have a regular 28-day
menstrual cycle.
1. First day of the last menstrual period: 09/11/2006
2. Add 7 days: 09/18/2006
3. Subtract 3 months: 06/18/2006
4. Add 1 year: 06/18/2007
Estimated date of confinement: June 18, 2007
GRAVIDITY AND PARITY
A. Gravity
1. Gravida refers to a pregnant woman.
2. Gravidity refers to the number of pregnancies.
3. Nulligravida is a woman who has never been
pregnant.
4. Primigravida is a woman who is pregnant for the
first time.
5. Multigravida is a woman in at least her second
pregnancy.
B. Parity
1. Parity is the number of births (not the number of
fetus; eg. Twins) past 20 weeks of gestation,
whether the fetus was born alive or not.
2. Nullipara is a woman who has not had a birth at
more than 20 weeks of gestation.
3. Primigravida is a woman who has had one birth
that occurs after the twenthieth week of
gestation.
4. Multipara is a woman who has had two or more
pregnancies resulting in viable offspring.
Use of GTPAL:
1. G is gravidity, the number of pregnancies.
2. T is term births, the number born at term
(40weeks).
3. P is preterm births, the number born before 40
weeks of gestation.
4. A is abortions/miscarriages, the number of
abortions/miscarriages (included in gravida if
before 20 weeks of gestation; included in parity
if past 20 weeks of gestation.
5. L is live births, the number of live births or living
children.
GTPAL
G- gravidity
T- term births
P- preterm births
A- abortions/miscarriages
L- live births
EXAMPLE: A woman is pregnant for the fourth
time. She had one elective abortion in the first
trimester, a daughter who was born ar 40 weeks
of gestation, and a son who was born at 36
weeks of gestation. Therfore she is gravida (G)
4, parity 2, and term (T) 1 (the daughter born at
40 weeks); preterm (P) 1 (the son born at 36
weeks); abortion (A) 1 (the abortion is counted
in the gravidabut is not included in the para
because it occurred before 20 weeks); live
births (L) 2.
GTPAL= 4,1,1,1,2
PREGNANCY SIGNS
A. Presumptive signs C. Positive signs
B. Probable signs
A. Presumptive signs b. During the second and third trimesters (weeks
18 to 30), fundal height in centimeters
1. amenorrhea approximately equals the fetus’s age in weeks
plus or minus 2 cm.
2. nausea and vomiting
c. At 16 weeks, the fundus can be found halfway
3. increased size and increased feeding of
between the symphysis pubis and the umbilicus.
fullness in breasts
d. At 20 to 22 weeks, the fundus is at the
4. pronounced nipples
umbilicus.
5. urinary frequency
e. At 36 weeks, the fundus is at the xiphoid
6. Quickening: the first perception of fetal process.
movement may occur as early as the fourteenth
to sixteenth week of gestation.

7. fatigue MEASURING FUNDAL HEIGHT

8. discoloration of vaginal mucosa. 1. Place the client in the supine position.

B. Probable signs 2. Place the end of the tape measure at the level of
the symphysis pubis.
1. uterine enlargement
3. Stretch the tape to the top of the uterine fundus.
2. Hegar’s sign: softening and thinning of the
4. Note and record the measurement.
lower uterine segment that occurs about week 6

3. Goodell’s sign: softening of the cervix that

occurs at the beginning of the second month.

4. Chadwick’s sign: bluish coloration of the MATERNAL RISK FACTORS

mucuous membranes of cervix, vagina, and
vulva that occurs about week 6. A. German measles (rubella)

5. Ballotement: rebounding of the fetus B. Sexuality transmitted diseases

against the examiner’s fingers on palpation. C. Human immunodeficiency virus

6. Braxston Hicks contractions: intermittent D. Substance abuse

contractions of the uterus during pregnancy;
E. ADOLESCENT PREGNANCY
painless but can be felt after about the 16th
week; that may occur about every 15 to 20
minutes; and are not labor pains.
A. German measles (rubella)
7. positive pregnancy test measuring for human
1. the risk of maternal and fetal or congenital
chorionic gonadotropin.
infection is related to the trimester of placental
C. Positive signs infection.

1. fetal heart rate detected by electronic device 2. Maternal infection during the first 8 weeks of
(DOPPLER transducer) at 10 to 12 weeks and gestation carries the highest rate of maternal
by nonelectronic device (Fetoscope) and fetal infection.

at 20 weeks of gestation. B. Sexuality transmitted diseases

2. active fetal movements palpable by examiner. 1. Syphilis

3. outline of fetus via radiography or ultrasound. a. Infection may cross the placenta.

b. Infection usually leads to spontaneous

abortions.
FUNDAL HEIGHT
c. Infection increases the incidence of mental
a. Fundal height is measured to evaluate the subnormality and physical deformities.
fetus’s gestational age.
2. Genital Herpes
 a. Infection may cross the placenta.
b. Fetus is contaminated after membranes
rupture or with vaginal delivery
3. Gonorrhea
a. Fetus is contaminated at the time of delivery.
b. maternal infection may result in postpartum
infection of the neonate.
c. risks to the neonate include ophthalmia
neonatotum, pneumonia.
C. Human immunodeficiency virus
1. the virus is transmitted through blood, blood
products, and other bodily fluids, such as urine,
semen, and vaginal fluid.
2. repeated exposure to the virus during
pregnancy through unsafe sex practices or
intravenous drug use can increase the risk of
transmission to the fetus.
D. Substance abuse
1. Many substances cross the placenta; therefore
no drugs, including over-the-counter
medications, should be taken unless prescribed
by physician.
2. Substances commonly abused include alcohol,
cocaine, crack, marijuana, amphetamines,
barbiturates and heroin.
3. substances abuse threatens normal fetal growth
and successful term completion of the
pregnancy.
4. Substance abuse places the pregnancy at risk for
fetal growth retardation, abruptio placentae, and
fetal bradycardia.
5. Physical signs of drugs abuse may include dilated
or contracted pupils, fatigue, tracks (needle)
marks, skin abscesses, inflamed nasal mucosa,
and inappropriate behavior by the mother.
6. Consumption of alcohol during pregnancy may
lead to fetal alcohol syndrome and can cause
jitteriness, physical abnormalities, congenital
anomalies, and growth deficits.
7. Smoking leads to low birth weights, a higher
incidence of birth defects, and stillbirths.
E. ADOLESCENT PREGNANCY
1. factors that result in adolescent pregnancy
include the early onset of menarche, changing
sexual behaviors in this age group, problems
with family development, poverty, and the lack
of knowledge of reproduction and birth
control.
2. the major concerns related to adolescent
pregnancy include poor nutritional status,
emotional and behavioral difficulties, lack of
support system, increased risk stillbirth, low-
birth-weight newborn infants, fetal mortality,
cephalopelvic disproportion, and the increased
risk of maternal complications such as
hypertension, anemia, prolonged labor, and
infections.
PRENATAL PERIOD:
1. PHYSIOLOGICAL MATERNAL CHANGES
A. Cardiovascular System F. Reproductive System
B. Respiratory System G. Skin
C. Gastrointestinal System H. Skeletal System
D. Renal System I. Metabolism
E. Endocrine System
A. Cardiovascular System
1. Circulating blood volume increases, plasma
increases, and total red blood cell volume
increases (total volume increases by 40% to
50%).
2. Physiological anemia occurs as the plasma
increase exceeds the increase in red blood cell
production.
3. Iron requirements are increased.
4. Heart size increases and is elevated upward
and to the left because of displacement of the
diaphragm as the uterus enlarges
5. pulse may increase about 10 beats per
minute.
6. Blood pressure may decline in the second
trimester.
7. Retention of sodium and water may occur.
B. Respiratory System
1. Oxygen consumption increases by 15% to
20%.
2. Diaphragm is elevated because of the enlarged
uterus.
3. Respiratory rate remains unchanged.
 4. A woman may experience shortness of breath.
C. Gastrointestinal System
1. Nausea and vomiting may occur as a result of
the secretion of human chorionic gonadotropin
and subsides by the third month.
2. Poor appetite may occur because of the
decreased gastric motility.
3. Alterations in taste and smell may occur.
4. Constipation may occur as a result of
decreased gastrointestinal motility or pressure
of the uterus.
5. Flatulence and Heartburn may occur because of
decreased gastrointestinal motility and slow
emptying of the stomach.
6. Hemorrhoids may occur as a result of increased
venous pressure.
7. Gum tissue become swollen and easily bleed.
8. Ptyalism (excessive secretion of saliva) may
occur.
D. Renal System
1. Frequency of urination occurs in the first
and third trimesters as a result of pressure of
the enlarging uterus on the bladder
2. Decreased bladder tone may occur and is
caused by hormonal changes.
3. Decreased bladder capacity is experienced.
4. Renal threshold for glucose may be reduced.
E. Endocrine System
1. Basal metabolic rate rises.
2. Anterior lobe of the pituitary gland enlarges.
3. Thyroid enlarges slightly, and thyroid activity
increases.
4. Parathyroid increases in size.
5. Aldosterone levels gradually increase.
F. Reproductive System
1. Uterus
a. Uterus enlarges, increasing in mass from 60
g to 1000 g.
b. Size and number of blood vessels and
lymphatics increase.
c. Irregular contractions occur.
2. Cervix
a. The cervix becomes shorter, more elastic, and
larger in diameter.
b. Endocervical glands secrete a thick mucus
plug, which is expelled from the canal when
dilation begins.
c. Increased vascularization causes a softening
and blue-purple discoloration known as
Chadwick’s sign, which occurs at about 6
weeks of gestational age.
3. Ovaries
a. The maturation of new follicles is blocked.
b. The ovaries cease ovum production
4. Vagina
a. Hypertrophy and thickening of the muscles
occurs
b. Increase in vaginal secretions is experienced,
and secretions are usually thick, white and
acidic.
5. Breasts
a. Breasts size increases.
b. Nipple become more pronounced.
c. Areola becomes darker in color.
d. Superficial veins become prominent.
e. Hypertrophy of the Montgomery’s follicles
occurs.
f. Colostrum may appear from the breasts.
G. Skin
1. Pigmentation increases. It is believed that
higher levels of estrogen and progesterone, and
melanocyte-stimulating hormone cause this
skin darkening.
2. A dark steak down the midline of the abdomen
may appear (linea nigra).
3.Chloasma (mask of pregnancy), a blotchy
brownish hyperpigmentation, may occur over
the forehead, cheeks, and nose.
 4. Reddish-purple stretch marks (striae) may
occur on the abdomen, breasts, thighs, and
upper arms.
5. Vascular spider nevi may occur on the neck,
chest, face, arm, and legs.
6. Rate of hair growth may decrease.
H. Skeletal System
1. Center of gravity changes
2. Postural changes occur as the increased weight
of the uterus causes a forward pull of the bony
pelvis.
I. Metabolism
1. Metabolic function increases.
2. Body weight increases.
3. Water retention is increased, which can
contribute to weight gain.
2. Psychological Maternal Changes
A. Ambivalence D. Body Image Changes
B. Acceptance E. Relationship with the fetus
C. Emotional Lability
A. Ambivalence
1. Ambivalence occurs early in pregnancy, even
when the pregnancy is planned.
2. Mother may experience dependence-
independence conflict and ambivalence related
to role changes.
3. Father may experience ambivalence related to
the new role he is assuming, the increased
financial responsibilities, and sharing the wife’s
attention with the child.
B. Acceptance: Factors that may be related to
acceptance of the pregnancy are the woman’s
readiness for the experience and her identification
with the motherhood role.
C. Emotional Lability
1. Emotional lability may be manifested by
frequency in the change of emotional states or
extremes in emotional states.
2. These emotional changes are common, and
the mother may feel that these changes are
abnormal.
D. Body Image Changes
1. The changes in a woman’s perception of her
image during pregnancy occurs gradually and
may be positive or negative.
2. The physical changes and symptoms that the
woman experiences during pregnancy
contribute to her body image.
E. Relationship with the fetus
1. The woman may daydream to prepare for
motherhood and think about the maternal
qualities she would like to possess.
2. the woman first accepts the biological fact that
she is pregnant.
3. The woman next accepts the growing fetus as
distinct from herself and a person to nurture.
4. Finally, the woman prepares realistically for the
birth and parenting of the child.
Discomforts of Pregnancy
A. Nausea and Vomiting I. Ankle edema
B. Syncope J. Varicose veins
C. Urinary urgency and frequency K. Headaches
D. Breast tenderness L. Hemorrhoids
E. Increased vaginal discharge M. Constipation
F. Nasal stuffiness N. Backache
G. Fatigue O. Leg Cramps
H. Heartburn P. Shortness of breath and dyspnea
A. Nausea and Vomiting
1. Nausea and vomiting occur in the first
trimester.
2. Nausea and vomiting are due to elevated
levels of human chorionic gonadotropin and
changes in carbohydrate metabolism.
Interventions:
a. Eating dry crackers before arising
b. Avoiding brushing teeth immediately after
arising.
c. Eating small, frequent, low-fat meals during
the day.
d. Drinking liquids between meals rather than
at meals
 e .Avoiding fried foods and spicy foods.
f. Acupressure (some type may require a
prescription).
g. Herbal remedies, only if approved by a
physician or nurse-midwife
B. Syncope
1. Syncope usually occurs in the first trimester,
supine hypotension occurs particularly in the
second and third trimester
2. Syncope may be triggered hormonally or
caused by the increased blood volume, anemia,
fatigue, sudden position changes, or lying
supine.
Interventions:
a. Sitting with the feet elevated
b. Changing positions slowly
c. Changing the position to the lateral
recumbent to relieve the pressure of the uterus
on the inferior vena cava\
C. Urinary urgency and frequency
1. usually in the first and third trimesters
2. Due to pressure of the uterus on the bladder
Interventions:
a. Drinking 2 qt of fluid during the day
b. Limiting fluid intake in the evening
c. Voiding at regular intervals
d. Sleeping on the side at night
e. Wearing perineal pads if necessary
f. Performing Kegel exercises
D. Breast tenderness
1. Tenderness can occur from the first through
the third trimesters
2. Tenderness is due to increased levels of
estrogen and progesterone.
Interventions:
a. Encouraging wearing a supportive bra.
b. Avoiding the use of soap on the nipples and
areola area to prevent drying.
E. Increased vaginal discharge
1. Increased discharge can occur from the first
through the third trimester.
2. Increased discharge is due to hyperplasia of
vaginal mucosa and increased mucus
production.
Interventions:
a. Proper cleansing and hygiene
b. Wearing cotton underwear
c. Avoiding douching
d. Advising the client to consult the physician
or nurse-midwife if infection is suspected.
F. Nasal stuffiness
1. Nasal stuffiness occurs during the first through
the third trimester
2. Nasal stuffiness results from increased
estrogen, which causes swelling of the nasal
tissues and dryness
Interventions:
a. Encouraging the use of a humidifier
b. avoiding the use of nasal sprays or
antihistamine
G. Fatigue
1. Fatigue occurs usually in the first and third
trimesters
2. Fatigue usually results from hormonal
changes.
Interventions:
a. Arranging frequent rest periods throughout
the day
b. Using correct body mechanics
c. Obtaining regular exercise
d. Performing muscle relaxation and
strengthening exercises for the legs and hip
joints
e. Avoiding eating and drinking foods
containing stimulants throughout pregnancy
H. Heartburn
1. Heartburn occurs in the second and the third
trimesters.
2. Heartburn results from increased progesterone
levels, decreased gastrointestinal motility and
 esophageal reflux, and displacement of the
stomach by the enlarging uterus.
Interventions:
a. Eating small, frequent meals
b. Sitting upright for 30 minutes following a
meal
c. Drinking milk between meals
d. Avoiding fatty and spicy food
e. Performing tailor-sitting exercises
f. Taking antacids only if recommended by the
physician or nurse-midwife
I. Ankle edema
1. Edema usually occurs in the second and the
third trimesters
2. Edema results from vasodilation, venous statis,
and increased venous pressure below the uterus.
Interventions:
a. Elevating the legs at least twice a day.
b. Sleeping on the left side.
c. Wearing supportive stockings
d. Avoiding sitting or standing in one position
for long periods of time.
J. Varicose veins
1. Varicose veins usually occur in the second and
the third trimesters.
2. Varicose veins result from weakening walls of
the veins or valves and venous congestion.
Interventions:
a. Wearing support hose
b. Elevating the feet when sitting
c. Lying with the feet and hips elevated
d. Avoiding long periods of standing or sitting
e. Moving about while standing to improve
circulation
f. Avoiding leg crossing
g. Avoiding constricting articles of clothing
K. Headaches
1. Headaches usually occur in the second and the
third trimester
2. Headaches result from changes in blood
volume and vascular tone
Interventions:
a. Changing position slowly
b. Applying a cool cloth to the forehead
c. Eating a small snack
d. Using acetaminophen (Tylenol) only if
prescribed by the physician
L. Hemorrhoids
1. Hemorrhoids usually occur in the second and
the third trimesters
2. Hemorrhoids result from increased venous
pressure and constipation
Interventions:
a. Soaking in a warm sitz bath
b. Sitting on a soft pillow
c. Eating high-fiber foods and avoiding
constipation
d. Drinking sufficient fluids
e. Increasing exercise, such as walking
f. Applying ointments, suppositories, or
compresses as prescribed by the physician
M. Constipation
1. Constipation usually occurs in the second and
the third trimesters.
2. Constipation result from decreased intestinal
motility, the displacement of the intestines, and
taking of iron supplements.
Interventions:
a. Eating high-fiber foods
b. Drinking sufficient fluids
c. exercising regularly
d. Avoiding laxatives or enemas without first
consulting with the physician
N. Backache
1. Backache usually occurs in the second and the
third trimesters.
2. Backache results from an exaggerated
lumbosacral curve resulting from the enlarged
uterus.
Intervention:
 a. Encouraging rest 2. Assists to confirm gestational age and
estimated date of delivery
b. Using correct body mechanics and
improving posture 3. May be done abdominally or transvaginally
c. Wearing low-heeled shoes during pregnancy

d. Performing pelvic rocking and abdominal Interventions

breathing exercises
a. If the abdominal ultrasound is being
e. Sleeping on a firm mattress performed, the woman may need to drink water
to fill the bladder before the procedure to obtain
O. Leg Cramps
a better image of the fetus.
1. leg cramps usually occurs in the second and
b. If the transvaginal ultrasound is being
third trimesters.
performed, a lubricated probe is inserted into
2. leg cramps results from altered calcium- the vagina.
phosphorus balance and pressure of the uterus
c. Inform the client that the test presents no
on nerves or from fatigue.
known risks to the client or the fetus.
Interventions:

a. getting regular exercise, especially walking

B. Alpha-fetoprotein screening
b. dorsiflexing the foot of the affected leg
1. Screening assesses the quantity of fetal serum
c. Increasing calcium intake proteins; elevated levels of protein are
associated with open neural tube and abdominal
P. Shortness of breath and dyspnea wall defects.

1. Dyspnea can occur in the second and third 2. Screenings can detect spina bifida and Down
trimesters syndrome.

2. Dyspnea results from pressure on the Interventions:

diaphragm.
a. Explain that the level is determined by a
Interventions: single maternal blood sample drawn at 15 to 18
weeks gestation.
a. Allowing frequent rest periods
b. If the level is elevated and the gestation is
b. Sleeping with the head elevated or on the less than 18 weeks, a second sample is drawn.
side
c. An ultrasound is performed for elevated
c. Avoiding overexertion levels to rule out fetal abnormalities or multiple
d. Performing tailor sitting exercises. gestation.

C. Chorionic villus sampling

DIAGNOSTIC TESTS
1. The physician aspirates a small sample of
A. Ultrasonography F. Fern test
chorionic villus tissue at 8 to 12 weeks
B. Alpha-fetoprotein screening G. Nitrazine test gestation.

C. Chorionic villus sampling H. NONSTRESS TEST 2. Test is performed for the purpose of detecting
genetic abnormalities
D. Kick counts (fetal movement counting)
Interventions
E. Amniocentesis I. CONTRACTION STRESS TEST
a. Obtain informed consent.

b. Instruct the client to drink water to fill the

A. Ultrasonography bladder before the procedure to aid in
positioning the uterus for catheter insertion.
1. Outlines and Identifies fetal and maternal
structures.
 c. Instruct the client to report bleeding,
infection or leakage of fluid at insertion site
after the procedure.
d. Rh-negative women may be given Rh,(D)
immune globulin (RhoGAM) because chorionic
villus sampling increases the risk of Rh
sensitization.
D. Kick counts (fetal movement counting)
1. Mother sits quietly or lies down on the left
side and counts fetal kicks for a period of time
as instructed.
2. Instruct the client to notify the physician if
there are fewer than 10 kicks in a 12-hour
period or as instructed by the physician.
E. Amniocentesis
1. Aspiration of amniotic fluid; may be done
from 13 to 14 weeks of pregnancy.
2. Amniocentesis is performed to determine
genetic disorders, metabolic defects, and fetal
lung maturity.
3. risks
a. maternal hemorrhage
b. infection
c. abruptio placentae
d. amniotic fluid emboli
e. premature rupture of the membrane
interventions
a. obtain informed consent
b. instruct the client to empty the bladder
before the procedure
c. prepare the client for ultrasonography,
which is performed to locate the placenta
d. obtain baseline vitalsigns and fetal heart
rate, and monitor every 15 minutes
e. position the client supine
f. instruct the client that if chills, fever,
leakage of fluid at the needle insertion site,
decreased fetal movement, or uterine
contraction occur, she is to notify the physician
or nurse-midwife
F. Fern test
1. The fern test is a microscopic slide test to
determine the presence of amniotic fluid
leakage.
2. By use of sterile technique, a specimen is
obtained from the external os of the cervix and
vaginal pool and is examined on a slide under
microscope.
3. A fernlike pattern occurring from the salts of
amniotic fluid indicates the presence of
amniotic fluid.
Interventions
a. Position the client in the dorsal lithotomy
position.
b. Instruct the client to cough to cause the fluid
to leak from the Uterus if the membranes are
ruptured.
G. Nitrazine test
1. A Nitrazine test strip is used to detect the
presence of amniotic fluid in vaginal secretions.
2. Vaginal secretions have a pH of 4.5 to 5.5 and
do not affect the yellow Nitrazine strip or swab.
3. Amniotic fluid has a pH of 7.0 to 7.5 and turns
the yellow Nitrazine blue
Interventions
a. Position the client in dorsal lithotomy
position
b. Touch the test tape to the fluid.
c. Assess the test tape for a blue-green, blue-
gray, or deep blue color, which indicates that
the membranes are probably ruptured.
H. NONSTRESS TEST
Description
The test is performed to assess placental function
and oxygenation
The test determines fetal well-being
The test evaluates fetal heart rate (FHR) in response
to fetal movement
Interventions
An external ultrasound transducer and the
tocodynamometer are applied to the mother,
and a tracing of at least 20 minutes duration is
obtained so that the FHR and the uterine
activity can be observed.
 Obtain baseline blood pressure and monitor blood
pressure frequently .
Position mother in the left lateral position to avoid
vena cava compression
The mother may be asked to press a button every
time she feels fetal movement; the monitor
records a mark at each point of fetal movement,
which is used as a reference point to assess
FHR response.
RESULTS:
 Reactive Nonstress Test
(Normal/Negative)
“Reactive” indicates a healthy fetus.
The result requires two or more FHR accelerations
of at least 15 beats per minute, lasting at least
15 seconds from the beginning of the
acceleration to the end, in association with fetal
movement, during a 20 minute period.
 Nonreactive Nonstress Test (Abnormal)
No accelerations or accelerations of less than 15
beats per minute or lasting less than 15 seconds
in duration occur during 40 minute observation.
 Unsatisfactory
The Result cannot be interpreted because of the
poor quality of the FHR tracing
I. CONTRACTION STRESS TEST
Description
The test assesses placental oxygenation and
function.
The test determines fetal ability to tolerate labor and
determines fetal well-being.
The fetus is exposed to the stressor of contractions
to assess the adequacy of placental perfusion
under stimulated labor conditions
The test is performed if the nonstress test is
abnormal
Interventions
The external fetal monitor is applied to the mother,
and a 20 to 30 minute baseline strip is recorded.
The uterus is stimulated to contract by the
administration of a dilute dose of oxytocin
(Pitocin) or by having the mother use nipple
stimulation until three palpable contractions
with a duration of 40 seconds or more in a 10-
minute period have been achieved.
Frequent maternal blood pressure readings are
done, and the mother is monitored closely while
increasing doses of oxytocin are given.
RESULTS:
 Negative Contraction Stress Test
(Normal)
A negative result is represented by no late or
variable decelerations of the fetal heart rate.
 Positive Contraction Stress Test
(Abnormal)
A positive result is represented by late or variable
decelerations of the fetal heart rate with 50% or
more of the contractions in the absence of
hyperstimulation of the uterus.
 Equivocal
An equivocal result contains decelerations but with
less than 50% of the contractions, or the uterine
activity shows a hyperstimulated uterus.
 Unsatisfactory
An unsatisfactory result means that adequate uterine
contractions cannot be achieved, or the fetal
heart rate tracing is not of sufficient quality for
adequate interpretation.
INTRAPARTAL PERIOD:
THEORIES OF LABOR ONSET
A. UTERINE MYOMETRIAL IRRITABILITY (UTERINE STRECTH)
B. OXYTOXIN THEORY
C. THEORY OF AGING PLACENTA
A. UTERINE MYOMETRIAL IRRITABILITY
(UTERINE STRECTH)- most acceptable theory
When the uterine muscles stretch with fetal growth
and increasing amniotic fluid, it results to
irritability and contractions to empty the
contents of the fetus.
 Progesterone is a uterine muscle relaxant
 Progesterone deprivation( low progesterone
theory)
When progesterone level decreases and uterine
muscle stimulants increase in late pregnancy,
labor will start.
B. OXYTOXIN THEORY
 The pressure of the fetal head on the cervix in late
pregnancy stimulates the posterior pituitary
gland to secrete oxytocin which causes uterine
contractions.
 ESTROGENIC, FETAL HORMONE, AND
PROSTAGLANDIN THEORIES.
All these have stimulating effect on uterine
musculature causing uterine contractility.
 As placenta aged, more pressure is exerted on
the fundal portion ( the usual placental site and
the most contractile portion of the uterus).
C. THEORY OF AGING PLACENTA
As the placenta matures, it is believed that the
resultant diminished blood supply to the area
causes contraction.
 Progesterone level decreases
 Oxytocin level increases
 Estrogen, fetal hormone and uterine
prostaglandin level increases contractility
 Placenta matures
a. false labor contractions: irregular
b. do not dilate the cervix
c. abdominal discomfort
d. relieved by walking, enema
e. generally painless but may be quite
uncomfortable
3. Increased maternal energy/burst of energy
because of hormone epinephrine
4. Slight decrease in maternal weight by 2 – 3
pounds, 1 to 2 days before labor.
5. Show
6. Ripening of the cervix
7. Rupture of the bag of waters
8. Progressive fetal descent
 Components of labor process
1. PASSAGEWAY. This refers to the adequacy
of the pelvis and birth canal in allowing fetal
descent.

PREmonitory SIGNS OF LABOR

1. Lightening : descent/dipping, dropping of the
presenting part to the true pelvis.

a. engagement is not exactly the same as

lightening.

b. onset

-Primigravida: lightening occurs earlier,

2 weeks before labor
A. Soft passages: cervix, vagina, perineum; may be
- Multigravida: lightening occurs either affected by laceration.
a day before labor or on the day of the labor.

c. signs of lightening

-. relief of dyspnea

- relief of abdominal tightness

- increased frequency of urination, varicosities,

pedal edema because of pressure on bladder and
pelvic girdle

- shooting pains down the legs because of the

pressure on the sciatic nerves

- increased amount of vaginal discharge

2. Increased braxton hicks contractions 3 to 4 weeks

before labor
 B. Bony passage: the pelvis
A. Type of pelvis – the shape of the pelvis may
affect the ease in which you can give birth
vaginally.
1. gynecoid- the most common pelvis shape
for females and is favorable for vaginal birth.
2. android
3. anthropoid
4. platypelloid
B. Structure(division) of pelvis
1. true pelvis
2. false pelvis
c. Pelvic inlet diameters
d. Pelvic outlet diameters
e. Ability of the uterine segment to distend the
cervix to dilate, and the virginal canal and
introitus to distend.
2. PASSENGER.
 This refers to the fetus and its ability to move
through the passage way, which is based on the
following:
1. Size of the fetal head( has 7 bones: 2 frontal, 2
parietal, 2 temporal, and 1 occipital) and
capability of the head to mold the passageway.
A. Suture; thin spaces in between bones/line of
junction or clossure between bones.
1.Sagittal suture-longitudinal, midline suture
between 2 parietal bones; most important suture
(overrides/overlaps in labor which reduces the
biparietal diameter of the head by 0.5-1 cm.
2.Frontal suture- anterior suture between 2
frontal bones.
3.Coronal suture- anterior suture between frontal
and parietal bones.
4.Lambdoidal suture- posterior suture between
parietal and occipital bones.
B. fontanels- points of intersection of cranial
bones; membranous spaces between cranial
bones during fetal life and infancy.
1. anterior fontanel ( bregma) formed by 2
frontal bones and 2 parietal bones: diamond
shaped, measures 2.5 cm x 2.5 cm, ossifies
( closes) in 12 to 18 months.
2.. posterior fontanel ( lambda)-formed by
union of 2 parietal and occipital bones:
triangular-shaped, ossifies in 6-8 wks or 2-3
months
fetal head diameters
A. anteroposterior (AP) diameters: wider than
the transverse diameters of the head
- occipitomental; 12.5 – 13.5 cm from
occiput to the chin, widest AP diameter.
- occipitofrontal; 12 cm from occiput to
midfrontal bone.
- suboccipitobregmatic: 9.5 cm from
below the occiput to the anterior fontanel,
narrowest AP diameter of the head.
B. Transverse diameters
1. biparietal diameter; 9.5 cm, widest
transverse
2. bitemporal diameter; 8 cm
3. bimastoid diameter; 7 cm
C. Fetal attitude – the relationship of fetal parts
to one another.
D. Fetal position – the relationship of a particular
reference points of the presenting part and the
maternal pelvis, described with a series of three
letters (side of maternal pelvis [L, left; R, right;
T, transverse], presenting [O, occiput; S,
sacrum; Sc, scapula; M, mentum], and the part
of the maternal pelvis (A, anterior; P, posterior)
 >Chosen landmarks/denominators

a. occiput (o)

b. mentum (m)

c. sacrum (s)

d. acromiodorso (ad)

-4 imaginary quadrants

a. left anterior
3. Fetal presentation
b. left posterior
-Cephalic
c. right anterior
a. vertex is the normal way that the baby is
positioned for birth. The baby is positioned d. right posterior
head first with their occiput ( the part of the
-Assessment of fetal position:
head close to the base the of skull) entering the
birth canal first.’ a. leopold’s manuever

b. vaginal examination

FETAL STATION

b. sinciput

c. brow

d. face

4. The Power

 Primary power: UTERINE

CONTRACTIONS

Characteristics:

 involuntary, rhythmical, regular activity of

uterine musculature

 Occurs intermittently by allowing period of

relaxation between contractions, promoting
ABNORMAL PRESENTATION uterine and maternal rest and restoration of
uteroplacental circulation which sustains fetal
-Breech
oxygenation.
a. complete
Purposes:
b. incomplete
 Propel presenting part downward/forward.
c. footling
 Effacement of the cervix
d. shoulders
 Dilatation of the cervix
-Fetal position
 Effects of contractions:  Have 4 or more pushes /contraction.

 Increased maternal BP. B. Intraabdominal pressure: as the woman

pushes, the intraabdominal pressure
 Decreases uteroplacental circulation.
increases.
 Fetal hypoxia
 Position of the parturient
st
 Cervical dilation during the 1 stage.

 Expel the fetus and the placenta during the 2nd

and 3rd stages of labor.

 Phases of uterine contractions: STAGES OF LABOR

1. Increment ( cresendo)-” building up” of

contraction, longest phase.

2. Acme (apex)- height/peak of contractions

3. Decrement ( descresendo)- “letting up”, end

phase of contractions.

 A. Duration – the period form the beginning of

increment to the completion of decrement of the
same contraction.

 B. Frequency – the period from the beginning

of one contraction to the beginning of the next
contraction; expressed in every minutes.
 C. Interval – the period from decrement of the
1st contraction to the increment of the next
contraction.
1. 1st stage of labor- (DILATATION STAGE)
begins with the initiation of true labor and ends
when the cervix if fully dilated.

 D. Intensity- refers to the strength of uterine

contraction during acme.(can be determined by
palpation).
 Strong- uterine fundus is very firm, and
cannot be indented with fingers.
 Moderate – fundus is difficult to indent.
 Mild – fundus is tense but can be
indented with fingertips.
- Intrauterine catheter- directly measures the
strength of contractions.
PHASES OF THE FIRST STAGE OF
LABOR:
A. Latent phase- 0-3cm cervical dilatation with
mild and short contractions, lasting 20-40
seconds.
B. Active phase-4-7 cervical dilatation with
stronger and longer contractions, lasting 40-60
seconds.
C. Transition phase-8-10 cervical dilatation with
strong discomfort contractions, lasting 40-90
seconds.

During first stage labor your cervix is effacing

 Secondary powers:
(getting thinner) and dilating (opening up). First
A. Maternal bearing down/ pushing stage labor is considered complete when your
readiness for pushing: cervix is fully dilated and your body switches
from opening contractions to expelling
 cervical dilatation: 10cm; fully dilated contractions.

 Fetal station: +1

 Correct pushing: -Early Stage of Labor ( latent phase) – the

majority of your labor will likely be in this
 Discourage prolonged maternal breath holding
stage. Ranging from 8-15 hours, contractions
of more than 6 seconds, during pushing.
 are usually between 30 and 55 seconds long and b. optimal position
5-20 minutes apart.
 may ambulate- if water is intact
@nursing intervention: Proper
positioning( side lying)  May still ambulate, provided the station is at
least 0 , or + stations to prevent cord prolapse –
@backrub(backache with abdominal water has ruptured.
cramps)
 If with IVF, a movable pole should be used to
@ support system allow ambulation.

-Active Labor – this stage generally lasts 3-5  In the choice of position in labor, consider the
hours. Contractions are 45- 60 seconds long and following; maternal, physical and psychologic
3-5 minutes apart, cervix is 4-7 cm; complete needs, fetal well being.
effacement

Nursing intervention:
Causes of labor pain
@encourage slow and shallow breathing
1st stage of labor
@offer paper bag to breathe into(
hyperventilate->hyperventilation is main @primary source of pain- dilatation of the cervix
problem in this stage)
@Hypoxia of the uterine muscles during
@instruct woman to cupped hands and contraction
breathe into it.
@stretching of the lower uterine segment
Note: Hyperventilation may lead to respiratory
alkalosis. @pressure at the adjacent structures

-Transition – this is the shortest stage and most

intense stage. It marks the complete dilation of
2. 2nd stage of labor: from the full dilatation of
your cervix: 8-10 cm. Typically only 10-60
the cervix until the birth of the infant.
minutes long, contractions are 60-90 seconds in
length for every 2-3 min. Generally women only
have between 5-10 transition contractions. The
mother may have strong desire to push but she
should not!>to eliminate the tendency to push
with contractions, lamaze technique suggest pant
blow pattern of chest breathing.

 Maternal problem: backache, pressure on

the bladder and rectum and leg trembling

Nursing intervention:

@provide comfort with dry lines and cool

clothes

@ clean up vomitus

@provide backrub

@pant blow breathing pattern

@stay with patient and help her focus on her

task: inform progress and be understanding of
her irritability.(PREIST: Praise, Reassure,
Encourage, Inform mother of progress, Support
system and Touch)
LL- most comfortable and best for fetal well being
as this prevents supine hypotensive syndrome
or vena caval syndrome. Avoid supine position.
a. Lithotomy position- most commonly used
which favors the nurse
 ensure equal height of the stirrups.
 Pad the stirrups.
 Simultaneous placement of the legs on the
stirrups.
  Avoid any pressure on the popliteal region.
 Psychologic response of the mother.
1. Factors that make labor meaningful:(Clark and
Alfonso, 1978)
a. Cultural influences integrating maternal
attitudes
b. Expectations and goals for the labor
process
c. Feedback from other people participating
in birthing process.
2. women’s psychologic responses to uterine
contractions.
a. fear
b. anxious
3.Other factors
a. childbirth preparation process- considered as
a valuable tranquilizer during child birth
process
b. support system
- husband – can provide emotional
support ( lessen anxiety -> lessen emotional
tension->less pain perception.
- attending nurse-should provide a supporting
and caring environment , respect the client’s/
family’s needs and attitudes->provide
therapeutic communications
Causes of Labor pain
nd
2 stage
@hypoxia of contracting uterine muscles
@distension of the vagina and perineum
@pressure on adjacent structures
NATURAL CHILDBIRTH:
 Dick – read method:
 Lamaze method of psychoprophylaxis
 Bradley Method
 Dick – read method: 1st of natural childbirth
- Utilizes relaxation techniques and primarily
abdominal breathing to interrupt the circular
pattern of “ fear”->”tension”->”pain”.
- Woman concentrates on forcing the abdominal
muscles to rise
- Use of slow abdominal breathing in the 1st stage
of labor: 1 breath/minute(30 seconds inhalation
and 30 sec. exhalation)
- Use of panting to prevent pushing until needed.
 Lamaze method of psychoprophylaxis –
relaxation and breathing exercise designed to
facilitate birth process.
 Mind prevention using body conditioning
exercises, education, relaxation,and chest
breathing.
- based on “Pavlov’s Theory on Conditioned
Reflexes”- the brain cells can respond to only 1
set of signals at a time and they accept only the
strongest signal.
- 2 components: education and training
- - uses focal points to concentrate on during
contractions.
Bradley Method- partner or husband coached
natural childbirth
-uses relaxation and slow controlled breathing
- Basically same techniques as the ones used in read
method.
CARDINAL MECHANISM OF
LABOR:
 Engagement
 Descent
 Flexion
 Internal rotation
 Extension
 Restitution
 External rotation
 Expulsion

 Second Stage

- best known as pushing stage, starts after you

have completely dilated. The top of your uterus
will now start contracting down towards your
cervix to expel your baby.

-Ranging from 20 minutes to 2 hours long,

pushing contractions are around 60 seconds long
with 5-10 minute breaks between pushing
contractions.

-Crowning is the hallmark of this stage.

-Maternal behavior: progresses from irritability

to participation, eagerness and excitement.

>pushes with uterine contractions due to the need

to bear down.

 Perineum bulges

 Increase bloody show with leg cramps

 BOW ruptures ( best time) then to check the

FHT immediatley.

Nursing intervention:

 Psychological support

 Monitor FHT

 Position the mother – lithotomy: padded

stirrups, no pressure on popliteal region, and
equal height of legs, simultaneously raised the
legs into stirrups.
 > slight lengthening of the cord (most definite
sign)

 Type of placental delivery

1. Schultze mechanism

2. Duncan’s mechanism

1. Schultze mechanism – most common(80% of

cases)

> shiny, clean bluish fetal side is first delivered

> less external bleeding because blood is

usually concealed behind the placenta.

>separation starts at the center then to the edges

causing inverted umbrella shape.

2. Duncan’s mechanism: less common( 20% of

cases)

>rough, dirty reddish maternal side out first.

> more external bleeding so I appears more

Third stage – placental stage
bloody.
-Period from the delivery of the baby to the
delivery of the placenta.
POSTPARTUM PERIOD
• Also known as Puerperium
 Signs of placental separation:
• Is the six-week period starting from child-birth,
>calkin’s sign- globular formation of the
during which reproductive organs undergo
uterus, becomes mobile.
physical and physiologic changes that reverse
> sudden gushing of blood the body’s adaptation to pregnancy -
INVOLUTION.
 • PUERPERA refers to the woman in puerperium
• Begins with the delivery of the placenta and
ends when all body systems are returned to , or
nearly to their prepregnant state
• Care during puerperium:
1. Checking of :
o Vital signs
o Vaginal discharges (lochia)
o episiotomy
o Urine output and bowel movement
o Fundus of the uterus
2. Establish early breastfeeding
3. Hygiene, care of perineal wound
4. Inspection of lower of extremities
5. Early ambulation
6. Family Planning
7. Health Instructions
8. Post partum Check-up
 Uterine involution - A decrease in size of an
organ, as of the uterus following childbirth
- the return of the uterus to its normal size after
childbirth
3 processes involved in involution
1. Muscle fiber contraction : uterus firmly
contracts to control bleeding from area of
placental attachment
2. Catabolism: enlarged muscle cells of the
uterus experience catabolic changes in protein
cytoplasm that reduce the size of each cells
3. Regeneration: endometrium is regenerated
within 2-3 weeks, except for the placental site,
which is healed and regenerated approximately
6 weeks.
• Psychological Changes
 Development of parental love and positive
family relationships
 Rooming-in
 Sibling visitation
PHYSIOLOGY OF PUERPERIUM :
Specific body changes
I. REPRODUCTIVE SYST V. HORMONAL SYSTEM
II. ABDOMINAL WALL/ SKIN VI. GASTROINTESTINAL TRACT
III. CARDIOVASCULAR SYSTEM/ CIRCULATORY SYSTEM
IV. URINARY SYSTEM VII. VITAL SIGNS CHANGES
I. REPRODUCTIVE SYSTEM
A. Uterus : rapid reversal in size
1. palpated after delivery below the umbilicus, the
uterus regresses approximately 1 fingerbreadth
(1cm) per day until by the end of the 2nd week
postpartum , it is a pelvic organ and cannot
be palpated through the abdominal wall.
2. The endometrial surface is sloughed off as
lochia, in three stages:
B. CERVIX : flabby immediately after delivery;
closes slowly
1. Admits one fingertip by the end of one week
after delivery.
2. Shapes of external os changed by delivery
from round to slitlike opening.
C. VAGINA/ PERINEUM
1. Edematous after delivery. Inspect episiotomy
daily for normal healing; observe for redness,
edema, ecchymosis, discharge approximation
(REEDA) , and hematoma.
2. May have small lacerations.
3. Smooth-walled for 3-4 weeks, then rugae
appear
D. OVULATION/MENSTRUATION
1. First cycle is usually anovulatory. If not
lactating, menses may resume in 6- 10 wks, ave
of 4-6 weeks.
2. If lactating, menses less predictable ; may
resume in 12-24 weeks.
E. BREASTS
1. NON LACTATING WOMAN
a. Prolactin levels fall rapidly.
b. May still secrete colostrums for 2-3 days.
 c. Engorgement of breasts tissue resulting Advantages :
from temporary congestion of veins and
-Non allergenic
circulation occurs on third day , lasts 24-
36 hours, usually resolves spontaneously. -Meets infants specific nutritional needs

d. Client should wear tight bra to compress -Immunologic properties help prevent infections
ducts & use cold applications to reduce
-Easily digested
swelling.
-Constipation unlikely

-Overfeeding less likely

2. LACTATING WOMAN
-Convenient, always available
a. High level of prolactin immediately after
delivery of placenta continued by frequent -No formula or bottles to buy
contact with nursing baby.
-No formula and bottles to prepare
b. Initial secretion of colostrums, with increasing
-Oxytocin release helps involution
amount of true breast milk appearing bet. 48-
96 hours. -Enhances mother /infant attachment through
skin to skin contact
c. Milk “ let down” reflex caused by oxytocin
from posterior pituitary gland released by Disadvantages :
sucking.
-Feed more frequently (2-3 hours)
d. Successful lactation results from complex
interaction of infant sucking reflexes & the -More frequent diaper changes
maternal production and let down of milk.
-Amount of milk taken in each feeding unknown
• Breast feeding
-Medications taken in mother present in milk
-Is the most universal recommended way of
-Discomfort of some mothers to nurse in public
providing infant with nourishment for a healthy ,
full term infant. -Expense of pumping and storing milk for
periods when mother is unable , such as work
-Breast milk is biologically designed to meet the
hours
needs of human infants

-Colostrum - is rich in immunoglobulins to

protect the newborns gastro intestinal tract from
infection

- helps establish normal intestinal flora and has

a laxative effect that assists in the passage of
meconium.

• The 3 E’s in breastfeeding

• Positions for feeding infants:
1. As Early as Possible – immediately after
1. Cradling
delivery, sucking the breast may reduce the risk
of post partum hemorrhage 2. Lying down
2. Exclusive for 4-6 months – for the first 6 months • Signs of good positioning are:
of life a well nourished mother can provide
through breast milk, all the nutrients and fluids  Baby in line with ear, shoulder and hip in a
an infant needs. straight line

3. Extent upto 2 years – mother can continue breast  Close to the mother’s body so the baby is
feeding the baby as long as she feels brought to the breast rather than the breast taken
comfortable to the baby
  Baby is supported at the head, shoulders, and if
newborn the whole body is supported
 Baby is facing breast with the baby’s nose close
as possible to the nipple
• Signs of good attachment
a. Areola more visible above than below the mouth
b. Mouth wide open
c. Chin touching breast
d. Lower lip turned outward
II. ABDOMINAL WALL/ SKIN
A. May need 6 weeks to re establish good muscle
tone. Sexual intercourse can be resumed.
B. Stretch mark gradually disappears or fade to
silvery appearance.
III. CARDIOVASCULAR SYSTEM/
CIRCULATORY SYSTEM
a. Normal blood loss in delivery of single infant is
from 500 cc up to 1000 cc for Ceasarean section
and 300cc to 500cc in vaginal birth.
b. Hematocrit usually returns to prepregnancy
value within 4-6 weeks
c. WBC count increases.
d. Increased clotting factors remain for several
weeks > risk for problems with thrombi
4. Inspection of lower extremities
 Varicosities (varicose veins)
o Are swollen veins just below the skin caused by
the increase in blood during pregnancy resulting
from the increase of hormone progesterone,
which also softens the tissues of the veins, and
the weight of the growing uterus putting
pressure on the veins to the legs and slowing the
flow of blood.
o Some have blue or purple spot
o Some veins are bulging
 Edema
o Also water retention and swollen limbs
o Swollen feet, ankles, legs and hands are
common symptoms of pregnancy. You may
notice the rings on your fingers feel tight. This
swelling happens when the body retains water,
which is caused by a couple of changes in the
body during pregnancy.
o If you suffered from water retention during your
pregnancy, it may last for a few days after you
deliver the baby as your hormones return to
normal. The swelling in your legs and feet will
reduce as you pass urine and flush the water out
of your body.
 Milk leg / phlegmasia alba dolens – is
classical puerperal thrombophlebitis involving
the lower extremities
o Occasionally reflects arterial spasm, causes a
pale, cool extremity with diminished pulsation
o Common during early puerperium as the
consequence of inappropriate contact between
the cuff and the delivery table leg holders
• 5. Early ambulation
IV. URINARY SYSTEM
A. May have difficulty voiding in immediate
postpartum periods due to urethral edema.
B. Mark diuresis begins within 12 hours of
delivery; increase vol of urinary output &
perspiration
C. Lactosuria in nursing mothers
D. Slight proteinuria during 1-2 days of involution
- full bladder is as hard or firm area just above
the
symphysis pubis
- during pregnancy as much as 2000ml-3000ml
excess fluid accumulates in the body
• Urine output
 Check for bladder distention of unable to void
(risk for UTI)
 Apply warm compress on hypogastric area
 Difficulty of urination may be caused by
traumatized urinary meatus during labor and
delivery
  Full bladder displaces the uterus up and to the
side, resulting in uterine atony or inability of the
uterus to contract and this is the primary cause
of excessive bleeding
V. HORMONAL SYSTEM
- levels of HCG and HPL are almost negligible
by 24 hours
- FSH is low for about 12 days and rises to
initiate a new menstrual cycles
VI. GASTROINTESTINAL TRACT
1. Mother usually hungry after delivery; good
appetite is expected.
2. May still experience constipation from lack of
muscle tone in abdomen and intestinal tract, &
perineal soreness.
VII. VITAL SIGNS CHANGES
TEMPERATURE: slightly increased during the
first 24 hours after birth because of
dehydration that occurred during labor. If she
receives adequate fluid during the first 24 hrs,
temp elevation will return to normal.
BLOOD PRESSURE:
If decreased= BLEEDING;
If elevated = to 140/90 mmHg = Pregnancy
Induced hypertension, a serious complication of
puerperium.
PULSE: is slightly slower than normal due to the
increased stroke vol brought about by the
increasing blood vol returning to the heart.
As diuresis diminished blood vol & causes blood
vol to fall, the pulse rate increases, and by the
1st week, it will be normal.
POST PARTUM ASSESSMENT
1. Check fundus frequently and massage gently if
fundus is not firm
2. Inspect perineum frequently for visible signs of
bleeding.
a. note color, amount and odor of the lochia
b. count the number of pads that are saturated in
each 8-hour period.
3. Assess bladder. Birth trauma, anesthesia, and
pain from lacerations and episiotomy
4. Assess vital signs
5. Assess breast engorgement and condition of
nipples if breast feeding.
6. Assess bladder and bowel elimination.
NURSING INTERVENTIONS
A. FIRST HOUR AFTER DELIVERY (4th stage of labor)
B. PERINEAL CARE F. EXERCISE
C. VOIDING G. REST AND AMBULATION
D. BREAST CARE H. RESUMPTION OF SEX
E. DIET AND ELIMINATION
A. FIRST HOUR AFTER DELIVERY (4th stage of
labor)
1. Evaluate woman’s v/s every 15minutes
2. Evaluate fundal height
3. Inspect perineum for signs of bleeding including
hematoma formation
4. Evaluate the amount of vaginal bleeding.
VAGINAL DISCHARGE- consisting of blood,
fragments of deciduas, white blood cells, mucus,
and some bacteria is termed LOCHIA.
Characteristics of Lochia:
 Lochia Rubra- red in color, 1 to 3
postpartal day, composition of blood,
fragments of deciduas, mucus.
 Lochia Serosa- pink in color, 4 to 10
postpartal day, composition of blood,
mucus, invading leukocytes.
 Lochia Alba- white in color, 10 to 14 ( may
last 6 weeks) postpartal day, largely mucus,
leukocytes count high.
B. PERINEAL CARE
1. Teach out women to carry out perineal care.
2. Sitz bath may be used for the same purpose.
C. VOIDING
D. BREAST CARE
1. Inspect nipples for reddening, erosions or
fissures.
 2. Teach woman to wash her breast with warm 1. Healing occurs within 2-4 weeks
water and NO soap.
2. Intercourse may be resumed when perineal and
E. DIET AND ELIMINATION uterine wounds have healed.

1. Emphasize food high in iron, protein and

vitamins to aid the healing the healing process.
Foods high in fiber will help reestablish normal MATERNAL CONCERNS AND
bowel habits. FEELINGS IN THE POST PARTAL
PERIOD
2. Hemmorhoids and episiotomy and laceration
pain may cause the woman to delay her first 1. Abandonment
bowel movement.
2. Disappointment
3. Promoting frequent ambulation, ensuring
adequate fluid intake and providing diet with 3. Postpartal blues
fresh fruits and fibers encourage regular bowel
elimination.

• Hygiene
POSTPARTAL PSYCHOSOCIAL CHANGES
-Advise regular perineal care

-After delivering the baby, the perineum must be

ADAPTATION TO PARENTHOOD
kept clean. Lochia may drain for up to four MOTOR SKILLS
weeks, so pads should be changed frequently:
- New parents must learn new physical skills to
-Take a bath or a shower once or twice daily. A care for infant ( eg. feeding, holding, burping,
sitz bath should be used after every bowel changing diapers, skin care)
movement. A sitz bath involves sitting in
shallow water, only deep enough to cover the ATTACHMENT SKILLS
hips and buttocks.
BONDING: the development of a caring
-Urinating can be painful after delivery. relationship with the baby.
Squirting warm water (or guava decoction) over
- Claiming: identifying the ways in which the baby
the perineum during urination may ease the pain.
looks or acts like members of the family.
When finished urinating, gently pat the
perineum dry.

-May also use betadine feminine wash PHASES OF THE RESTORATIVE

• Bowel movement PERIOD OF MATERNAL BEHAVIOR
FOLLOWING DELIVERY.
-Assessment of bowel, assess the patient’s
bowel sounds  Rubin’s Post partum phases of regeneration

-Assess return of bowel function  Taking-in Phase: First 3 days

 Taking-hold Phase: Days 3-10

-Assess for flatus
 Letting-go Phase
-Assess for color and consistency

F. EXERCISE • Rubin’s Post partum phases of regeneration

1. Toe stretch • Taking-in Phase: First 3 days

2. Kegel’s exercise – Mother focuses on her own primary
needs, such as sleep and food
G. REST AND AMBULATION
– This phase is not an optimum time to
teach the mother about baby care
H. RESUMPTION OF SEX
• The woman becomes dependent on her
healthcare provider or support person with some
of the daily tasks and decision-making.
• This dependence is mainly due to her physical
discomfort from hemorrhoids or the after pains,
from the uncertainty of how she could care for
the newborn, and also from the extreme
tiredness she feels that follows childbirth.
• The taking-in phase provides time for the
woman to regain her physical strength and
organize her rambling thoughts about her new
role.
• Encouraging the woman to talk about her
experiences during labor and birth would greatly
help her adjust and let her incorporate it into her
new life.
• Taking-hold Phase: Days 3-10
-The woman is more in control of
independence
-The woman begins to assume the tasks of
mothering
-This phase is an optimum time to teach the
mother about baby care
o Generally, this phase occurs when the mother
returns home.
o During the letting go phase, the woman finally
accepts her new role and gives up her old roles
like being a childless woman or just a mother of
one child.
o This is the phase where postpartum depression
may set in.
o Readjustment of relationship is needed for an
easy transition to this phase.
• Letting-go Phase
-Mother may feel deep loss over separation of
the baby from the part of the body and may
grieve over the loss
-Mother may be caught in the
dependent/independent role, wanting to make
decisions
o Generally, this phase occurs when the mother
returns home.
o During the letting go phase, the woman finally
accepts her new role and gives up her old roles
like being a childless woman or just a mother of
one child.
o This is the phase where postpartum depression
may set in.
o Readjustment of relationship is needed for an
easy transition to this phase.
The Newborn
• PROFILE OF THE NEWBORN
• Newborn Period / Neonatal Stage – from birth
to 4 wks or 28 days .
• Neonate – newborn infant
• Essential Newborn Care (WHO) -1st 90 mins
• The ENC Protocol is a series of time bound,
chronologically-ordered, standard procedures
that a baby receives at birth. At the heart of the protocol
are four time-bound interventions:
1. Immediate drying – prevents hypothermia
2. Skin to skin contact
3. Cord clamping
a. Clamping of the cord after 1 to 3 minutes – until
the umbilical cord stops pulsating decreases
anemia in 1 out of every 3 premature babies
and prevents brain hemorrhage in one out of
two. It prevents anemia in one out of every
seven term babies.
b. After the umbilical pulsation stopped( 1-3min)
clamped the cord using a sterile plastic clamp
or tie at 2 inches from the newborn umbilical
base.
c. Clamp again at 5 cm from the base
d. Cut the cord close to the plastic clamp with
sterile instrument
e. Observe for oozing of blood.
NOTE:
-Do not milk the cord towards the newborn
-After the 1st clamp, you may strip the cord
-Cut the cord close to the plastic clamp so that
there is no need for a 2nd trim
4. Non-separation of baby from mother, and
breastfeeding initiation- Keeping the mother
and baby in uninterrupted skin to skin contact
prevents hypothermia, increases colonization
with protective family bacteria and improves
breastfeeding initiation and exclusivity.
Breastfeeding within the first hour of life
prevents an estimated 19.1% of all neonatal
deaths
WITHIN 90 MINUTES OF AGE
-Provide support for initiation of breastfeeding
Note: Do not give sugar , water, formula, pre lacteals
NON IMMEDIATE INTERVENTION
- DO EYE CARE
• Mandatory – done to all newborns
Drugs used – 1% Silver Nitrate 1 – 2 gtts into
each conjunctival sac and Terramycin
opthalmic 1 cm
-CORD CARE
 Strict asepsis prevents TETANUS
NEONATORUM
 CHECK for 1 umbilical vein and 2 umbilical
arteries
 Report incomplete vessels
• Establishing Respiration (resp distress)
• 1. Clear the neonate’s air passage with extension
of the fetal head.
• 2. Wipe off mucus from mouth to nose; suction
the mouth gently and then the nose using the
bulb syringe.= prevents the stimulation of the
sensitive nerve receptors in the nasal mucosa,
which can cause the NB to gasp for breath,
thereby favoring the reflex inhalation of
pharyngeal secretions into the trachea & bronchi
causing aspiration.
• 3. Suctioning time: 5 to 10 secs in full term and
low –risk NB and less than 5 secs in preterm and
other high risk NB. – prevents breathlessness.
• 4. Oxygenate the NB between suctioning time;
suctioning the NB may necessitate oxygenating
him.
RETROLENTAL FIBROPLASIA or NEONATAL
BLINDNESS – due to improper use of oxygen /oxygen
toxicity
ASPHYXIA NEONATORUM – is the failure to
initiate breathing in the first 60 secs of life commonly
due to clogged air passages. ; prevention: ensure patent
airway.
APGAR SCORE
-was devised in 1952 by Dr. Virginia Apgar
as a simple and repeatable method to quickly
and summarily assess the health of newborn
children immediately after birth.
-Apgar was an anaesthesiologist who
developed the score in order to ascertain the
effects of obstetric anesthesia on babies.
-Virginia Apgar evaluates the newborn baby on
five simple criteria on a scale from zero to two,
then summing up the five values thus obtained.
-The resulting Apgar score ranges from zero to
10.
• The five criteria are summarized using words
chosen to form (Appearance, Pulse, Grimace,
Activity, Respiration).
• Interpretation of Score:
-The test is gen done at 1 and 5 mins. after birth,
& may be repeated later if the score remains
low.
. -The FIRST APGAR score detects cardio-
respiratory nervous functioning of the NB.
-The SECOND APGAR score is used for
planning nursing care; to determine the NB adjustment
to extra uterine life.
Scores 3 and below - critically low- medical
attention needed; needs resuscitation
4 to 6 fairly low-suctioning & oxygenation
needed
7 to 10 generally normal/good –needs only
admission care , no special care
Anthropometric measurement
A. Weight C. Head Circumference
B. Length D. Abdomen
A. WEIGHT
1. Ave bet 2750g and 4000g (6-9 lb) at term.
2. under 2750 g (5 1/2 lb): Small for gestational
age (SGA)
3. Over 4100 g (9 lb): large for gestational age.
4. Initial loss of 5%-10% of body weight normal
during first few days; should be regained in 1-2 wks.
B. LENGTH 2 types:

1. Ave 46 – 55.9 cm ( 18-22in) 1. Anterior Fontanel – diamond shaped ; closes in

12-18 month
2. Under 45.7 cm (18 in); SGA
2. Posterior Fontanel- triangular shaped; closes in
3. Over 55 cm ( 22 in) :LGA 2-3 months
C. HEAD CIRCUMFERENCE 1. Anterior Fontanel
1. Ave circumference 33 – 35.5 cm ( 13- 14 in); equal -Is located at the junction of two parietal bones
to or 2-3 cm slightly larger than chest; remeasure after and the two fused frontal bone.
several days if significant molding or caput
succedaneum present. - It is diamond shape

2. Under 31.7 cm ( 12in): Microcephaly/SGA - Measures 2-3 cm in length

D. ABDOMEN - Closes at 12-18 mos.

Shape – cylindrical protrudes slightly, moves 2. Posterior Fontanel

synchronously with chest in respiration.
-Located at the junction of parietal bones and the
occipital bones

NEWBORN SCREENING -Triangular in shape

-1 cm in length
• Profile of a Newborn
-Closes at 2-3 months
A. Head D. Nose
B. Eyes E. Mouth 2. SUTURES
C. Ears
-Skull sutures

A. HEAD -The separating line of the skull

-Disproportionately larger than the body -May override at birth because of extreme
pressure exerted by the passage of fetus thru the
-¼ larger than the body canal.

-In adult head 1/8: body -Overriding of sutures is a normal phenomenon

Common features found:

3. MOLDING ( Dunce Cap)

1. Fontanelles -Overlapping of skull bones caused by

compression during labor and delivery.
2. Sutures
-The part of the infant’s head (vertex) that
3. Molding engages in the cervix

4. Caput Succedum -The head molded to fit in the cervical contour

5. Cephalhematoma -At birth appears prominent

6. Craniotabs -Head becomes asymmetrical

1. FONTANELS (Soft spot) -Common in primi baby

-A space or opening where skull bones join 4. CAPUT SUCCEDANEUM

-soft spot where sutures cross meet
-Too easily felt or identified
-Should be flat and open; enlarged or bulging
may indicate increased intracranial pressure,
sunken often indicates dehydration.
-swelling of the soft tissues of the scalp because
of pressure from the cervix against presenting
part. Usually caused by continuous pressure of
undelivered head against the partially dilated
cervix.
-Edema of the presenting part (head)
 -Edema is gradually absorbed -Chlamydia, Glaucoma, Edema, Opthalmia
neonatorum,
-Disappears at 3rd-4th day of life without Trabismus and Twitch
intervention.

-Requires no treatment C. EARS

5. CEPHALHEMATOMA
- A collection of blood beneath the periosteum
of the skull bone and the bone itself caused by
the rupture of periosteum capilliary due to the
pressure at birth.
- Occurs 24 hours after birth
- Prolonged labor and tight passage (bruising)
- Discolored- black, blue, or red (accumulation
of blood)
-Newborn’s ears are not completely formed, the
pinna tends to bend easily.
-The level of the top part of the external ear should
be in line with inner canthus of the eyes.
D. NOSE
-Larger for the face
-Normally flat
-Flaring- obstruction of airway with mucus
-Test for choanal atrisia - blockage of nose
(close newborn’s mouth, compress one nare, assess
for discomfort or stress)

- Absorbed and disappears after several weeks E. MOUTH

- Not harmful, requires no treatment
6. CRANIOTABS
-Is the localized softening of the cranial
bones
-Pressure of fetal skull against the pelvic
bones
-Corrected after few months
-Opens evenly when crying
-Epstein Pearl/s- one or two small round, glistening,
well circumscribed cyst on the palate as a result
of the extra load of calcium during pregnancy.
-Epithelial Pearl- benign inclusion cyst, seen on the
gum margin. No tx.
-Natal teeth- 1-2 teeth, if loose should be e

-Normal in newborn, pathologic in older child-

faulty metabolism or kidney dysfunction

B. EYES
-Newborns cry tearlessly- immature lacrimal duct,
matures at 3 mos.
-Color of eyes gray or blue
-Sclera- blue, thinness
-Permanent color 3-12 mos

ASSESSMENT OF THE EYES

-Lay on supine position, lift the head
-Eyes should appear clear without redness or
purulent discharge

Administer antimicrobial ent to prevent:

-Chlamydia infection

-Opthalmia neonatorum (gonorheal

conjunctivitis)- purulent discharge
-Redspot or red ring- subconjunctival hemorrhage,
needs no treatment, absorbed at 2-3 weeks
-Edema- orbit of the eyelids, 2-3 days, eliminated
by the kidneys
-Cornea round and proportionate in size: larger
cornea – glaucoma
-Pupil- dark, white- Cataract
-May have Strabismus eyes (cross eyes) or
Myetagmus eyes (twitch) , should not be
persistent up to 4-6 mos.
-Chinky eyes and slanted eyes- Down’s syndrome
or Mongolian syndrome