DAY 1&2

SUBJECT: MATERNAL AND CHILD CARE

TOPIC: Anatomy and Physiology of the Reproductive System
LESSON 1: Parts of the female External Genitalia

 Mons Pubis (Mons Veneris)

 Most superior part of the vulva – triangle in shape and lies
 Over the symphysis pubis of the pubic bone and provides
 Normal escutcheon of women due to the presence of pad of fatty tissues which
 Serves as a cushion and protection of pubic bone during sexual intercourse and
junction of bone from trauma. From the time of puberty, it is covered with pubic
hair and its distribution is triangular. It contains sebaceous glands that secrete
pheromones to drive sexual attraction

 Clitoris
 Comprise about 8,000 or more sensory nerve endings which are the main reason for
being sensitive to touch, and temperature and swells with blood when stimulated.
 Landmark for female catheterization because it is situated higher than urethra
 It is about the size of pea – average is 1 inch in length and ½ in diameter and
 The center and most sensitive erectile and female arousal
 Organ for sexual pleasure
 Removal of clitoris as a rite of initiation into womanhood in Islamic Cultures
 Internal structure includes the body, crura, bulb and roots
 Supplied with blood from the internal pudendal artery

 Labia

A. Labia Majora
 Large, outer or greater lips
 Analogous to the male scrotum
 Rounded folds of adipose tissue and skin
 Growth of hair on the outer surface and have a pink and smooth inner surface
 External two folds of fats over the opening of the vaginal orifice. Serves as
protection for external genitalia, urethra and vagina. Join medially forming
posterior commissure

B. Labia Minora
 Small, two thin flat and reddish internal lips.
 Medial to labia majora – hairless
 Anterior fusion (clitoral hood/prepuce), posterior fusion (fourchette), inferior
fusion (frenulum)
 Lighter in color (fleshy/moist pink)
 Lie just inside the labia majora and encloses vestibules

 Vestibule

1
  Almond-shaped area is enclosed by labia minora laterally, extend from clitoris to
fourchette in which the opening of the urethra and vagina are situated.

 Urethral meatus
 Posterior to the clitoris
 External opening of urethra
 External urethral meatus is part of vestibule
 Shorter urethra among women – are more likely to develop a UTI than men because
women have shorter urethras than men. The bacteria from the anus can ascend easily to
the urethra.
 Vaginal introitus is hidden by the overlapping labia minora, almost completely closed by
hymen
 Orifice or opening of the vagina
 Part of vestibule
 Examine for any prolapse: cystocele or rectocele
 Note for any tenderness, redness and swelling at the sides – are signs of Bartholinitis
o Cystocele – protrusion of the posterior bladder into the vagina – bulging in the
anterior vaginal wall
o Rectocele – protrusion of anterior rectal wall into the vagina – bulging in the
posterior wall of the vagina

a. Bartholin’s glands gland

o Greater vestibular glands (paravaginal)
o Located posterior sides of vaginal opening
o Abscess formation due to gonorrhea and chlamydia infection
o Normally secreted alkaline fluid for vaginal lubrication
o Ducts open at 4 and 8 o’clock position at the vaginal vestibule

b. Hymen
o Hymen: thin membrane of stratified squamous epithelium
o Yes it can be torn by deep penetration (sex, tampon, insertion, and pelvic
examination)
o Myrtiform caruncles: scarred tags of hymenal tissue
o Estrogen causes hymen thick, rigid and very elastic during puberty
o Normal shape: half-moon/crescent
o Imperforate hymen – vaginal orifice – occluded cause retention of menstrual
discharge

 Perineum
 Position between anus and vaginal orifice
 Episiotomy site (fourchette)
 Ritgens maneuver prevents laceration
 It is diamond in shaped
 Normal perineal body length is 4 cm
 Erogenous, comes from the Greek word eros which means love
 Urogenital triangle is the anterior half of the perineum
 Main pelvic floor muscle is the levator ani. The levator ani is a broad muscular
sheet located in the pelvis.

LESSON 2:PARTS OF THE FEMALE INTERNAL GENITALIA

ORGANS

2
 The internal genitalia is the structure within the pelvis, which includes the vagina, cervix,
uterus, fallopian tubes, and ovaries. These are collectively, the female reproductive organs.
 Vagina
 Vagina is a hollow distensible fibromuscular tube that extends from the vestibule
to the cervix
 Anterior of vagina is the bladder; posterior of vagina is the rectum
 Good bacteria in vagina is the Doderlein bacilli - breaks down glycogen to lactic
acid
 Internal iliac arteries are the main blood supply of the vagina
 Normal pH by Lactobacillus acidophilus bacteria
 Acidic pH of 3.5 – 4.5 is maintained by estrogen
o Vaginal Rugae
 Ridges in vaginal wall
 Usually noticeable and prominent among nulligravida
 Gravid multiparous women vaginal rugae is scanty
 Absent rugae is present in postmenopausal
 Estrogen maintains vaginal rugae

o 3 main types of vaginal fistula (abnormal connections)
 Vesicovaginal – between vagina and bladder. Urine enters vagina constantly
 Urethrovaginal – between vagina and urethra. Urine only enters the vagina during
during voiding
 Rectovaginal – between vagina and rectum. Feces/flatus escapes in vagina
o Function
 Vagina allows the escape of the menstrual flow
 Receives the penis and the ejected sperm during sexual intercourse
 Provides an exit for the fetus during birth
 Cervix
 Cervix is the most inferior part of the uterus
 Efface and dilates during labor and delivery
 Round/cylindrical shape in nulliparous; horizontal slit-like after delivery
 Vaginal portion of cervix is the ectocervix
 In labor, progress of labor is determined by cervical dilation
 X is use to plot cervical dilation in partograph
 Uterus (Womb)
 Uterus is hallow, muscular organ
 Transverse cervical/Cardinal/Mackenrodt’s ligament (main support of uterus)
 Exact anatomical location of uterus: posterior of bladder and anterior of colon
 Reproduction function is for implantation
 Uterus normally lies in anteversion and anteflexion position
 Shape: inverted avocado or pear

o Positions of the Uterus

 Anteverted: the uterus is tipped forward so that it lies over the bladder
 Anteflexed: fundus of uterus is pointing forward relative to the cervix
 Retroverted: also known as tipped/tilted uterus
 The uterus leans backwards to the rectum
 Retroflexed: fundus of the uterus is completely bent back and lies against
the recto-sigmoid region

3
 o Three layers of the uterus
 Epimetrium - outer layer, also known as serosa or perimetrium
 Myometrium – middle layer, rich in muscles fiber (living ligature) for
uterine contraction (CBQ)
 Thickness in the fundus and thinnest in the cervix

 Endometrium: inner layer, composed of mucous membrane

 Most active layer and responds to cyclic ovarian hormone changes
(CBQ)
 Sheds in menstruation; site of blastocyst implantation (CBQ)

o Two uterine segments

 Upper uterine segments (active during labor and delivery)
 Fundus
 Domed upper wall between the insertions of the uterus tubes
 Body or corpus
 This forms the upper third of the uterus
 Upper triangular portion
 Site of implantation and growth of fetus

o Lower uterine segment

 Gradually develops in pregnancy period
 Most suitable site for a traverse incision during caesarean section

o The lower uterine segment

a. Isthmus – inferior-posterior part of the uterus
b. Cervix – lower constricted segment of the uterus (connects vagina and
uterus)
 The internal os (mouth) is the narrow opening between the isthmus
and the cervix
 The external os is a small round opening at the lower end of the
cervix.
o Ligaments that supports the uterus
 Broad ligament – attached the sides of uterus to the pelvis. Acts as a
mesentery for the uterus
 Round ligament – remnant of the gubernaculum and maintains the
anteverted position of the uterus
 Ovarian ligament – attach the ovaries to the uterus
 Cardinal ligament – main support of the uterus
 Uterosacral ligament – extends from the cervix to the sacrum. It
provides support to the uterus

 Fallopian tubes
 Fertilization site (ampulla)
 Also known as oviducts, salphynx, uterine horn
 Length 10-12cm, J shaped structure
 Long slender tubes connecting ovaries to the uterus Ovum transportation
 Pelvic inflammatory disease (PID) most common site
 Interstitial/intramural – most dangerous site of ectopic pregnancy
 Ampulla is the most common site of ectopic pregnancy
 Narrowest portion of the tube is the isthmus

4
 o Parts of the Fallopian Tubes
 Interstitial – with in the uterus muscle
 Isthmus – narrowest, thick portion, site of tubal ligation
 Ampulla – widest, longest 2/3 of tube, site of fertilization
 Infundibulum – distal end of tube, funnel shaped
 Fimbrae – finger-like projections to sweep egg up into the tube
 Fimbria ovarica – largest fimbria, attach to the ovary

DAY 3
SUBJECT: MATERNAL AND CHILD CARE
TOPIC: Anatomy and Physiology of the Reproductive System
LESSON 1:. Female Internal Reproductive Organs

 Ovaries
 Ovulation is the main function
 Venous drainage - ovarian vein
 Arterial blood supply – ovarian artery – branch of abdominal aorta and uterine artery
 Responsible for oocyte and hormone production
 Inner most layer is the ovarian medulla
 Estrogen and progesterone are the major hormones produce by the ovaries
 Suspensory ligament attaches ovary to abdominal wall

o Oocyte production
 Mid – gestation: 6-7 million (highest number of oocyte in 20 weeks gestation
 At birth: 1-2 million
 Puberty: 300,000 to 400,000
 Take note: only about 400 mature during a woman’s life.

o Two main hormones produce by the ovaries

 Estrogen
o Estrone (E1) – produce by adipose; predominant during menopause
o Estradiol (E2) – produce by ovaries; predominant during reproductive years
o Estriol (E3) – produce by placenta; predominant during pregnancy
o Take note: Estradiol is the strongest form of estrogen while estriol is the most
abundant, but weakest form of estrogen
o Functions of estrogen
Inhibits follicle stimulating hormone (FSH)
 Endometrial growth
 Secondary sexual characteristics in female
 Thinning of cervical mucus
 Reduce bone resorption
 Osteoporosis prevention
 Gum bleeding
 Epulis, epistaxis and rhinitis
 Na and water retention

5
  Progesterone functions
o Inhibit luteinizing hormone
 Pregnancy maintenance
 Relaxes ureters, bladder and uterus
 Ovulation highest hormone
 Gum problems
 Embryo nourishment
 Secretory phase most predominant hormone
 Thickening of cervical mucus
 Endometrial tortuosity
 Rising body temperature in ovulation
 Onset of labor occurs when level drops
 Normalizes blood clotting
 Edema and varicosities and constipation

o Two portions
 Cortex
o Outer layer becomes thin as one ages
o Ova and Graafian follicles are located (primordial and Graafian follicles)
o As women ages follicles become less numerous
o Outermost portion, dull and whitish is designated as the tunica albuginea
o Surface : single layer of cuboidal epithelium, the germinal epithelium of
waldeyer
o Functioning part of the ovary
 Medulla
o Inner portion
o Central portion with loose connective tissue
o Large number of arteries and veins
o Onset puberty – no. of oocytes estimated at 200,000 to 4000, 000

LESSON 2: Male Reproductive System

Male External Genitalia

Penis
 Penis average length – 3-4 inches (flaccid) and 5-7 inches (erected)
 Engorged with blood during sexual response
 Nerve supply: dorsal pudendal and cavernous nerves
 It is the organ of copulation and urination
 Supplied with blood mainly by internal pudendal artery

 It has 3 parts
o Root – this is the part of penis that attaches to the wall of the abdomen
o Body or shaft - Shaped like a tube or cylinder, the body of the penis.
o Glans - is the cone-shaped end of the penis. The glans, which is also called the head
of the penis, is covered with a loose layer of skin called foreskin. This skin is

6
 sometimes removed in a procedure called circumcision. All boys are born with
a foreskin, a fold of skin at the end of the penis covering the glans

 The penis has three columns of erectile tissue

o The corpora/corpus carvenosa are two lateral columns that lie on either side in
front of the urethra
o The corpus spongiosum is the posterior column that contains the urethra. The tip
is expanded to form the glans penis

 Functions
o Deposits spermatozoa in the female reproductive tract
o With sensory nerve endings for sexual pleasure
o Outlet urinary tract

Scrotum/Scrotal sac
 Skin pouch that holds the two testicles below the pendulous penis
 Cremaster muscle – elevates testes
 Right testicle is higher than left (left testes is lower)
 Organ structure homologous to labia majora in female
 Temperature control maintaining 2-4 ºC below body temperature
 Unilateral swelling should be reported (possible hydrocele or hernia)
 Median raphe: divides the two lateral compartments of scrotum

Functions
o It contains the testicles, as well as many nerves and blood vessels.
o It houses the testicle/testes, epididymis
o Protects the testes and sperm from high body temperature. A temperature around
34.4ºC enables the production of viable sperm, whereas temperature of or above
36.7 ºC can be damaging to sperm count.

Male Internal Reproductive System

Testes/Testicle
 Tunica albuginea: thick connective tissue that surrounds each testes
 Exocrine and endocrine gland – testosterone by leydig cells
 Seminiferous tubules: long coiled tubules, site for spermatogenesis
 Tunica vaginalis: pouch of serous membrane covering the testes
 Efferent ducts: connect the rete testes and epididymis
 Sertoli cell: part of seminiferous tubule helps for sperm production

 Two ova-shaped glandular organ inside the scrotum

 Function
o The testes are responsible for making testosterone, the primary male sex hormone,
o For generating sperm.
o Within the testes are coiled masses of tubes called seminiferous tubules. These tubes
are responsible for producing sperm cells.
 Hypothalamus releases GnRH which then influences the anterior pituitary to release FSH and
LH
 FSH – release androgen producing hormone
 LH for releasing of testosterone (responsible for the development of secondary sex
characteristics)

7
 DAY 4
SUBJECT: MATERNAL AND CHILD CARE
TOPIC: Anatomy and Physiology of the Reproductive System and
Female Pelvis
LESSON 1:. Male Reproductive System

Epididymis
 Comma –shaped structure
 On the top of testes
 Maturation site and initial storage of sperm cell (100 million sperms)
 Average of 12 days for sperm to move through the coils of the epididymis

 A long, coiled tube that rests on the backside of each testicle

 It transports and stores sperm cells that are produced in the testes
 It also is the job of the epididymis to bring the sperm to maturity, since the sperm that emerge
from the testes are immature and incapable of fertilization. Takes 12 to 20 days for the sperm
to travel the length of epididymis, 64 days to reach maturity
 During sexual arousal, contractions force the sperm into the vas deferens.

Matured sperm
 Spermatozoa (constitute 5% of total semen volume)
 Pear-shaped head with a long tail (matured)
 Each ejaculation of 2-5ml contains 20-120 million sperm per ml
 Remains viable 2 to 3 days (average 48hours)

Motility is the most significant criterion when assessing male infertility

Vas deferens/Ductus deferens

 Vessel carrying sperm cell away from epididymis to ejaculatory duct
 Arterial blood supply is by superior vesical artery
 Site for male sterilization procedure known as vasectomy
 Is a long, muscular tube that travels from the epididymis into the pelvic cavity, to just
behind the bladder, the vas deferens transports mature sperm to the urethra in preparation
for ejaculation.

Ejaculatory duct
 Located between the seminal vesicles and urethra
 These ducts are formed by the fusion of the vas deferens and the seminal vesicles. The
ejaculatory ducts empty into the urethra.

Seminal vesicles
 Seminal fluid (60% of the total seminal volume)
 Essential for the nourishment of sperm cell
 Male accessory gland located below/behind urinary bladder
 Each vesicle is a coiled and folded tube

8
  Normally appears like a honeycomb

 Are sac-like pouches that attach to the vas deferens near the base of the bladder. The
seminal vesicles produce a viscous secretion or make a sugar-rich fluid (fructose) that
provides sperm with a source of energy and helps with the sperms’ ability to move
(motility). The fluid of the seminal vesicles makes up most of the volume of your
ejaculatory fluid.

Prostate gland
 Production of 30% of prostatic fluid
 Responsible for coagulation and liquefaction of semen
 Organ involved in BPH and prostate cancer
 Shape: walnut, doughnut oval or chestnut-shaped gland
 Three layers of tissue: transition zone, central zone, peripheral zone
 Anterior to the rectum and posterior to symphysis pubis, just below bladder
 Testosterone and dihydrotestosterone regulate prostate growth/function
 Examination to screen prostate problems
 Is a walnut-sized structure that’s located below the urinary bladder in front of the rectum.
The prostate gland contributes additional fluid to the ejaculate. Prostate fluids also help to
nourish the sperm and enhance sperm motility and lubricate the urethra during sexual
activity. The urethra, which carries the ejaculate to be expelled during orgasm, runs
through the center of the prostate gland.

Cowper’s gland
 Cleanse and prepares urethra
 Other name: bulbourethral glands
 Works to lubricate the urethra
 Pre-ejaculate fluid
 Exocrine glands located posterolaterally to urethra
 Responsible for the 5% of seminal volume
 Size: pea –size gland located on the sides of the urethra, just below the prostate gland.
These glands produce a clear, slippery fluid that empties directly into the urethra. This
fluid serves to lubricate the urethra and to neutralize any acidity that may be present due
to residual drops of urine in the urethra.

Urethra
 Urogenital structure
 Responsible for passage of both urine and sperm
 It connects bladder base to the urethral meatus
 Normal length: 18-20cm
 Escherichia coli (E. coli) is the most common cause of UTIs

LESSON 2: FEMALE PELVIS

 The Female Bony Pelvis

The female pelvis is adapted for childbirth and has a wider and flatter shape than the male
pelvis. The pelvis is made up of pairs of bones, which fuse together, so tightly that the joints are
hard to see.
 Ilium is the major part and the largest part of the hip bone, it is broad and fan-shaped.

9
  Ischium is the thick lower part of the pelvis, formed from two fused bones — one on
either side. The ischial spines are smaller and rounder in shape in the woman’s pelvis than
in that of the man.
 The pubic bones on both sides form the front part of the pelvis. The two pubic bones
meet in the middle at the pubic symphysis. (The symphysis is a very strong lump that
sticks together.)
 Sacrum is a tapered, wedge-shaped bone at the back of the pelvis, consisting of five fuse
vertebrae (the small bones that make up the spinal column or spine).

 Pelvic Canal

The roughly circular space enclosed by the pubic bones at the front, and the ischium on either
side at the back, is called the pelvic canal — the bony passage through which the baby must pass.
This canal has a curved shape due to the difference in size between the anterior (front) and
posterior (back) borders of the space created by the pelvic bones.

 The size and shape of the pelvis

The size and shape of the pelvis is essential for labor and delivery. It has a round pelvic brim and
short, blunt ischial spines. This shape is called gynecoid. It is thought to be the most favorable
pelvis type for a natural birth because of its wide and open shape gives the baby considerable
room during delivery.
Pelvic inlet
The pelvic inlet is formed by the pelvic brim. The pelvic brim is rounded, except where the sacral
promontory and the ischial spines project into it.
The pelvic outlet
The pelvic outlet is formed by the lower border of the pubic bones anteriorly and by the lower
border of the sacrum posteriorly.

DAY 4
SUBJECT: MATERNAL AND CHILD CARE
TOPIC: Female Pelvis
LESSON 1:. Diameters of the Pelvis
A. Anteroposterior Diameter (ADP)
 The anteroposterior or conjugate diameter is the distance the pubic symphysis and the
sacral promontory.

Three distances are

 Diagonal conjugate
 Obstetric conjugate
 True conjugate

a. Diagonal Conjugate
 Measured between the sacral promontory and the lower edge /Inferior margin of the pubis
symphysis
 Can be clinically evaluated by I.E
 Used as a baseline to get OB and true conjugate average of 12.5cm

10
b. Obstetric conjugate
 Measured from the sacral promontory to the point bulging the most on the back of the
symphysis pubis, located about 1cm below its upper border
 Average of 10.5 cm or more
 Most critical measurement and shortest anteroposterior diameter of the pelvis
 The obstetrical conjugate is computed by subtracting 1.5 to 2.0 cm from diagonal
conjugate

c. True conjugate
 Also known as conjugate Vera and anatomical conjugate
 Measured between the sacral promontory and upper edge of symphysis pubis and average
of 11.0 cm
 Cannot clinically evaluated or not measured by I.E

B. Transverse Diameter (anatomical) – 13 cm

 At right angle to obstetrical conjugate
 Greatest distance between linea terminal on either side
 Intersects the obstetrical conjugate at a point above 4 cm in front of promontory
o Posterior sagittal diameter of inlet – is the segment of the obstetrical conjugate
from the intersection of these two lines to the promontory
C. Oblique Diameter
 Right oblique diameter – from the right sacroiliac joint to the left ileopectineal eminence
= 12cm
 Left oblique diameter – from the left sacroiliac joint to the right ileopectineal eminence =
12cm

Pelvic Ligaments
 Broad ligament
The broad ligament supports the uterus, fallopian tubes, and ovaries. It extends to both sides
of the pelvic wall.
The broad ligament can be further divided into three components that are linked to different
parts of the female reproductive organs:
 Mesometrium, which supports the uterus
 Mesovarium, which supports the ovaries
 Mesosalpinx, which supports the fallopian tubes

 Uterine ligaments
Uterine ligaments provide additional support for the uterus. Some of the main uterine
ligaments include:
 The round ligament
 Cardinal ligaments
 Pubocervical ligaments
 Uterosacral ligaments
 Ovarian ligaments
The ovarian ligaments support the ovaries. There are two main ovarian ligaments:
 the ovarian ligament
 the suspensory ligament of the ovary

11
The bony pelvis is held together with the support of the 3 vertebropelvic ligaments.
1. Iliolumbar ligament
2. Sacrospinous ligament
3. Sacrotuberous ligament

These ligaments, amongst others, provide critical, structural support and connection of various
tissues in and around the pelvis.

The iliolumbar ligament is composed of thick and strong fibrous bands of connective tissue
originating from the tip of the transverse process of the fifth lumbar vertebra and stretching out to
the posterior part of the inner lip of the iliac crest. They stabilize and strengthen the lumbosacral
joint

The sacrotuberous ligament is a fan-shaped fibrous band of connective tissue. It runs from
the sacrum and the upper coccyx to the tuberosity of the ischial tuberosity in the human pelvis

The Sacrospinous ligament is a triangular band of connective tissue that attaches to the ischial
spine of the ischial bone and the lateral side of the sacrum and coccyx in the human pelvis. The
sacrospinous ligament divides the greater sciatic notch to the greater sciatic for a men and the
lesser sciatic foramen.

LESSON 2: TYPE OF PELVIS

Four types of female pelvis were described. The majority of pelvis are of mixed types:
a. Gynecoid – the genuine female pelvis – most common/prevalent type round brim
 Pear-shaped pelvis
o Most favorable pelvis for vaginal delivery
 Ischial spine; blunt non prominent
 Pubic arch: more than 90 degree angle wide arch

b. anthropoid – Ape-like pelvis

 2nd most favorable for vaginal delivery
 It shows and favors passage of OP fetus
 Has an oval brim and a slightly narrow pelvic cavity
 Anteroposterior diameter (APD): wide
 Transverse diameter: narrow

c. Android
 Male pelvis
 Heart shaped brim/apple shaped pelvis
 Triangular inlet with convergent side walls poor prognosis for vaginal delivery
 Ischial spines: usually prominent and encroaching
 Pubic arch: less than 90 degrees and narrow

d. Plattypelloid – rarest/least type of pelvis

 Flat pelvis
 APD narrow/short
 Transverse diameter: wide
 Kidney bean shaped brim

The bony pelvis is held together with the support of the 3 vertebropelvic ligaments.

12
 1. Iliolumbar ligament
2. Sacrospinous ligament
3. Sacrotuberous ligament
These ligaments, amongst others, provide critical, structural support and connection of various
tissues in and around the pelvis.

DAY 5&6
SUBJECT: MATERNAL AND CHILD CARE
TOPIC: Human sexuality and sex health intervention
LESSON 1:. Physiology of Menstruation

A. PHYSIOLOGY OF MENSTRUATION
The monthly physiological changes take place in the ovaries and the uterus and is regulated by
hormones produced by the hypothalamus, anterior pituitary gland and ovaries. These monthly
cycles commence at puberty and occur simultaneously and together are known as the female
reproductive cycle.

Two types of Menstrual Cycle

1. Ovarian Cycle – changes in the ovaries

 Follicular phase
 Ovulation phase
 Luteal phase

 The ovarian cycle refers to the series of changes in the ovary during which the follicle
grows and matures, the ovum is shed, and the corpus luteum forms and develops
Phases Days Events
Follicles released by APG
Ovarian follicles begins to mature into a Graafian
follicle
Level of estrogen hormone is high
Follicular 0-13 Late follicular phase: very high estrogen
Increase in endometrial thickness

13
 Corresponds to proliferative phase of the uterine cycle
LH surge before ovulation
Estrogen levels drop rapidly just before ovulation
Ovum is the product of ovulation
Viable up to 24 hours in the fallopian tube (24-48
hours)
Ovulation 14th day Usually, 14 days before the start of the next
menstruation
Must be fertilized by a sperm cell within 12-14 hours
 Mittelschmerz – mild abdominal pain during
ovulation

Lasts for 14 days, occurs right after ovulation

Under LH and progesterone influences
Thickened and sustained endometrium
Luteal 15-28 days Empty follicle develops into corpus luteum
Uterus is prepared for pregnancy
Massive rise in progesterone

2. Uterine Cycle – changes in uterus

 Menstrual phase
 Proliferative phase
 Secretory phase

Premenstrual syndrome refers to emotional and physical symptoms that regularly occur in
the one or two weeks before the start of each menstrual period.
Menstruation – periodic discharge of blood, fluid, endometrial cellular debris from the
uterus.
Structures involved in Menstrual Cycle:

 Hypothalamus – releases gonadotropin-releasing hormone (GnRH)

 Anterior pituitary gland – secretion of FSH and LH
 Two ovaries – production of oocytes (eggs) and hormones ( Estrogen and Progesterone
 Endometrium of uterus

Hormones involved in menstrual cycle

Secreted from Function

Hormones
GnRH Hypothalamus  Stimulates APG to produce FHS and LH
FSH APG  Stimulates maturation of ovarian follicles
 Stimulates estrogen production
LH APG  Stimulates release of matured follicle
 Surge before ovulation (11-13th day of cycle)
 Development of corpus luteum
 Stimulates progesterone secretion
Estrogen Follicles  Dominant hormone during proliferative

14
 Progesterone Corpus luteum  Dominant hormone during Secretory
Phase/Luteal Phase
 Maintains thickness of endometrial lining
 Progesterone inhibits GnRH, LH release
(negative feedback)

LESSON 2: Phases of menstrual cycle

 Phase 1 – menstrual phase (day 1-5)
 Menstrual or destructive phase
 Estrogen is low
 Normal blood loss is 10-80ml (average of 60ml)
 Sloughing off of the 2/3 of stratum functionalis of endometrium

 Phase 2 – Proliferative phase (day 6-14)

 Proliferative and vascularization
 Regeneration, restoration of the endometrium
 Ovarian follicles produces estradiol
 Length varies among women
 Increasing amount of estrogen
 Follicles in the ovaries matures
 Estrogenic phase (estrogen is the main hormone)
 Release of clear, thin watery, stretchy, elastic cervical mucus
 Antral follicles/Graafian follicles matured
 Thickening of endometrium 98-10 fold increase
 Endometrial stroma become richly vascularized

 Phase 3 – Secretory phase (day 15-28)

 Saw-toothed/serrated appearance of the gland
 Endometrial tortuosity (spiral arteries have begun to coil)
 Cork-screw shaped endometrial glands
 Rich in glycogen and mucin secretions by the spongy glands
 Endometrial thickness is maintained by progesterone
 The most ideal time for implantation/pregnancy
 Ovarian corpus luteum (yellow body) secretes progesterone
 Role of progesterone: for implantation and successful pregnancy
 Yes! It is the progesteronic phase

Take note: if fertilization does not occur, the secretory endometrium goes into an ischemic or
premenstrual phase during the last 2 days of the menstrual cycle
Definition of Terms/Menstrual Abnormalities
 Menarche – the first occurrence of menstruation or menstrual cycle
 Eumenorrhea – normal menstruation with 10 or more periods per year
 Amenorrhea – absence of menstrual cycle for 3 or more months
 Menorrhagia – bleeding that occurs at normal intervals but with heavy flow (more than
80cc) or duration (more than 7 days)

15
  Metrorrhagia – frequent and irregular uterine bleeding of varying amounts but not
excessive volume or duration
 Menometrorrhagia – bleeding occurs at irregular, noncyclic interval and with heavy
flow more than 80cc) or duration (more than 7 days)
 Polymenorrhea – regular bleeding at shorter intervals (less than 21 days)
 Oligomenorrhea – menstrual cycle length of longer than 35 days
 Dysmenorrhea – pain left during menstruation

Two types
 Primary dysmenorrhea – pain during menstruation where the patient feels a lower
abdominal pain that radiates to her back down to her thighs, without any pathological
cause.
 Secondary dysmenorrhea – pain caused by other medical conditions, most often
endometriosis
 Endometriosis – endometrial tissue implants outside the uterus

Definition of Terms/Menstrual Abnormalities

 Menarche – the first occurrence of menstruation or menstrual cycle

 Eumenorrhea – normal menstruation with 10 or more periods per year
 Amenorrhea – absence of menstrual cycle for 3 or more months
 Menorrhagia – bleeding that occurs at normal intervals but with heavy flow (more than
80cc) or duration (more than 7 days)
 Metrorrhagia – frequent and irregular uterine bleeding of varying amounts but not excessive
volume or duration
 Menometrorrhagia – bleeding occurs at irregular, noncyclic interval and with heavy flow
more than 80cc) or duration (more than 7 days)
 Polymenorrhea – regular bleeding at shorter intervals (less than 21 days)
 Oligomenorrhea – menstrual cycle length of longer than 35 days
 Dysmenorrhea – pain left during menstruation

Two types

 Primary dysmenorrhea – pain during menstruation where the patient feels a lower
abdominal pain that radiates to her back down to her thighs, without any pathological
cause.
 Secondary dysmenorrhea – pain caused by other medical conditions, most often
endometriosis
 Endometriosis – endometrial tissue implants outside the uterus
 Endometriosis – endometrial tissue implants outside the uterus

DAY 7
SUBJECT: MATERNAL AND CHILD CARE
TOPIC: Fertilization, Implantation, and the Fetal and Placental
Circulation
LESSON 1:. Male and Female Sex cells

16
a. Male Sex cells: Gamete/Sperm
Sperm cells are gametes (sex cells) made in the testicular organ (gonad) of men.
The general morphology of sperm cells consists of the following components:
 Distinctive head
 Midpiece (body)
 Tail

b. Female Sex Cells: Ova/egg cell

Egg cells or ova, are the cells used by female to produce offsprings. Egg cells are made of the
following parts.

 The corona radiata

 The cytoplasm
 The zona pellucida (egg wall)
 The nucleus

 Fertilization and ovum Implantation

Chronological Sequence of fertilization

 Fertilization fusion of ovum and sperm on day one
 Morula: solid ball of cells after three days
 Blastocyst: hollow ball of cells after five days
 Trophoblast: forms early embryo, fetal membranes and placenta after five to seven days
 Embryo: the developing human from fertilization to the eighth week of pregnancy
 Fetus: the developing human from nine weeks of pregnancy to birth at around 40 weeks
 Neonate: newborn baby from birth to 28 days old
 Infant: baby or young child aged less than one year.

Implantation
Once the embryo reaches the blastocyst stage, approximately 5 to 6 days after fertilization, it
hatches out of its zona pellucida and begins the process of implantation in the uterus. The
implantation site is usually in the upper and posterior walls in the midsagittal plane of the uterus.

Implantation consists of three stages

a. Apposition - the blastocyst contacts the implantation site of the endometrium
b. Adhesion - trophoblast cells of the blastocyst attach to the receptive endometrial epithelium
c. Invasion - invasive trophoblast cells cross the endometrial epithelial basement membrane and
invade the endometrial stroma

Fetal structures
Decidua – specialized endometrium
Decidua basalis
 Innermost portion of the layer which rests directly under the embryo, remains after
delivery to give rise for a new endometrium.
Decidua capsularis
 Encapsulates the trophoblast
Decidua vera
 Becomes the remaining portion of the uterine lining, and sheds as the lochias
Chorionic villi - Syncytiotrophoblast or syncytial layer

17
  Produces hormones such as hPL, hCG, estrogen, and progesterone
 Cytotrophoblast or Langhan’s layer
 Protects the fetus against infectious diseases like syphilis as the lochias

LESSON 2: FETAL, MATERNAL AND LLACENTAL

CIRCULATION
Oxygenated blood: Blood that carries enough oxygen and nutrients to the cells, tissues and
organs of the body to function normally.
Deoxygenated blood: Blood that contains less oxygen and a higher proportion of dissolved
wastes and carbon dioxide than is found in oxygenated blood.
Umbilical arteries: The arteries usually carry oxygenated blood, but the two umbilical arteries
collect deoxygenated blood from the fetal body and carry it to the placenta. Blood in the umbilical
arteries is pumped into the placenta by the fetal heart.
Maternal veins: The mother’s veins collect deoxygenated blood from the placenta; as the blood
passes through her liver and kidneys, dissolved wastes are removed-including those collected
from the placenta by her endometrial veins. When the deoxygenated blood reaches the mother’s
heart, it is pumped to her lungs to pick up more oxygen.
Maternal arteries: The mother’s arteries carry oxygenated blood around her body, pumped by
her heart. Her endometrial arteries bring blood to her uterus and into the placenta, delivering
oxygen from the mother’s lungs, and nutrients from her digestive system.
Umbilical vein: Veins usually carry deoxygenated blood, but the single umbilical vein carries
oxygenated and nutrient-rich blood from the placenta and delivers it to the fetal heart, which
pumps it around the body of the fetus.

Development and circulation of the fetus and placental function

Stages of Fetal Development

Heart begins to beat around 14-28 days

1 month Extremities like tiny buds
( 4 weeks) Amniotic sac
Rudimentary senses
Tiny like a grain of rice
Cartilage are replaced by bones
2 month Neural tube (brain and spinal cord)
(8 weeks) Sense organs are forming
Urinary and circulatory system is working
Reproductive organs are developing
3 month Increase urine production
(12 weeks) Nose, mouth, lips, ears, tooth buds and eyelids form
Extremities, fingers and toes are formed
Sucks its thumb, swallow and removed around
4 month Eyebrows and eyelashes developing
(16 weeks) X x – Girl, or Xy – Boy (sex identifiable by utz)

Hair
5 month Actively moves
(20 weeks) Vernix caseosa and lanugo
Eyebrows and eyelashes
Quickening

18
 Hiccups
6 month Enjoy music
(24 weeks) Active hearing
Responds to mothers voice
Sleep wake patterns and surfactants begins to form
Taste buds develops
Accelerated fat deposition
7 month Surfactants develops
(28 weeks) Testis descent (right first0
Epidermis (skin) is still wrinkled and red
Startle with loud noises (reacts by jerking reflex)
Testes completely descended
8 month Achieved 2:1 ratio of Lecithin and Sphingomyelin
(32 weeks) Reduce risk of infection (IgG and IgM)
Toe nails and finger nails become longer
Lung alveoli maturation
Energy and iron begins to store
Foot creases
Aging of placenta begins
9 month Lightening occurs
(36 weeks) Lanugo starts to diminish
Stores glycogen, iron, CHO, calcium

Table: Milestones of Fetal Development

DAY 8
SUBJECT: MATERNAL AND CHILD CARE
TOPIC: Fertilization, Implantation, and the Fetal and Placental
Circulation
LESSON 1:. FETAL CIRCULATION
During pregnancy, the fetal circulatory system works differently than after birth:

Fetal blood follows this pathway:

 Oxygen and nutrients from the mother’s blood are transferred from the placenta to the
fetus through the umbilical cord.
 This enriched blood flows through the umbilical vein to the fetus liver. There it passes
through a shunt called the ductus venosus.
 It allows some of the blood to go to the liver. But most of this highly oxygenated blood
flows into a large vessel called the inferior vena cava and then into the right atrium of
the heart.

19
  When oxygenated blood from the mother enters the right side of the heart it flows into the
upper chamber (the right atrium). Most blood flows into the left atrium through a shunt
called the foramen ovale.
 From the left atrium, blood moves down into the lower chamber of the heart (the left
ventricle). It's then pumped into the first part of the large artery coming from the heart
(the ascending aorta).
 From the aorta, the oxygen-rich blood is sent to the brain and to the heart muscle
itself. Blood is also sent to the lower body.
 The blood that returns to the heart from the fetal body contains carbon dioxide and waste
products as it enters the right atrium. It flows down to the right ventricle, where it is
normally sent to the lungs for oxygen. Instead, it passes through the lungs and flows
through the ductus arteriosus into the descending aorta, which connects to the umbilical
arteries. From there, blood flows back to the placenta. There carbon dioxide and waste
products are released into the mother’s circulatory system. Oxygen and nutrients from the
mother’s blood are transferred to the placenta. Then the cycle begins again.

LESSON 2: PLACENTA
The placenta is formed during pregnancy. It grows in the uterine wall next to the fetus. This organ
plays an invaluable role in fetal growth and development for it serves as nutrition and protection
of the fetus.

Placenta is a fetomaternal organ. It has two parts:

Fetal part – develops from chorionic sac – chorion frondosum
Maternal part – derived from the endometrium – the functional layer – decidua basalis

Parts of the Placenta

 Umbilical cord - twisted cable that connects the fetus to the placenta and carries the two
umbilical arteries and a single umbilical vein
 Amnion - innermost covering of amniotic cavity.
 Chorion - connective tissue membrane containing fetal vessels, internal to amnion,
external to villi.

Placental Function
The placenta plays numerous functions for fetal development that can be identified by pneumonic
serpent
o Storage
o Endocrine
o Respiration
o Protection
o Excretion
o Nutrition
o Transfer of substances

Anatomical variations of the placenta and the cord

1. Succenturiate lobe of placenta

2. Battledore cord insertion

20
3. Circumvallate lobe of placenta
4. Velamentous insertion of the cord.
5. Bipartite Placenta

The Amniotoc Fluid and its Function

Amniotic fluid is the fluid that surrounds the fetus during pregnancy. It’s very important for the
fetus development.
The fluid serves as:
 Protecting the fetus
 Temperature control
 Infection control
 Development of the lungs and digestive system
 Muscle and bone development
 Lubrication
 Umbilical cord support

DAY 9
SUBJECT: MATERNAL AND CHILD CARE
TOPIC: Change and Adaptation in Pregnancy
LESSON 1:. Signs and Symptoms of Pregnancy

Signs and Symptoms of Pregnancy

Pregnancy indications based on physical and hormonal changes associated with pregnancy are
generally classified into three groups.

Presumptive signs and symptoms of pregnancy – these changes may be noticed by the mother
and health care provider but are unreliable and considered subjective and recorded under the
history of presence of illness.
 Leukorrhea
 Amenorrhea/missed menstruation .
 Nausea and vomiting
 Tiredness/fatigability
 Increase size of breast
 Quickening
 Urinary frequency
 Increase size of breast
 Skin changes/pigmentation

21
Probable signs and symptoms of pregnancy – these changes are usually noted by the health
care provider but are still unreliable or not conclusive for pregnancy but considered as objective
and recorded as physical assessment findings.
 Chadwick’s sign
 Hegar’s sign
 Uterine growth
 Positive pregnancy test
 Ballottement
 Uterine soufflé
 Goodel’s sign
 Fetal outline
 Braxton Hick’s contraction

Positive signs of pregnancy – these are the confirmed or definitive signs of pregnancy
 Fetal heat tone
 Fetal movement
 Funic soufflé
 Fetal outline

LESSON 2: DIAGNOSIS OF PREGNANCY

Pregnancy diagnosis requires a multifaceted approach using the three main diagnostic tools such
as:
 History and physical assessment
 Hormonal test
 Ultrasound
Currently, obstetricians can use all of these tools to diagnose pregnancy in early pregnancy and to
help prevent other pathologies.

History and physical assessment

The diagnosis of pregnancy is traditionally made from history and physical examination.
Important aspects of menstrual history should be obtained. The woman should describe her usual
menstrual pattern, including the date of onset of the last menses, duration, flow, and frequency.
Items that may confuse the diagnosis of early pregnancy are an atypical late menstrual period
(LMP), contraceptive use, and history of irregular menses.

Hormonal test/Immunological test

HCG – Human chorionic gonadotropin – is a hormone produced by the placenta when a woman is
pregnant. It can be measured in the urine.
Immunological test

 Principle of pregnancy test – detection of the antigen of HCG present in the maternal
urine serum
 Selection of time – 8-10 days after conception
 Collection of urine – the first voided urine in the morning in a clean container

Ultrasonography

 There are transvaginal and abdominal ultrasonography

 A gestational sac can usually be identified at 5-6weeks after the beginning of the last
period.

22
  Fetal heart beating can be detected by about 7th week and fetus itself can be seen by about
8th week
 Doppler is also an ultrasound technique, which diagnoses the pregnancy by revealing the
beating

LESSON 3: Physical and Psychological changes during pregnancy

Reproductive
a. Vagina
 Increased blood supply may cause a bluish color (Chadwick’s sign)
 pH is acidic due to increased production of lactic acid (3.5-6)
 Take note and report the following unusual findings:
 Foul discharges – infection
 Itchiness – vaginitis
 Cheesy patches – candidiasis
 Fishy discharges – vaginosis - an imbalance of the bacteria that are normally present
in the vagina
 Frothy – trichomoniasis
b. cervix
 Softens and loosens in preparation for labor and delivery (Goodell’s sign)
 Mucous production increases and plug (Operculum) is formed as bacterial barrier to
bacteria to prevent the entry of microorganisms into the uterus (due to increased
progesterone)
 Remember this:
 During pregnancy, progesterone makes the cervical mucus a thick, sticky fluid
that protects the growing fetus from any invading microorganisms
c. Uterus
 Increased vascularity and softening of isthmus (Hegar’s sign)
 Mild contractions (Braxton hick’s sign) beginning in the fourth month

Gastrointestinal
 Morning sickness (nausea and vomiting)
 Ptyalism: known as sialorrhea gravidarum
 Pyrosis also known heartburn
 Constipation
 Craving
Cardiovascular
 Cardiac output increases throughout pregnancy
 Blood Pressure
 Anemia
 Supine hypotensive syndrome
 Hemorrhoids
 Varicose veins
Respiratory
 Dyspnea
 Epistaxis
Integumentary
 Palmar erythema
 Melesma/chloasma
 Linea nigra
 Striae gravidarum
Musculoskeletal
 Muscle cramps

23
  Dependent edema
Musculoskeletal
 Lordosis/sway back
 Back pain/backache
Genitourinary
 Bladder
 Urinary frequency, incontinence
Endocrine
 FSH and LH are greatly reduced; oxytocin is secreted during labor and after delivery, the
prolactin responsible for the initiation and continuation of lactation
 Progesterone secreted by corpus luteum until formation of placenta
 HPL produced by placenta that prepares breasts for lactation
 Ovaries secrets relaxin during pregnancy
 Prolactin responsible in milk production and oxytocin is responsible in milk ejection

DAY 10
SUBJECT: MATERNAL AND CHILD CARE
TOPIC: Change and Adaptation in Pregnancy
LESSON 1:. Psychological Changes during Pregnancy

 Ambivalence
 Occurs early in pregnancy
 Mother is self-centered, baby is part of her
 Grandparents are usually the first relatives to told of the pregnancy
 Acceptance
 The woman’s readiness for the experience and her identification with the
motherhood role
 Emotional lability
 Changes in emotional state or extreme
 Body image changes
 Perception of image either positive or negative
 Related to the physical changes and symptoms
Psychologic task of the mother
 Ensures safe passage of pregnancy, labor and birth
 Seeking acceptance of the child from others
 Finding communication and self-acceptance as a mother to the infant.

First trimester
 Ambivalence/denial
 Accept the biological facts or reality of pregnancy
 Focus on changes in the body of pregnancy and nutrition

Second trimester
 Accepts growing fetus as baby to be nurtured
 Growth and development of fetus

Third trimester
 Birth preparation, parenting
 Prepare baby’s layette
 Attendance in Lamaze classes

24
Minor discomforts for pregnancy

A. First trimester
Discomforts
a. Nausea/vomiting
b. Urinary frequency
c. Fatigue
d. Breast tenderness
e. Increased vaginal discharge
f. Nasal stuffiness/ nosebleed
g. Ptyalism
Reason/cause
HCG, CHO metabolism, emotions and fatigue
Pressure on the bladder
Specific cause unknowably due to nocturia
Estrogen and progesterone
Hyperplasia of vaginal mucosa, endocervical mucus
production (estrogen)
Estrogen
Specific cause unknown

B. Second trimester
a. Heartburn Progesterone, motility, relax cardiac sphincter,
regurgitation
b. Ankle edema Standing/sitting, sodium level, lower extremities
circulatory congestion, increase capillary permeability,
and varicose veins
c. Varicose veins Venous congestion, hereditary, increase age and weight
gain
d. Hemorrhoids Constipation and pressure on hemorrhoid veins
e. Constipation Progesterone, pressure on intestine, iron supplement, diet,
lack of exercise and decreased fluid
f. Backache Curve of lumbosacral vertebrae, hormone, fatigue, poor
body mechanics
g. Leg cramps Calcium/phosphorus ratio, pressure on nerves, fatigue,
poor circulation

C. Third trimester

a. Faintness Postural hypotension, standing for long periods and

anemia
b. Dyspnea Decreased vital capacity from pressure of gravid uterus
c. Flatulence GI motility and emptying, pressure on large intestine, air
swallowing
d. Carpal tunnel syndrome Compression of median nerve in carpal tunnel of the wrist
or repetitive movement

LESSON 2: ANTENATAL CARE

 Refers to the health care given to a woman and her family during pregnancy
Antenatal care
 The primary goal of antenatal care is to provide maximum health to expectant mothers
and their babies.

a. Goals of prenatal care

 Ensures a healthy and uncomplicated pregnancy and the delivery of a healthy baby
 Identifies and treats high risk conditions
 Individualizes patient care
 Assists the patient for her preparation for labor, delivery and puerperium

25
  Screens and identifies risk factors or diseases that may affect the mother or the baby’s
health and life
 Reinforces healthy habits to the woman and her family

b. Components of prenatal care at Barangay Health Station

 History taking
 Physical examination per visit
 Weight, height, BP, examination of conjunctiva and palms for pallor
 Abdominal exam for fundal height, fetal position and presentation and fetal heart
tone
 Examination of face, hands, lower extremities for edema, breast, thyroid for
enlargement and goiter (one capsule of iodized oil a year for goiter endemic area
 Treatment disease
 Prophylaxis against malaria: in malaria infected area, all pregnant women shall be
given prophylaxis in the form of chloroquine (150mg) 2 tablets per week during
the entire week of pregnancy.
 Tetanus toxoid Immunization
Tetanus Immunization Schedule for Pregnant Women
Vaccine When to Give Dose Route Site Number of
years
protection
TT1 Early in 0.5 ml Intramuscular Upper arm (deltoid Zero
pregnancy muscle) protection
TT2 4 weeks after 0.5 ml Intramuscular Upper arm (deltoid 3 years
TT1 muscle)
TT3 6months after 0.5 ml Intramuscular Upper arm (deltoid 5 years
TT2 muscle)
TT4 1year after 0.5 ml Intramuscular Upper arm (deltoid 10 years
TT3 muscle)
TT5 1year after 0.5 ml Intramuscular Upper arm (deltoid Life time
TT4 muscle)
 Supplementation
 Iron supplementation from 5 months of pregnancy to two months postpartum
100-200mg simple iron salts for 210days to prevent anemia
 Iodine supplementation in the form of one iodine capsule a year to prevent goiter
 Health education
 Prenatal visits: First visit in the first trimester, as soon as mother missed a
menstrual period when pregnancy is suspected
 Every 4 weeks – first 28-32 weeks
 Every 2 weeks – from 32-36 weeks
 Every week – from 36-40 weeks
 Prenatal contacts (2016 WHO ANC Model)
 Eight prenatal contacts
 First trimester
 Contact 1: up to 12 weeks
 Second trimester
 Contact 2 – 20 weeks
 Contact 3 – 26 weeks
 Third trimester
 Contact 4 – 30 weeks
 Contact 5 – 34 weeks
 Contact 6 – 36 weeks

26
  Contact 7 – 38 weeks
 Contact 8 – 40 weeks
 Return for delivery at 41 weeks if not given birth
 Laboratory examination/ hospital laboratories and diagnostic examination
 Heat and acetic acid test for albuminuria
 Benedict’s test for glycosuria
 Ultrasound – first ultrasound before 24 weeks
 Urinalysis
 Complete blood count (CBC)
 Oral glucose test
 Oral dental examination except in BHS
 Referral when necessary
 Deliveries
 Birthing homes
 Hospitals

c. Procedures during pregnancy

 Baseline data collection ( age, sex, occupation, educational background, identify risk
conditions or factors
 History taking
 Complete PE
 Laboratory tests
 Fetal assessment to ascertain fetal well-being and or fetal maturity

Subsequent clinic visits

 Maternal assessment
 Blood pressure
 Weight and edema assessment
 Nutrition and appetite, discomforts of pregnancy, signs and symptoms of
pregnancy, danger signals
 Other problems and concerns of the woman
 Fetal assessment
 Fetal heart rate
 Quickening and presence of daily fetal movement after 20 weeks
 Fundal height to estimate fetal growth
 Specific assessments as indicated
 Abdominal palpation after 24 weeks to determine lie, position and presentation
 Late in pregnancy: vaginal examination is performed to obtain data about
presenting part, pelvic measurement, cervical effacement and dilatation and station
 Health teachings
 Normal signs and symptoms of pregnancy
 Minor discomforts, prevention and management
 Danger signs and symptoms
 Nutrition and diet
 Rest, exercise and relaxation
 Avoidance of drugs, alcohol, cigarettes and too much caffaine
 Clothing
 Sexual relations
 Employment
 Travel
 Preparation for baby’s birth, labor, delivery and puerperium

d. Estimating date of pregnancy

27
  Once pregnancy is confirmed, it is imortant to next determine the age of gestation and
the EDD/EDC/EDB


Parameters that can be used to estimate EDC and measure duration of pregnancy
 LMP
 Naegele’s rule – count back three calendar months from the first of
LMP then add 7 days
 If LMP falls between January to march you can do this;
 Add 9 to month of LMP and add 7 to day of LMP
Example: If the first day of a woman’s LMP was January 22, 2021. When is her EDC?

January is the first month in the calendar

01 22 2021
+9 +7______
10 29 2021 therefore the EDC will be on October 29, 2021

 If LMP falls between April to december you can do this

 Subtract 3 to month of LM, add 7 to days of LMP and add 1 to year
 Keyword: -3 +7, +1

Example: if the first day of a woman’s LMP was on June 07, 2021. When is her EDC?

06 07 2020
-3 +7 +1
3 14 2021 therefore the EDC will be on march 14, 2021

 Estimated gestational age or AOG determination

 Mc Donald’s rule – measure fundal height from symphysis pubis to top of
uterine fundus
 First action: empty bladder first
 Position woman lie on her back with knees slightly flexed
 Equipment is tape measure in centimeter
 Formula
AOG in weeks = FH in cm x 8/7
AOG in monthhs = FH cm x 2/7
 Take note:
Larger than date uterus may indicate
 Maternal hydramnios
 Molar pregnancy
 Multiple pregnancy
 Macrosomic baby
 Miscaculated AOG
Smaller than date uterus may indicate
 Small gestation age baby
 Missed abortion
 Anomalous baby
 Length miscalculation
 Low amniotic fluid (oligohydramnios)

Date of check up: Trick: just sum up the days between the LMP to check up date of a
woman.

28
Example: a pregnant woman with LMP of January 22 came for a clinic visit on april 19. The
mother is how many weeks pregnants?

January is 31 days
-22 (22 is the LMP)
9 days for the month of January
28 days for the month of February
31 days for the month of March
19 days for the april (date of checkup)
87 days /7days in a week = 12 3/7 weeks AOG

 Bartholomew’s rule - calculate the estimated age of gestation of a fetus in

relation to the height of the fundus

According to this method, all you need to remember are 3 landmarks

 Symphysis pubis
 Umbilicus/navel
 Xiphoid process

12 weeks – level of symphysis pubis

16 weeks – midway between symphysis pubis and umbilicus
20 weeks – level of umbilicus
28 weeks – midway/between umbilicus and xiphoid process
36-38 weeks – xiphoid process

DAY 10
SUBJECT: MATERNAL AND CHILD CARE
TOPIC: Labor and Delivery
LESSON 1: Theories on the Onset of Labor

A. Theories on the Onset of Labor

29
  Prostaglandin Theory - the onset of labor is said to result from the release of
arachidonic acids that produce steroid action on lipid precursors. Arachidonic acid is said
to increase prostaglandin synthesis which in turn causes uterine contractions
 Uterine Stretch Theory – any hollow organ once stretched to its maximum will contract
and expels its content. Releases of oxytocin from the pituitary gland
 Oxytocin Theory - Release of oxytocin from the posterior pituitary glands causes
contraction of the smooth muscles.
 Placental Degeneration Theory – Life span of placenta is 42 weeks, once this
degenerates it stimulates uterine contraction.
 Progesterone Deprivation - Decreasing progesterone level leads to uterine contraction

Factors that Cause Labor

 Uterine muscle stretching
 Pressure on cervix by the presenting part
 Prostaglandin and oxytocin
 Increase in estrogen
 Placental aging
 Rising fetal cortisol level
 Fetal membrane production of prostaglandin
LESSON 2: Premonitory signs of labor
B. Premonitory Signs of Labor
A series of changes occur in the uterus and cervix to speed up the onset of labor and achieve
childbirth. These signs and symptoms begin about 2-3 weeks before the start of labor on
primigravida but only a few days before multigravida.
 Lightening – A drop at the level of the uterus in the last weeks of pregnancy as the head
of the fetus engages the pelvis. Earliest sign approaching labor also known as baby drops
 Braxton Hick’s Contraction – may become more noticeable, may play a part in ripening
of cervix. Intermittent, irregular and painless uterine contraction
 Easier respiration– as the fetal head descent, the pressure on the pulmonary diaphragm
decreases, giving relief from breathlessness.
 Frequent urination - due to increased pressure in the bladder
 Nesting instinct – burst of energy, mothers seems energetic due to a surge in adrenaline
in the final months or weeks of pregnancy. The hormones most likely nest building area-
estradiol and progesterone.
 Bloody show – sign of cervical effacement and dilatation. It occurs as a result of the
softening, dilation and effacement of the cervix. The bloody show will continue and
increase during labor as the cervix continues to dilate and efface.
 Ruptured membrane – most common for admission and your priority is to place the
mother in bed and check FHT. Note the color, odor, amount and time of rupture
(COAT).Confirm ROM is Fern Test (ferning pattern is due to estrogen
 Leukorrhea - expulsion of mucus plug, a thick, whitish or yellowish vaginal discharge.
Due to increasing level of estrogen, the mucus plug thins and dislodged.

LESSON 3: SIGNS OF TRUE LABOR

C. Signs of True Labor

a. True labor contractions – are regular, progressive with increasing duration and intensity and
decreasing internals. The uterine contraction is the primary power in labor. It is the one that
effects the physiologic alterations in labor.

30
  Cervical dilatation – opening/widening/enlarging of the cervical os (external os) from
a pinpoint size opening to 10cm (fully dilated cervix).
 Cervical effacement – shortening/narrowing/thinning of the cervical canal from about
2 to 2.5cm to paper thin or no canal at all.
b. Labor pains/discomfort starts from the back (lumbosacral) radiating to the front and
intensified by walking
c. Show is present and increasing
d. The cervix is open and increasingly dilates and effaces. The presence of cervical dilatation
is the most important sign of true labor.

True Labour False Labour

Contractions are regular and increase in
frequency, intensity and duration
Pain is intensified by walking
Pain starts in the lower back to abdomen
Cervical dilatation is progressive
Show is present and increasing
Contractions are irregular and no increase
in frequency, duration and intensity
Pain is relieved by walking, rest and warm
bath
Pain confines in the abdomen
No cervical effacement and dilatation
Show is absent

DAY 11&12
SUBJECT: MATERNAL AND CHILD CARE
TOPIC: Labor and Delivery
LESSON 1: Stages of Labor

1. First stage - Cervical dilatation/preparatory stage -from the onset of true labor to fully
dilatation of the cervix (10cm)

Phases of First Stage of Labor

a. Latent phase (0-3cm)
 Duration (15-30 seconds)
 Frequency – Every 5-8 minutes; or greater than 10 minutes in early labor
 Intensity – Mild
 Behaviors
 Woman feels able to cope with the discomfort, express feelings of anxiety,
talkative, smiles and is eager to talk about herself, is highly excited and can still
prepare for her things.
 Relaxation measures
 ambulation, diversional activities, light meals and full liquids, void every 2 hours
and can do basic hygiene

b. Active phase (4-7cm)

 Duration (30-45seconds)
 Frequency – 3-5 minutes
 Intensity – Moderate
 Behaviors

31
  Cervical dilatation is rapid, more difficult time, increased in anxiety noted, fear to
lose, may use a variety of coping mechanisms, show and spontaneous rupture of
membrane may occur.
 Relaxation measures
 Coach breathing techniques, encourage effleurage, relaxation techniques,
ambulation, position changes, void every 2 hours, comfort measures No maternal
pushing in first stage of labor until cervix is fully dilated
 They should be discouraged from bearing down until the cervix is fully dilated so
that they do not tear the cervix or waste energy

c. Transitional phase (8-10cm)

 Duration (45-90 seconds), average 60seconds
 Frequency – every 2-3minutes
 Intensity – strong
 Behaviors
 Significant anxiety or panic, resist being touch, restlessness and frequent changing
of position, inner directed or focused on her delivery and tired, has fear of being
alone and has an irresistible urge to push
 Relaxation measures
 Coach breathing techniques such as:
 Slow paced breathing
 Shallow breathing
 Pant-blow breathing
 Non-routine procedures
 Maternal shaving
 Oxytocin to augment labor
 Total restrictions of fluids and food (NPO)
 Having an artificial rupture of membrane (Amniotomy)
 Enema
 Routine IVF insertion
 Transfer of woman from labor room to delivery room
 Primis – cervix is fully dilated
 Multis – cervix is 8cm dilated
 Position during transport: left lateral
 Delivery position
 Lithotomy – used when forceps delivery and episiotomy are to be performed
(stirrups). Lift the patient’s legs slowly and place legs simultaneously into the
stirrups to prevent lumbosacral strain.
 Dorsal recumbent – head of the bed is 35-45º elevated, knees are flexed and feet
flat on bed. This position facilitates the pushing effort of the mother

2. Second stage - Fetal expulsion stage - begins with fully cervical dilatation and ends with the
fetal birth
 Primis – 50- 80 minutes
 Multiparas – 20-30 minutes
 Fetal monitoring – every 5-15minutes
 Crowning – when the fetal head is encircled by the external opening of the vagina, it
means birth is imminent. This signals second stage of labor
 The force exerted by the uterine contractions, gravity and maternal bearing-down efforts
facilitates achievement of the expected outcome of spontaneous, uncomplicated
vaginal birth.
 Modified Ritgen’s Maneuver – is done by covering the anus with a sterile towel and
exert upward and downward pressure to the fetal chin while exerting gentle pressure

32
 with two fingers on the head to control the emerging head. This will not only support
the perineum, thus also favor flexion so that the smallest suboccipitopregmatic
diameter of the fetal head is presented

 Mechanism of labor (ED-FIRE-EE-RE

 Engagement – settling of the head in pelvic brim
 Descent – entrance of biparietal diameter of fetal head to inlet
 Flexion – the chin of the fetus touches chest
 Internal rotation – baby head rotates from transverse diameter to AP diameter
 Extension – the head of the fetus extend towards the vaginal opening
 Restitution (External rotation) – when the head comes out, the body turns from
transverse to AP diameter
 Expulsion – when the head is born, next is the anterior shoulder then posterior
shoulder and the rest of the body follows without much difficulties

 Fetal delivery
 Instruct mother to push during contraction and rest in between
 No fundal pressure or kristeller maneuver
 Facilitate and assist head delivery by modified ritgens maneuver
 Modified Ritgens Maneuver preserves the perineum to prevent massive perineal
laceration
 Immediately after delivery
 Head comes out: check neck for any cord coil
 Wipe mucus or secretions on face (no routine suctioning)
 After calling out the time of birth , your first action is to dry the baby
 After calling out the time of birth and sex of newborn
 1st 30 seconds
 First action: dry the baby immediately (dry, warm towel)
 No wiping out of vernix caseosa
 After 30 seconds
 Initiate skin contact (position the baby prone in mothers abdomen
 Within 1-3 minutes or until cord pulsation stops
 Clamp and cut cord
 Cord clamp: 2cm above base
 2nd clamp: 5cm above base
 No milking of the cord
 No to any substances in the cord (maintain it dry and clean)
 Oozing blood in the cord: apply firm pressure
 Cut with sterile scissor to prevent tetanus infection of the cord
 Take note
 No buttocks and feet slapping
 Provide warmth to newborn by placing it skin to skin contact with mother

LESSON 2: The 5 Ps of Labor and Fetal Presentation

Factors that can prolong or influence the duration of labor
a. Passenger
 Size of the passenger – how big the passenger is?
 Number of passengers – how many passengers are there?
 Position of passenger – What is the position of the passenger?
 Presentation of passenger – What is the presentation of the passenger?
 Fetal head
The largest part of the fetus, found to affect the birthing process

33
 The bones of the skull are connected by membranous sutures, which allow for
overlapping or molding of cranial bones during birth process.
Eight (8) cranial bones
 Temporal (2)
 Sphenoid (1)
 Ethmoid (1)
 Frontal (1)
 Parietal (2)
 Occipital (1)
Sutures – are joint spaces between cranial bones that allow molding of the head
 Frontal – connect the frontal bone
 Sagittal – connect the parietal bone
 Coronal – connect the parietal and frontal bones
 Lambdoidal – connect the parietal and the occipital bones
Fontanelles
 Anterior fontanel – diamond shaped, closes at 12-18 months
 Posterior fontanel – inverted triangle, closes at 2 months
 Fontanels should be flat, soft and firm
Fetal skull diameter/head measurements
 Biparietal diameter – measurement from one parietal prominence to another
(9.25cm)
 Suboccipitobregmantic – measures from the undersurface of the occiput to
the center of the anterior fontanel (9.5cm)
 ccipitofrontal diameter – measures from posterior fontanel to the bridge of
the nose (11cm)
 Occipitomental diameter – measures from the occipital bone to chin/mentum
(13.5cm)
 Fetal Lie - is the relationship between the long axis of the fetus to the long axis of the
mother spine.
 Longitudinal – long axis of the fetus and the mother are parallel to each other
 Oblique/diagonal lie - 45º angle to one another
 Transverse – long axis of the fetus is at right angle to the woman (90º angle to one
another)
 Fetal Position – relationship of the fetal presenting part to the four quadrants of the
maternal pelvis. Occiput anterior are the most favorable normal position.
 Four quadrants of pelvis
 Left occiput anterior (LOA)
 Right occiput anterior (ROA)
 Left occiput posterior (LOP)
 Right occiput posterior (ROP)
 Left occiput transverse
 Right occiput transverse

 Assessment of fetal position

Leopold’s Maneuver – external palpation of the maternal uterus through the abdominal
wall to determine fetal contours.
Leopold’s maneuver can assess the following:
 Presentation
 Attitude
 Lie
 Position
 Actual number of fetuses
 Term level weight
 Engagement

34
 Vaginal examination – located of sutures and fontanels and determination of relationship
to maternal bony pelvis.
Auscultation of the fetal heart tone and determination of quadrant of maternal abdomen
where best heard.

LM Grips Palpate Assessment Normal Abnormal

LM 1 Fundal Upper pole of  Determine Soft mass Hard mass
abdomen consistency,  If mass is  If hard mass is
shape and palpated it means palpated it means
mobility fetal buttocks or fetal head and the
 Assess fetal breech is on the presentation is
presentation, fundal area and breech
fundic height the presentation  If angular mass is
to determine is cephalic palpated it means
age of extremities and the
gestation presentation is
shoulder
LM 2 Umbilical Sides of  Fetal lie, fetal Elongated shaped Triangular shaped
abdomen position and abdomen suggest abdomen suggest
fetal back  Normal lie as  Abnormal lie
 Fetal back is longitudinal known as
smooth, hard, transverse lie
and resistant
surface
LM 3 Pawlicks Lower pole Fetal engagement Non ballottable Ballottable means
above means engaged floating
symphysis
pubis
LM 4 Pelvic 2 inches Determine fetal Cephalic Head is extended if
above attitude, cephalic prominence is on the fetus is in the face
inguinal prominence and the side as the presentation
ligament descent small parts, then
the fetus is vertex

 Fetal presentation – relationship of presenting part to the mother’s cervix which part of
the fetus that enter the pelvis in the birth process.
 Types of presentations
 Cephalic presentation
o Vertex – fetal head is completely flexed on to the chest
o Military – neither flexed nor extended fetal head
o Brow – fetal head is partially extended
o Face – fetal head is hyperextended
 Vertex
 Breech presentation – buttocks or lower extremities present first
 Complete breech – thigh rest on the abdomen while legs rest on thigh
 Frank breech – thigh rest on the abdomen while legs extends to the
head.
 Footling – one or both legs are presenting
 Kneeling breech – one or both knees are presenting part
 Shoulder – presenting part is the scapula and baby is in horizontal
or transverse position. Cesarean birth is indicated.

35
 Fetal attitude – refers to the posture of a fetus during labor

B. Passageway – shape and measurement of maternal pelvis and distensibility of birth canal
a. Engagement – the fetal presenting part enters the true pelvis (inlet). It can take two
weeks before labor in the primipara and usually occurs at the beginning of labor for
the multipara. The birth canal is composed of the body pelvis, cervix, pelvic floor and
vaginal opening.
b. Station – measurement of how far the presenting part has descended into the pelvis.
Referent is ischial spines, palpated through lateral vaginal walls. When the presenting
part is:
 At ischial spine is 0
 Above ischial spine the station is negative number
 Below ischial spine the station is positive number
 High or floating termed used to denote unengaged presenting part.
 Accurate determination of engagement may be difficult if elongation of fetal head
(molding or caput succedaneum)
c. Soft tissue – such as cervix and vagina: stretches and dilates under the force of
contractions to accommodate the passage of the fetus.
C. Powers – forces or labor, acting in concert to expel fetus and placenta.
o Major forces are:
a. Primary power is the involuntary power of the uterine contraction (Ferguson reflex)
b. Secondary power is the voluntary power which the woman should have bearing
down effort (Valsalva maneuver).
 After full dilatation of the cervix, the mother can use her abdominal muscles
to help expel fetus
 These efforts are similar to those for defecation but the mother is pushing out
the fetus from the birth canal
 Contraction of the levator ani muscles
c. Phases of uterine contraction
 Increment/crescendo – increasing force of contraction
 Acme/apex – peak of uterine contraction
 Decrement/decrescendo –decreasing force of contraction
d. Progress of labor
 assessment
 Duration – length of uterine contraction, measured from the beginning of
a contraction to the end of the same contraction.
 Interval – measured from the end of contraction to the beginning of the
next contraction
 Frequency – rate of uterine contraction, measured from the beginning of
a contraction to the beginning of the next contraction
 Intensity – the strength of uterine contraction

D. Position of the woman

 Position affects the woman’s anatomic and physiologic adaptation to labor
o Upright position such as walking, sitting, kneeling and squatting can
provide gravity to promote fetal descent and contractions are stronger.
o All fours position – hands and knees are used to relieve backaches if
fetus is in occipitoposterior position and can assist in anterior rotation of
the fetus in case shoulder dystocia.
o Lithotomy
o Semi-recumbent
o Lateral

36
 E. Psychologic response – the psychological and emotional condition of the mother as they
go on labor. The mother should be prepared for labor because anxiety affect the labor
process
o Culture
o Preparation
o Past experience
o Support system

3. Third Stage
Placental expulsion stage
 Begins with birth of the baby and ends with delivery of the placenta.
 During placental separation, bleeding occurs leading to the formation of a hematoma between
the placental tissue and remaining decidua.
 The separation appears about 3-5minutes after the baby’s birth but takes up to 10minutes to
manifest the signs and be delivered.
 Placental separation
 The fundus rises in the abdomen and it becomes globular and firm – calkin’s signs
 The uterus becomes hard and mobile
 Lengthening of the cord
 Sudden gush of blood

 Brandt Andrew’s Maneuver – slowly pulling the cord and winding it to the clamp
 Types of placental separation
 Schultz mechanism – separates placenta from inner to outer margins, fetal (shiny) side
presents
 Fetal side comes first
 Shiny, smooth potion
 Grayish white
 Delivered like a folded umbrella
 Duncan mechanism – separates the placenta from the out inward margin, it will roll up
and present sideways with the maternal surface presenting.
 Maternal side comes first
 Dirty side, meaty portion
 Dark red
 Risk for retentions
 Administer medications as ordered (Active management of third stage of labour) three
main of components of AMTSL
 Methylergonovine Maleate (methergine) this given in the hospital
 Oxytocin (Syntocinon)
 Controlled cord traction to deliver placenta
 Massage uterus to keep it contracted after delivery

LESSON 3: EPISIOTOMY
Episiotomy - the perineum is incised with scissors or a scalpel as the infant’s head is crowning.
Two types of episiotomy have been described: midline (median) and mediolateral.
 Widens the vaginal canal opening
 It is commonly done in second stage of labor
 Doctors practice only – malpractice if performed by the midwife
 Episiotomy shortens the second stage of labor
 Note and assess for the REEDA

37
  R= redness
 E = edema
 E = ecchymosis
 D = discharge
 A = approximation
 Midline episiotomy – less bleeding, and fast healing
 Right/left mediolateral – more bleeding and longer healing
 Watch out for: perineal hematoma
 Patient complains of rectal pressure and increasing perineal pain
 Initial action: apply cold packs for 15-20 minutes every 4 hours
 Application of ice packs help reduce pain and swelling, and is the most
appropriate initial action for a vaginal hematoma
 Cold sitz bath of 20-30 minutes

Degree of perineal lacerations

 First degree
 Tear of fourchette, vaginal mucous membrane and perineal skin
 The muscles are still intact
 Second degree
 Tear that extends from fourchette, vaginal mucous membrane, perineal skin and
muscles of perineal body
 Still intact anal sphincter
 Third degree
 Tear that extends from skin and vaginal mucosa, subcutaneous tissues, fascia and
muscle sphincter ani.
 Still intact rectal muscles
 Fourth degree
 Fourchette, vaginal mucous membrane, perineal skin, muscles of perineal body,
anal sphincter and mucous membrane of rectum

Perineal Repairs
 A continuous or uninterrupted suture is defined as a kind of suture that is made with a
single strand of suture material. Continuous sutures are one with a series of stitches but they
are not individually knotted. They are typically used when the wound is in the visible region
of the body and thus the stitches will not be readily apparent.

4. Fourth Stage
Recovery stage/immediate postpartum
Begins with complete placental delivery to first 1-2 hours after delivery
 Most dangerous stage
 Danger for postpartum hemorrhage
 Monitor vital signs: BP, PR, may be slightly increased (within normal after 1hour)
 Immediately after delivery, the fundus is palpable between the umbilicus and symphysis pubis,
two hours after delivery it is the same height as the umbilicus.
 Interventions
 Maintain firmness/contracted uterus
 Assess for a soft and boggy uterus (uterus atony)
 Massage fundus
 Administer uterotonic drugs – oxytocin is the first choice to prevent PPH
 Postpartum care – priority in first 6-12 hours after delivery
 Blood loss/bleeding
 Pain
 Blood pressure

38
  Warning signs
 Postpartum assessment
 Every 15mins for 1st hour
 Every 30 mins for 2nd hour
 Every 4 hours for 1st 24 hours
 After 24hours every 8 hours
 Lochia – postpartum vaginal discharge with blood, mucus and placental tissue. Should be
moderate in amount
 Rubra – first three day/red
 Serosa – 3 to 10days /pink
 Alba more than 10days/white in colour
 Involution – process of return of uterus and other reproductive organ to non-pregnant state
 Happens by 3-4 weeks after delivery or until 6 weeks postpartum
 Two process of involution
 Retrogressive changes
 Involution of the uterus
 Lochia discharges
 Progressive changes
 Production of milk for lactation
 Restoration of normal menstrual cycle
 Watch out for subinvolution or non-returning of uterus to normal state like:
 Non shrinking of uterus
 Bright red/lochia rubra at 6 days postpartum
 Most common cause is retained fragments of placental tissues

After pains

 Normal
 Painful uterine contractions
 Breastfeeding stimulates oxytocin release which cause powerful and painful uterine
contractions
 More acute in and common among:
 Breastfeeding mothers
 Multiparous women
 Cs delivery mothers

DAY 13
SUBJECT: MATERNAL AND CHILD CARE
TOPIC: Bleedings Disorder of pregnancy
LESSON 1: First trimester bleeding disorders

39
40
41
42
 Chapter 6
Postpartum Care

Introduction
The postpartum period is believed to be the time after the expulsion of all products of
conception when the physiological and anatomical changes of the mother, along with
levels of hormones return to the nonpregnant state. Puerperium is the other term for
postpartum, it begins after the delivery of the placenta until complete physiological
recovery of different organ systems.
Postpartum Midwifery Assessment
This is an essential aspect of care to identify early signs of complications in the woman
who has just given birth. After giving birth, the woman is at risk of hemorrhage and
infections. Therefore the midwife should learn to assess correctly the postpartum mother
to maintain health and prevent possible postpartum complications. Below are the body
parts that should be examined and evaluated?

A. Postpartum period – begins immediately after birth up to 6 weeks (puerperium,

puerperal period)

World Health Organization (WHO) describes the postnatal period is the most critical or
dangerous and yet the most neglected.

Discharge of mother and baby:

43
  Normal spontaneous vaginal delivery – discharge after 24 hours to 48 hours (1-2
days). Cesarean section delivery – discharge after 3-4 days

Postpartum assessment
a. Breast
b. Uterus
c. Bladder
d. Bowels
e. Lochia
f. Episiotomy and perineum
g. Lower extremities, and
h. Emotions

a. Breast
 Breastfeed immediately after delivery initiate within 1 hour
 Rooming-in up to 24 hours
 Exclusively breastfeed the baby up to six months
 Assess proper latching on and positioning
 Support breastfeeding (do not give anything other than breastmilk even water

Inverted breast
 Instruct to perform Hoffman’s maneuver
 Roll nipple to toughen
 Use breast shells and nipple shield
 Express milk
 Do not stop breastfeeding

Sore/cracked nipples
 Correct latching on and positioning
 Advise to use the least sore breast first
 Cream: Lanolin ointment
 Keep the breast air dried after feeding
 Express milk or colostrum and apply to nipples
 Do not use soap, silk, bra with plastic straps

Engorgement - Breast engorgement is breast swelling that results in painful, tender

breasts. It’s caused by an increase in blood flow and milk supply in your breasts, and it
occurs in the first days after childbirth
 Heavy and tight
 Erythema
 Warm to touch
 Very firm or hard and painful
 Shiny and swollen

Onset: First 3-5 days

Management
 Frequent breastfeeding

44
  Use engorged breast first
 Latch the baby properly
 Let mother massage, express milk and air dry the breast

Remember
 Apply warm packs 15-20 minutes before feeding cold compress between feeding,
 Warm compress during feeding, cold compress between feeding, pump milk
 Warm shower before breastfeeding
 Use the last use breast first in your next feeding
 Never stop breastfeeding
 Massage and manually express milk in a cup

Mastitis
Inflammation of the breast can be infective or non-infective
Most common: 2-3 weeks postpartum
Noninfectious type – milk stasis
Infectious type: staphylococcus aureus bacteria

Signs and symptoms

 Inflamed
 Nursing discomfort
 Flu like
 Elevated temperature
 Continuous burning sensation
 Tender and swollen
 Erythema
 Discharge (pus) – I&D

Management
 Alternating warm and cold compress
 Breastfeed on demand
 Correct position and latching on
 Do not use soap in breast
 Express milk and message
 Free the breast to air

Proper Breastfeeding Attachment

45
 Chin of baby touching
mother’s breast
Areola is more visible
above
Lower lip is turned
outward
Mouth is widely open

Sucking is low, deep

with some pauses

Regulatory laws

E.O 51 – Milk code

RA7600 - Rooming in

b. Uterus
 Height – Fundus descends 1cm or 1 finger breadth each day
 Location of fundus
o Immediately after delivery – just below umbilicus (midline and palpable
halfway between the symphysis pubis and the umbilicus)
o One hour after delivery, the fundus is firm and at the level of umbilicus
o By 10 days postpartum, uterus cannot be palpated already
 Position of the uterus
o Fundus should be midline near the umbilicus
o
 Tone of uterus
o Firm/hard means contracted uterus and it is good
o Soft and boggy means relaxed/atony and it is not good
o Uterine atony – increases risk of PPH
o Gently massage the uterus to help the muscles to contract
o Adjust IV flow rate to control bleeding if pitocin is in the IV solution
o If no IV, administer per mouth or IM methergine or ergometrine per
doctor’s order
c. Bladder
 Palpate for distention above symphysis pubis
 Encourage the patient to pass urine
 Ensure passage of urine 6-8 hours after delivery
If patient has not voided in 6-8 hours post- delivery
o Stimulate urge to void
o Pour warm water over perineum
o Place hands in basin of warm water
o Open the faucet

46
 o Straight catheter per doctor’s order (last resort)

d. Bowel
 Bowel sound assessment every shift
 Observe any fecalith passing in vagina (refer) - sign of rectovaginal fistula
 Wipe front to back (anterior to posterior) in care of vulva to prevent infection
 Encourage patient to eat digestible food
 Leafy green vegetables and fruits in diet
Take note: First bowel movement usually occurs on or after 2nd postpartum day (2-3days)

B. Health Education
a. Postpartum perineal care is the cleaning and care of your perineum after having a
baby. The perineum is the area between the vagina (birth canal) and the anus
(posterior opening). In the first few weeks after giving birth, you are more likely to
have pain or soreness in your perineum. You will also have discharge from your
vagina.

Pericare
Use of perilight
Wipe vulva from
front to back patting
gently Perilight 25 watts –
distance: 12-18 inches
After each voiding,
change the peripad
Perilight 40 watts – 18-24
inches

Involves thorough cleaning of the client’s external genitalia, anal area and surrounding
skin. Involves washing the external genitalia with soap and water or alone in water or
with any commercially prepared periwash. The perineal area is able to conduct the growth
of the pathogenic organism because it is warm, moist, and poorly ventilated. Hygiene is
important to prevent bad smell and promote comfort. To prevent or eliminate infection,
smell and promote healing

b. Episiotomy

47
Purposes
 To cleanse perineum and vulva
 To inspect the area
 To observe amount, color, odor and consistency of lochia or vaginal discharge
 To prevent contamination or infection
 To take care of stitched perineum
 To prevent ascending infection into the urinary tract in patients with indwelling
catheter
 To minimize pain, tenderness and edema due to operational trauma e.g. after
episiotomy

c. Bowel Elimination cares

Concern about the ability to have a bowel movement is common after having a baby.
Mothers are often afraid of tearing their stitches or experiencing pain. Bowel function
should return to normal three to four days after delivery. A diet high in fiber and fluids
can help prevent constipation. Walking promotes bowel movements, gas passage and
increases overall circulation. Raising your feet on a stool during a bowel movement
can help reduce straining. For constipation, take an over-the-counter stool softener
(Colace, Metamucil) or add prunes, prune juice or bran to your diet. If you have
additional questions, please contact your doctor's office.
d. Breast Care and Breastfeeding
 Wear a supportive bra, even at night. Make sure it fits well and is not too tight.
Nursing bras are convenient for feeding.
 Avoid restrictive clothing and underwire bras, which can cause blocked milk ducts
and increase the risk of breast infection.
 Change nursing pads whenever they become damp, wet, or soiled.
 Take a daily shower. Use only clear water on the nipples. Soap washes off the
natural lubricant produced by the glands around your nipples; it can cause your
nipples to become dry and cracked.

48
Pumping Breast Milk

At times, women who breastfeed need to use a pump to express their breast milk. Reasons
for expressing breast milk vary. Women pump milk to relieve breast engorgement, permit
another person (spouse, family member, caregiver) to feed the baby, or because they are
returning to work.

Expressing milk can be done with a commercial pump or with your hands. Breast milk
volume is regulated by supply and demand. Pumping is a way to keep your breasts
regularly stimulated while you’re at work, on errands or if your baby is sick and has
temporarily stopped feeding. It’s normal not to get milk the first few times your pump;
keep trying.

Storing Breast Milk

Whether you plan to use your expressed milk the same day or later, you must store it
safely. These guidelines are for healthy infants. Storage times may vary for premature or
sick babies.
 Store milk in a clean bottle or disposable milk storage bag.
 Fill each bottle with enough milk for one feeding. Storing 2-4 ounces of milk per
container should cut down on waste.
 Use a solid cap to create an airtight seal.
 Hold the bottle under warm running water, or place in a bowl of warm water for a
few minutes, until milk reaches room temperature.
 Do not warm milk in the microwave or on a stove. Rapid heating destroys
nutrients and causes hot spots that can burn baby’s mouth.

e. Nutrition
Nutrition Goals
First let’s talk about a postpartum woman’s needs - replenishing all those valuable
nutrients depleted after nine months of pregnancy. Every mother’s needs are different
depending on
 Diet while pregnant.
 Underlying conditions.
 Severe morning sickness or blood loss during delivery.
 Twin or triplet pregnancy.
 Use of cigarettes, drugs or alcohol. A well balanced diet will help replenish all
the nutrient stores used during pregnancy

Important Nutrients and Minerals

Most postpartum women don’t have to make major changes to their diets as long as they
were eating healthy during pregnancy. However, two groups do need additional nutrients
in their diets; women who are breast feeding and teens because they’re still growing.

Adequate nutrient stores can prepare women for future pregnancies.

Folic Acid

49
The body needs folic acid or folate to make new cells and to build protein for growth.
 Taking folic acid prevents up to 70% of neutral-tube defects.
 Foods containing folic acid include: legumes, leafy greens, orange juice,
asparagus, fortified cereals and breads.
 The body absorbs half of the folate that occurs naturally in foods. Bioavailability
of folic acid from fortified foods and supplements is higher.
 Recommended dosage of 400 ug per day, 500 ug if breastfeeding, additional if
the mother has a history of baby with neural-tube defects.

Calcium
Another important nutrient is calcium. It’s important to postpartum women because:
 It helps keep bones and teeth strong.
 Low intake over time may lead to thin brittle bones (osteoporosis).
Tips
 Get plenty of calcium during teen years while still growing.
 To reduce bone loss during adult years – 1300 mg per day.
 19 and older – 1000 mg per day (three 8 ounce servings of milk or milk products
per day).
 Sources – dairy products, canned fish with bones, certain nuts and seeds, leafy
greens; and calcium fortified breads, juices, or soy products.

Lactose Intolerance and low-fat options

 For lactose intolerance – substitute cheeses, yogurt, or small amounts of milk or
milk with cereal.
 Keep calcium while reducing calories from fat by choosing low-fat and fat-free
dairy products. Ex: consume 1% milk in place of 2%.

Iron
Iron is an important mineral because it carries oxygen through the blood.
 Iron needs are increased in postpartum women.
 Women need to eat plenty of iron rich foods to meet the daily requirements.
 Low levels of iron may lead to anemia over time.

Iron in foods Sources of iron:

 Animal products – beef, chicken, pork or fish.
 Plant foods – dried beans, tofu, and fortified cereals.
 Cooking in cast-iron pans.
 More iron absorbed – vitamin C foods eaten with iron sources.
 Less iron absorbed – coffee or tea consumed with a meal.

Vegetarian Diets
Vegetarian diets can be perfectly healthy for postpartum women provided they eat foods
containing adequate nutrients and minerals.
 Postpartum women need protein, calcium, and vitamin B12.
 Protein sources include – nuts, dry beans, soy products, eggs, and milk.

50
  Calcium sources include – fortified soy milk, firm tofu, and fish with edible
bones, fortified breads and juices.
 Vitamin B12 sources include – eggs, milk, fortified breakfast cereal, soy products,
and vegetarian burgers
Fluids
Fluids are especially important for new moms. Drinking plenty of water helps carry
nutrients throughout the body and helps flush toxins out of their system. In addition,
drinking plenty of fluids helps:
 Get a woman’s body back to pre-pregnancy state more quickly.
 Eliminate constipation. • Reduce edema (swelling) after delivery.

f. Family Planning Counselling

 Counsel on importance of birth spacing and family planning
 Inform about all contraceptive choices in postpartum period
 Discuss the family planning methods for the breastfeeding and non-breastfeeding
woman
o Method options for breastfeeding woman
 Immediately postpartum: lactation amenorrhea method (LAM), condom,
BTL, IUD
 Delay 6 weeks: progesterone only oral contraceptives and injectable
(DMPA)
 Delay 6 months combine OCP, Natural Family planning
o Method options for non-breastfeeding woman
 Immediately postpartum: condoms, IUD, BTL, Progesterone-only OCP and
injectable
 Delay 3 weeks: combined OCP, injectable and natural family planning
 Stress that a woman who is not exclusively breastfeeding can become pregnant as
soon as 4 weeks after delivery if she has sex
 Reinforce that non-hormonal methods (LAM, barrier methods, IUD and
sterilization) are best
 Facilitate free informed choice for all women

g. Return Visit
 All postpartum women should have at least 2 routine postpartum visits
o 1st visit: 1st week postpartum, preferably within 48-72 hours
o 2nd visit6 weeks postpartum
 Women who do not return for post visits or those who do not bring along their
newborns during their postnatal visits should be visited at home

Chapter 7
The Newborn Care
A. Immediate Care of the Newborn

51
1. Essential Newborn Care (ENC)
 Simple cost-effective newborn care intervention
 Program of WHO to address the increasing mortality rate of neonates
 Majority die within the first week of like

2. Unang Yakap (First Embrace)

 Administrative Order 2009-0025
 Adaptation of the essential intrapartum newborn care (EINC) in the Philippines
 The unang yakap protocol provides specific details on newborn care during birth
until first 6 hours of life.

At perineal bulging, with presenting part visible (2nd stage of labor)

Intervention: Prepare for the delivery

Action:
 Ensure that delivery area is draft-free and between 25-28ºC
 Wash hands with clean water and soap
 Double glove just before delivery

Within 30 seconds After Birth the most important to check is the Breathing of newborn

Four Core Steps of Essential Newborn Care

Steps Four Interventions Time-bound
1st Step Immediate and thorough First 30 seconds
drying
2nd Step Early skin-to-skin After 30 seconds
3rd Step Properly-timed clamping Within 1-3 minutes
and cutting of the cold
Non-separation of the Within 90 minutes
4th Step newborn from the mother
for early breastfeeding
initiation and rooming-in

The following practices should never be done anymore to the newborn

 No routine suctioning of secretions

 Early bathing earlier than 6 hours. It must be done after 24 hours or at least after 6
hours
 Wiping out or removal of vernix caseosa if present
 Buttocks slapping, foot slapping and foot printing
 Offering baby pre-lacteal feedings or sugar water before breastfeeding
 Rubbing baby oil to baby’s skin or oil bath
 No squeezing of the chest and hanging the baby upside down just to drain
secretions
Interventions Benefits
Immediate thorough drying  Provide warmth to the baby
 Immediate action  Prevents hypothermia to set in

52
  First 30 seconds  Stimulates newborn respirations
 Wipe the fluids and secretions
not the vernix caseosa
Early skin to skin contact  Prevent hypothermia,
 Uninterrupted hypoglycemia and sepsis
 Place the baby in chest or  Increases colonization of
abdomen of mother protective bacterial flora
 Baby prone position  Improved breastfeeding initiation
 Doable even in C/S delivery and exclusivity
 Cover newborn’s back with a  Establishes mother and child
blanket and head with a bonnet bonding
 Place identification band on
ankle
Properly timed cord clamping and  Decreases anemia in 1 out of
cutting every 7 term babies
 Remove first set of gloves  Prevents brain hemorrhage in
 Delay cord clamping one of two preterm babies
 Wait until cord pulsation stops
 Clamp the cord at 2cm and 5cm
from the newborn’s abdomen
 Cut between clamp with sterile
surgical blade or scissor
Note
 Do not milk the cord towards the
newborn
 After cord clamping, ensure 10
IU IM of oxytocin is given to the
mother
Breastfeeding initiation within the first  Prevents an estimated 19.1% of
hour of life all neonatal deaths
Non-separation of the newborn from the mother for early breastfeeding
initiation and rooming-in
 Initiate breastfeeding within first hour of life
Interventions
 Provide support for initiation of breastfeeding
 Leave the newborn on mother’s chest in skin to skin contact
 Observe the newborn
Only when the newborn shows feeding cues
 Licking
 opening of mouth
 Tonguing
 Rooting
 Flexing arms
 Clenching of fist
 Crying – late signs of hunger
Remember: biting fingers is not a feeding cue
Counsel on proper positioning and attachment. When the baby is ready, advise the
mother to:

53
  Make sure the newborn’s neck is not flexed nor twisted
 Make sure the newborn is facing the breast, with the newborn’s nose
opposite her nipple and chin touching the breast
 Hold the newborn’s body close to her body
 Support the newborn’s whole body, not just the neck and shoulders
 With until the newborn‘s mouth is opened wide
 Move the newborn onto her breast, aiming the infant’s lower lip well below
the nipple not aiming directly to the nipple

Look for signs of good attachment and suckling

 Chin touching the breast
 Areola is more visible above
 Lower lip turned outwards
 Mouth wide open
 Suckling is slow, deep with some pauses

Remember:
 Health works should not touch the newborn unless there is a medical
indication
 Do not give sugar water, formula or other pre-lacteal
 Do not give bottles and pacifier
 Do not throw colostrum

APGAR SCORING SYSTEM

Apgar score – standardized evaluation of the newborn’s condition

Purpose:
 To determine how well the newborn is adjusting to extra-uterine life
 To assess newborns cardiac and respiratory adaptations to extra-uterine life

Not assessed are the following:

 Blood pressure
 Temperature
 Weight

Evaluated by Apgar:

 Color
 Respiratory rate
 Heart rate
 Muscle tone
 Reflex irritability
Remarks
Apgar Sign 0 1 3
1 min 5 min

54
 Activity No Some flexion of Active movement
(muscle tone) movement, extremities
Limp/flaccid
Pulse Absent Below 100 More than 100
(heart rate) beats/minute beats/minute
Most important
Grimace No response Feeble/weak cry Sneezing,
(reflex irritability) to when stimulated coughing, or
stimulation pulling away
when stimulated
Good or strong
cry
Appearance Cyanotic, Body pink, Pinkish in color
(skin color) blue, pale Extremities blue all over
Least important all over Acrocyanosis
Respiration absent Weak, slow or Strong cry
(breathing) irregular breathing,
feeble cry
Total

Add all scores and interpret:

The score of:
7-10 indicates good adjustment, vigorous (good healthy)
 Well and good condition
 Good and in the best possible health
 Document and proceed to newborn care procedures

4-6 moderately depressed, infant needs airway clearance (fair, guarded, moderately
depressed need suction) and supplementary oxygenation
 Note: administering high level of oxygen to premature neonate can cause
blindness as result of retrolental fibroplasia or retinopathy of prematurity
 Suction the newborn properly
 Positions the infant with his neck slightly hyperextended in a sniffing
position
 Suction gently and quickly 5-10seconds
 Suction the mouth before the nose
 Apply suction upon withdrawing catheter
 Gentle rotating suctioning it must not vigorous suction
 Remember: place the newborn in slight Trendelenburg position to facilitate further
drainage of secretions

0-3 severely depressed/distress

 The baby is in serious danger and need immediate resuscitation (poor, severely
depress)

Activity

55
Nurse Gretchen’s assessment reveals the following: heart rate is 110beats per minute, has
vigorous cry, moves actively and with good flexion, normal skin color and bluish
extremities. What would be the Apgar score of baby Jam?

Write your answer inside the box

56