Labor and delivery reduce progesterone formation and

(the woman in labor) increase prostaglandin.

 Antepartum care refers to the medical and  Prostaglandin produced by fetal
nursing care given to the pregnant woman membranes( amnion and chorion) and the
between conception and the onset of labor. decidua stimulates contractions.
 Intrapartum care refers to the medical and Theoretically, labor is thought to result from:
nursing care given to a pregnant woman
a) Progesterone deprivation
and her family during labor and delivery.
b) Oxytocin stimulation
 Postpartum care refers to the 1st 6 weeks
after childbirth. c) Fetal endocrine control
 Labor is the series of events by which d) Uterine decidua activation
uterine contractions and abdominal
THE FOUR COMPONENTS OF LABOR
pressure expel a fetus and placenta from
the uterus. Regular contractions cause 1.THE PASSAGE (passageway)
progressive dilatation of the cervix and
 The passage refers to the route a fetus must
create sufficient muscular uterine force to
travel from the uterus through the cervix
allow a baby to be pushed out into the
and vagina to the external perineum.
extra-uterine world. Labor represents a
time of change as it is both an ending and a a) Type of pelvis
beginning for the woman, her fetus, and her
b) Pelvic inlet diameters
family.
c) Pelvic outlet diameters
 Labor normally begins between 37 and 42
weeks of pregnancy, when a fetus is d) Ability of the uterine segment to distend,
sufficiently mature to adapt to extrauterine the cervix to dilate, and the vaginal canal
life, yet not too large to cause mechanical and introitus to distend.
difficulty with birth. In some instances,
2.THE PASSENGER
labor begins before a fetus is mature
(preterm birth). In others, labor is delayed  The passenger is the fetus. The body part of
until the fetus and the placenta have both the fetus that has the widest diameter is
passed beyond the optimal point for birth the head, so this is the part least likely to be
(postterm birth). able to pass through the pelvic ring.
Whether a fetal skull can pass depends on
Maternal factors:.
both its structure (bones, fontanelles, and
 Uterine muscle stretch , causing release of suture lines) and its alignment with the
prostaglandin. pelvis.
 Pressure on the cervix stimulates nerve a) Size of the fetal head and capability of the
plexus, causing release of oxytocin by head to mold to the passageway
maternal posterior pituitary gland
b) Fetal presentation
( Ferguson complex).
c) Fetal attitude
 Oxytocin stimulation in circulating blood
increases slowly during pregnancy, rises d) Fetal position
dramatically during labor, and peaks during
3. THE POWER - This refers to the frequency,
2nd stage. Oxytocin and prostaglandin work
duration and strength of uterine contractions to
together to inhibit calcium binding in
complete cervical effacement and dilation.
muscle cells, raising intracellular calcium
and thus activating contractions. 4. THE PSYCHE - Refers to the client’s psychological
state, available support systems, preparation for
 Estrogen/progesterone ratio shift
childbirth, experiences and coping strategies.
Fetal factors:
5.THE PASSAGEWAY
 Placental aging and deterioration triggers
initiation of contractions.
 Fetal cortisol, produced by the fetal adrenal
glands, rises and acts on the placenta to
 because the mother’s pelvis is too small. It
can be much more upsetting to think their
infant’s head is too large because it implies
something may be seriously wrong with
their baby (and that is rarely true).

TYPES OF PELVIS

 The cranium, the uppermost portion of the

skull, is composed of eight bones. The four
superior bones—the frontal (actually two
fused bones), the two parietal, and the
occipital—are the bones important in
childbirth. The other four bones of the skull
(sphenoid, ethmoid, and two temporal
bones) lie at the base of the cranium and so
are of little significance in childbirth
because they are never presenting parts.
Pelvic Inlet
 Fontanelle spaces compress during birth to
aid in molding of the fetal head. Their
presence can be assessed manually through
the cervix after the cervix has dilated during
labor. Palpating for fontanelle spaces during
a pelvic examination helps to establish the
position of the fetal head and whether it is
in a favorable position for birth.
Pelvic outlet
 The shape of a fetal skull causes it to be
wider in its anteroposterior diameter than
in its transverse diameter. To fit through the
inlet of the birth canal best, a fetus must
present the smaller diameter (the
transverse diameter) of the head to the
smaller diameter of the maternal pelvis (the
diagonal conjugate); otherwise, progress
can be halted and vaginal birth may not be
possible. The diameters of the fetal skull
vary depending on where the measurement
is taken.
 In most instances, if a disproportion
 • The smallest diameter of the fetal skull is
between fetus and pelvis occurs, the pelvis
the bi-parietal diameter or the transverse
is the structure at fault. If the fetus is the
diameter, which measures about 9.25 cm.
cause of the disproportion, it is often not
because the fetal head is too large but  • The smallest anteroposterior diameter is
because it is presenting to the birth canal at the suboccipitobregmatic measurement
less than its narrowest diameter. Keep this
 (approximately 9.5 cm) and is measured
in mind when discussing with parents why
from the inferior aspect of the occiput to
an infant may not be able to be born
the center of the anterior fontanelle.
vaginally. It can be upsetting for parents to
learn that a child cannot be born vaginally
 • The occipitofrontal diameter, measured pressed against the not yet dilated cervix.
from the occipital prominence to the The overlapping that occurs in the sagittal
suture line and, generally, the coronal
 bridge of the nose, is approximately 12 cm.
suture line can be easily palpated on the
 • The occipitomental diameter, which is the newborn skull.
widest anteroposterior diameter
Parents can be reassured that molding only
(approximately 13.5 cm), is measured from
lasts a day or two and will not be a
the posterior fontanelle to the chin.
permanent condition. There is little molding
 The anteroposterior diameter of the pelvis, when the brow is the presenting part
a space approximately 11 cm wide, is the because frontal bones are fused. No skull
narrowest diameter at the pelvic inlet, and molding occurs when a fetus is breech
so the best presentation for birth is when because the buttocks, not the head, present
the fetus presents a biparietal diameter (the first. Babies born by cesarean birth when
narrowest fetal head diameter) to this. At there is no pre-procedure labor also
the outlet, the fetus must rotate to present typically have no molding.
this narrowest fetal head diameter(the
 Fetal Attitude. Attitude describes the
biparietal diameter) to the maternal
degree of flexion a fetus assumes during
transverse diameter, a space, again,
labor or the relation of the fetal parts to
approximately 11 cm wide.
each other.
 • If a fetus presents one of the
• • A fetus in good attitude is in complete
anteroposterior diameters of the skull to
flexion: The spinal column is bowed
the anteroposterior diameter of the inlet,
forward, the head is flexed forward so much
engagement, or the settling of the fetal
that the chin touches the sternum, the arms
head into the pelvis, may not occur.
are flexed and folded on the chest, the
 • If the fetus does not rotate, leaving the thighs are flexed onto the abdomen, and
anteroposterior diameter of the skull the calves are pressed against the posterior
presenting to the transverse diameter of aspect of the thighs. This usual “fetal
the outlet, an arrest of progress may occur. position” is advantageous for birth because
it helps a fetus present the smallest
 Which anteroposterior diameter that
anteroposterior diameter of the skull to the
presents to the birth canal is determined
pelvis and also because it puts the whole
not only by rotation but also by the degree
body into an ovoid shape, occupying the
of flexion of the fetal head.
smallest space possible.
• • In full flexion, the fetal head flexes so
• • A fetus is in moderate flexion if the chin is
sharply that the chin rests on the chest, and
not touching the chest but is in an alert or
the smallest anteroposterior diameter, the
“military position” . This position causes the
suboccipitobregmatic, presents to the birth
next widest anteroposterior diameter, the
canal.
occipitofrontal diameter, to present to the
• • If the head is held in moderate flexion, birth canal. A fair number of fetuses assume
the occipitofrontal diameter presents. a military position early in labor. This does
not usually interfere with labor, however,
• • In poor flexion (the head is
because later mechanisms of labor (descent
hyperextended), the largest diameter (the
and flexion) force the fetal head to fully
occipitomental) will present.
flex.
• It follows that full head flexion is an
• • A fetus in partial extension presents the
important aspect of labor because a fetal
“brow” of the head to the birth canal.
head presenting a diameter of 9.5 cm will fit
through a pelvis much more readily than if • • If a fetus is in complete extension, the
the diameter is 12.0 or 13.5 cm. back is arched and the neck is extended,
presenting the occipitomental diameter of
• Molding is overlapping of skull bones along
the head to the birth canal (a face
the suture lines, which causes a change in
presentation. This unusual position usually
the shape of the fetal skull to one long and
presents too wide a skull diameter to the
narrow, a shape that facilitates passage
birth canal for vaginal birth. Such a position
through the rigid pelvis.
may occur in an otherwise healthy fetus or
Molding is caused by the force of uterine may be an indication there is less than the
contractions as the vertex of the head is usual amount of amniotic fluid present
 (oligohydramnios), which is not allowing the pelvis is divided into four quadrants
fetus adequate movement space. It also according to the mother’s right and left:
may reflect a neurologic abnormality in the
a) right anterior,
fetus causing spasticity.
b) left anterior,
 Fetal Lie Lie is the relationship between the
long (cephalocaudal) axis of the fetal body c) right posterior, and
and the long (cephalocaudal) axis of a
d) left posterior.
woman’s body—in other words, whether
the fetus is lying in a horizontal (transverse)  Four parts of a fetus are typically chosen as
or a vertical (longitudinal) position. landmarks to describe the relationship of
Approximately 96% of fetuses assume a the presenting part to one of the pelvic
longitudinal lie (with their long axis parallel quadrants.
to the long axis of the woman).
 • In a vertex presentation, the occiput (O) is
 Fetal presentation denotes the body part the chosen point.
that will first contact the cervix or be born
 • In a face presentation, it is the chin
first and is determined by the combination
(mentum [M]).
of fetal lie and the degree of fetal
flexion(attitude).  • In a breech presentation, it is the sacrum
(Sa).
 A cephalic presentation is the most
frequent type of presentation, occurring as  • In a shoulder presentation, it is the
often as 96% of the time. With this type of scapula or the acromion process (A)
presentation, the fetal head is the body part
 Position is indicated by an abbreviation of
that first contacts the cervix. The four types
three letters. The middle letter denotes the
of cephalic presentation are vertex, brow,
fetal landmark , O for occiput, M for
face, and mentum. The vertex is the ideal
mentum, Sa for sacrum, and A for acromion
presenting part because the skull bones are
process. The first letter defines whether the
capable of effectively molding to
landmark is pointing to the mother’s right
accommodate the cervix. This exact fit may
(R) or left (L). The last letter defines whether
actually aid in cervical dilatation as well as
the landmark points anteriorly (A),
prevent complications such as a prolapsed
posteriorly (P), or transversely (T).
cord (a portion of the cord passes between
the presenting part and the cervix and  If the occiput of a fetus points to the left
enters the vagina before the fetus).During anterior quadrant in a vertex position, for
labor, the area of the fetal skull that example, this is a left occipitoanterior (LOA)
contacts the cervix often becomes position. If the occiput points to the right
edematous from the continued pressure posterior quadrant, the position is right
against it. This edema is called a caput occipitoposterior (ROP).
succedaneum. In the newborn, what was
 LOA is the most common fetal position, and
the point of presentation can be analyzed
right occipitoanterior (ROA) is the second
from the location of the caput.
most frequent.
 A breech presentation means either the
Mechanisms of Labor
buttocks or the feet are the first body parts
that will contact the cervix.  Engagement
• A good attitude brings the fetal knees up against  Descent
the fetal abdomen.
 Flexion
• A poor attitude means the knees and legs are
 Internal rotation
extended.
 Extension
 Breech presentation can cause a difficult
birth, with the presenting point influencing  External rotation/ Restitution
the degree of difficulty. Three types of
 Expulsion
breech presentation are complete, frank,
and footling(incomplete). 1.Engagement
 Fetal position is the relationship of the Engagement refers to the settling of the
presenting part to a specific quadrant and presenting part of a fetus far enough into
side of a woman’s pelvis. The maternal the pelvis that it rests at the level of the
 ischial spines, the midpoint of the pelvis.  3.Flexion - As descent is completed and the
Descent to this point means the widest part fetal head touches the pelvic floor, the head
of the fetus (the presenting skull diameter bends forward onto the chest, causing the
in a cephalic presentation, or the smallest anteroposterior diameter (the
intertrochanteric diameter in a breech suboccipitobregmatic diameter) to present
presentation) has passed through the pelvis to the birth canal. Flexion is also aided by
or the pelvic inlet has been proven abdominal muscle contraction during
adequate for birth. In a primipara, non- pushing.
engagement of the head at the beginning of
 4.Internal Rotation - During descent, the
labor suggests that a possible complication
biparietal diameter of the fetal skull was
such as an abnormal presentation or
aligned to fit through the anteroposterior
position, abnormality of the fetal head, or
diameter of the mother’s pelvis.
cephalopelvic disproportion exists. In
multiparas, engagement may or may not  As the head flexes at the end of descent,
present at the beginning of labor. the occiput rotates so the head is brought
into the best relationship to the outlet of
 The degree of engagement is established
the pelvis, or the anteroposterior diameter
by a vaginal and cervical examination.
is now in the anteroposterior plane of the
 A presenting part that is not engaged is said pelvis.
to be “floating.”
 This movement brings the shoulders,
 One that is descending but has not yet coming next, into the optimal position to
reached the ischial spines may be referred enter the inlet, or puts the widest diameter
to as “dipping.” of the shoulders (a transverse one) in line
with the wide transverse diameter of the
Station - Station refers to the relationship of
inlet.
the presenting part of the fetus to the level
of the ischial spines.  Crowning - As the occiput of the fetal head
is born, the back of the neck stops beneath
 • When the presenting fetal part is at the
the pubic arch and acts as a pivot for the
level of the ischial spines, it is at a 0 station
rest of the head.
(synonymous with engagement).
 The head extends, and the foremost parts
 • If the presenting part is above the spines,
of the head, the face and chin, are born.
the distance is measured and described as
minus stations, which range from −1 to −4 5.Extension - As the occiput of the fetal head is
cm. born, the back of the neck stops beneath the
pubicarch and acts as a pivot for the rest of the
 • If the presenting part is below the ischial
head. The head extends, and the foremost parts of
spines, the distance is stated as plus
the head, the face and chin, are born.
stations (+1 to +4 cm).
6.External Rotation - In external rotation, almost
 • At a +3 or +4 station, the presenting part
immediately after the head of the infant is born,
is at the perineum and can be seen if the
the head rotates a final time (from the
vulva is separated (i.e., it is crowning).
anteroposterior position it assumed to enter the
2.Descent - Descent is the downward outlet) back to the diagonal or transverse position
movement of the biparietal diameter of the of the early part of labor. This brings the after
fetal head within the pelvic inlet. coming shoulders into an anteroposterior position,
which is best for entering the outlet. The anterior
Full descent occurs when the fetal head
shoulder is born first, assisted perhaps by
protrudes beyond the dilated cervix and
downward flexion of the infant’s head.
touches the posterior vaginal floor.
7.Expulsion - Once the shoulders are born, the rest
Descent occurs because of pressure on the
of the baby is born easily and smoothly because of
fetus by the uterine fundus. As the pressure
its smaller size. This movement, called expulsion, is
of the fetal head presses on the sacral
the end of the pelvic division of labor.
nerves at the pelvic floor, the mother will
experience the typical “pushing sensation,” The Powers of Labor
which occurs with labor. As a woman
 The third important requirement for a
contracts her abdominal muscles with
successful labor is effective powers of labor.
pushing, this aids descent.
This is the force supplied by the fundus of
the uterus and implemented by uterine
 contractions, which causes cervical millimeters wide to one large enough
dilatation and then expulsion of the fetus (approximately 10 cm) to permit passage of a fetus.
from the uterus. After full dilatation of the
Dilatation occurs first because uterine contractions
cervix, the primary power is supplemented
gradually increase the diameter of the cervical
by use of a secondary power source, the
canal lumen by pulling the cervix up over the
abdominal muscles. It is important for
presenting part of the fetus.
women to understand that they should not
bear down with their abdominal muscles to Secondly, the fluid-filled membranes push ahead of
push until the cervix is fully dilated. Doing the fetus and serve as an opening wedge. If they
so impedes the primary force and could are ruptured, the presenting part will serve this
cause fetal and cervical damage. same function, although maybe not as effectively.
As dilatation begins, there is an increase in the
 During pregnancy, the uterus begins to
amount of vaginal secretions (show) because
contract and relax periodically as if it is
minute capillaries in the cervix rupture and the last
rehearsing for labor (Braxton Hicks
of the mucus plug that has sealed the cervix since
contractions, or false labor). These
early pregnancy is released.
contractions are usually mild but can be so
strong that a woman mistakes them for true The Stages Of Labor
labor.
 THE FIRST STAGE - The first stage, which
 Effective uterine contractions have takes about 12 hours to complete, is divided
rhythmicity, a progressive increase in length into three segments:a latent, an active, and
and intensity, and accompany dilatation of a transition phase.
the cervix.
 The latent or early phase begins at the
 Contractions are assessed according to onset of regularly perceived uterine
frequency, duration, and strength. contractions and ends when rapid cervical
dilatation begins. Contractions during this
DIFFERENTIATING BETWEEN TRUE
phase are mild and short, lasting 20 to 40
AND FALSE LABOR CONTRACTIONS
seconds.
False Contractions
Cervical effacement occurs, and the cervix
 Begin and remain irregular dilates minimally. A birthing parent who is
 Felt first abdominally and remain confined multiparous usually progresses more
to the abdomen and groin quickly than a nullipara. A woman who
 Often disappear with ambulation or sleep enters labor with a “nonripe” cervix will
 Do not increase in duration, frequency, or probably have a longer than average latent
intensity phase. If a woman wants analgesia at this
 Do not achieve cervical dilatation point, she shouldn’t be denied of it, but
analgesia given too early in labor is a factor
True Contractions that tends to prolong this phase.
 Begin irregularly but become regular and In a woman who is psychologically prepared
predictable for labor and who does not tense at each
 Felt first in lower back and sweep around to tightening sensation in her abdomen, latent
the abdomen in a wave phase contractions cause only minimal
 Continue no matter what the woman’s discomfort and can be managed by
 level of activity controlled breathing. During this phase,
 Increase in duration, frequency, and encourage women to continue to walk
 intensity about and make preparations for birth, such
 Achieve cervical dilatation as doing last minute packing for her stay at
Cervical changes - Effacement is shortening and the hospital or birthing center, preparing
thinning of the cervical canal. All during pregnancy, older children for her departure and the
the canal is approximately 1 to 2 cm long. During upcoming birth, or giving instructions to the
labor, the longitudinal traction from the person who will take care of them while she
contracting uterus shortens the cervix so much that is away. If desired, she could begin
the cervix virtually appears. alternative methods of pain relief such as
aromatherapy, distraction, or acupressure.
Dilatation - refers to the enlargement or widening
of the cervical canal from an opening a few  During the active phase of labor, cervical
dilatation occurs more rapidly. Contractions
 grow stronger, lasting 40 to 60 seconds, and shiny and glistening from the fetal
occur approximately every 3 to 5 minutes. membranes, this is called a Schultze
presentation.
Show (increased vaginal secretions) and
perhaps spontaneous rupture of the If, however, the placenta separates first at
membranes may occur during this time. its edges, it slides along the uterine surface
and presents at the vagina with the
Encourage women to be active participants
maternal surface evident. It looks raw, red,
in labor by keeping active and assuming
and irregular, with the ridges or cotyledons
whatever position is most comfortable for
that separate blood collection spaces
them during this time, except flat on their
evident; this is called a Duncan
back.
presentation.
The Second Stage - The second stage of
* A simple trick of remembering the
labor is the time span from full dilatation
presentations is remembering that, if the
and cervical effacement to birth of the
placenta appears shiny, it is a Schultze
infant. A woman typically feels contractions
presentation. If it looks “dirty” (the irregular
change from the characteristic crescendo–
maternal surface shows), it is a Duncan
decrescendo pattern to an uncontrollable
presentation
urge to push or bear down with each
contraction as if to move her bowels. She * This stage can take anywhere from 1 to 30
may experience momentary nausea or minutes and still be considered normal.
vomiting because pressure is no longer Because bleeding occurs as the placenta
exerted on her stomach as the fetus separates, before the uterus contracts
descends into the pelvis. She pushes with sufficiently to seal maternal capillaries,
such force that she perspires and the blood there is a blood loss of about 300 to 500 ml,
vessels in her neck become distended. not a great amount in relation to the extra
blood volume that was formed during
The fetus begins descent and, as the fetal
pregnancy.
head touches the internal perineum to
begin internal rotation, her perineum THE fourth STAGE (RECOVERY & BONDING)
begins to bulge and appear tense. The anus
 This stage lasts from 1 – 4 hours after birth.
may become everted, and stool may be
expelled. As the fetal head pushes against  The mother and the baby recover from the
the vaginal introitus, this opens and the physical process of birth.
fetal scalp appears at the opening to the
 The maternal organs undergo initial
vagina and enlarges from the size of a dime
readjustment to the non-pregnant state.
to a quarter, then a half-dollar. This is
termed crowning.  The newborn body systems begin to adjust
to the extrauterine life and stabilize.
The THIRD STAGE - The third stage of labor, the
placental stage, begins with the birth of the infant  The uterus contracts in the midline of the
and ends with the delivery of the placenta. Two abdomen with the fundus midway between
separate phases are involved: placental separation the umbilicus and symphysis pubis.
and placental expulsion.
MATERNAL DANGER SIGNS
 The placenta has loosened and is ready to
High or Low Blood Pressure. Normally, a
deliver when:
woman’s blood pressure rises slightly in the
1. • There is lengthening of the umbilical cord. second (pelvic) stage of labor because of
her pushing effort. A systolic pressure
2. • A sudden gush of vaginal blood occurs.
greater than 140 mmHg and a diastolic
3. • The placenta is visible at the vaginal pressure greater than 90 mmHg, or an
opening. increase in the systolic pressure of more
than 30 mmHg or in the diastolic pressure
4. • The uterus contracts and feels firm again.
of more than 15 mmHg (the basic criteria
If the placenta separates first at its center for gestational hypertension), should be
and lastly at its edges, it tends to fold on reported. Just as important to report is a
itself like an umbrella and presents at the falling blood pressure because it may be the
vaginal opening with the fetal surface first sign of intrauterine hemorrhage,
evident. Approximately 80% of placentas although a falling blood pressure from
separate and present in this way. Appearing hemorrhage is often associated with other
 clinical signs of hypovolemic shock, such as the vagal reflex and leads to increased bowel
apprehension, increased pulse rate, and motility. Although meconium staining may be usual
pallor. in a breech presentation because pressure on the
buttocks causes meconium loss, it should always be
Abnormal Pulse. Most women during
reported immediately even with breech
pregnancy have a pulse rate of 70 to 80
presentations so its cause can be investigated.
beats/min. This rate normally increases
slightly during the second stage of labor Low Oxygen Saturation. Oxygen saturation in a
because of the exertion involved. A fetus is normally 40% to 70%. A fetus can be
maternal pulse rate greater than 100 assessed for this by a catheter inserted next to the
beats/min during labor is unusual and cheek (under 40% oxygenation needs further
should be reported because it may be assessment). If fetal blood is obtained by scalp
another indication of hemorrhage. puncture, the finding of acidosis (blood pH lower
than 7.2) suggests fetal well-being is becoming
Inadequate or Prolonged Contractions. Uterine
compromised and that further investigation is also
contractions normally become more frequent,
necessary.
intense, and longer as labor progresses. If they
become less frequent, less intense, or shorter Hyperactivity. Ordinarily, a fetus remains quiet and
in duration, this may indicate uterine barely moves during labor. Fetal hyperactivity may
exhaustion (inertia). be a subtle sign that hypoxia is occurring because
frantic motion is a common reaction to the need
Abnormal Lower Abdominal Contour. If a woman
for oxygen.
has a full bladder during labor, a round bulge
appears on her lower anterior abdomen. This is a The Leopold’s Maneuvers
danger signal for two reasons: First, the bladder
Determining Fetal Position, Presentation, and Lie:
may be injured by the pressure of the fetal head
the LEOPOLD’s Maneuver
pressing against it; and second, the pressure of the
full bladder may not allow the fetal head to
descend. To avoid a full bladder, ask women to try
to void about every 2 hours during labor.
Increasing Apprehension. Warnings of
psychological danger during labor are as important
to consider in assessing maternal well-being as are
physical signs. As she approaches the second stage
of labor, a woman who is becoming increasingly
apprehensive despite clear explanations of
unfolding events may not be “hearing” because she INTRAPARTUM PAIN MANAGEMENT
has a concern that has not been met. Using an Overview of Pain
approach such as “You seem more and more
concerned. Could you tell me what is worrying  Intrapartum pain is a subjective experience
you?” may be helpful. Increasing apprehension also of physical sensation associated with
needs to be investigated for physical reasons uterine contractions, cervical dilation and
because it can be a sign of oxygen deprivation or effacement, and fetal descent during labor
internal hemorrhage. and birth.

High or Low Fetal Heart Rate. As a rule, an FHR of  Physiologic responses to pain may include
more than 160 beats/min (fetal tachycardia) or less increased blood pressure, pulse,
than 110 beats/min (fetal bradycardia) is a sign of respiration, pupil diameter, muscle tension
possible fetal distress. An equally important sign is (such as facial tension or fisted hands) or
a late or variable deceleration pattern revealed on muscle activity ( such as pacing, turning or
a fetal monitor. Frequent monitoring by a twisting).
fetoscope, Doppler, or a monitor is necessary to
 Nonverbal expressions of pain may include
detect these changes as they first occur.
withdrawal, hostility, fear or depression.
Meconium Staining. This is not always a sign of
Verbal expressions of pain may include
fetal distress but is highly correlated with its
statements of pain, moaning and groaning.
occurrence. Meconium staining, a green color in
the amniotic fluid, reveals the fetus has had a loss
of rectal sphincter control, allowing meconium to
pass into the amniotic fluid. It may indicate a fetus
has or is experiencing hypoxia, which stimulates
  Hypnosis
 Acupuncture and acupressure
 Yoga
Pharmacologic Pain Relief
1. Narcotic analgesics
2. Barbiturates
3. Tranquilizers
Sources of intrapartum pain
4. Regional anesthesia
 Uterine contractions
5. General anesthesia
 Dilation
Narcotic analgesics
 Distention
a. Narcotic analgesic are systemic drugs that
 Pressure on adjacent organs readily cross the placental barrier, with
 Tension depressive effects on the neonate occurring
2 to 3 hours after intramuscular injection.
The two goals of intrapartum pain
management are: b. Maternal side effects include nausea,
vomiting, mild respiratory depression, and
1. Provide maximum relief of pain with transient mental impairment.
maximal safety for mother and fetus.
c. Fetal effects are reduced fetal heart rate
2. To facilitate labor and delivery as a positive and decreased variability; neonatal effects
family experience. are lowered APGAR score and respiratory
depression.
Pain relief may be achieved by using
prepared childbirth methods (such as d. Opioid antagonists such as
Lamaze, analgesics or regional anesthetics). naloxone(Narcan) must be readily available
in case of respiratory depression in the
Intervention for pain relief during labor
mother or newborn.
depends on the following factors:
e. The decision to administer a narcotic
a. Gestational age of the fetus
analgesic is based on the results of a vaginal
b. Frequency, duration and intensity of the examination; if birth is anticipated within 2
contractions to 3 hours, the risk of neonatal narcosis my
preclude the use of analgesics.
c. Labor progress
f. The dosage is kept to the smallest effective
d. Maternal response to pain and labor
dose.
e. Allergies and sensitivities to analgesics and
Opioid analgesics
anesthetics
Meperidine (Demerol)
Nonpharmacologic Pain Management
Morphine
 Relaxation techniques
Fentanyl
 Positioning
 These drugs do not eliminate pain. They
 Focusing and imagery
decrease the perception of pain and allow
 Therapeutic touch and massage for rest and relaxation between
contractions.
 Music therapy
 Category of frugs most commonly
 Birthing partner or coach
administered parenterally during labor. It
 Breathing techniques should be given only after a labor pattern Is
established.
 Heat and cold application
 Opioids may be administered every 2- 3
 Counterpressure
hours by the IV or IM routes. Give IV slowly
 TENS during a contraction to decrease the
transfer of the medication to the fetus.
  These drugs may decrease the frequency e. Newborn effects: hypotonia, hypothermia,
and duration of uterine contractions and generalized drowsiness and a reluctance to
may result in decreased fetal heart rate feed for the 1st few days.
variability.
Regional anesthesia
 In the newborn, respiratory depression and
 Types of regional anesthesia spinal,
decreased muscle tone amy occur and last
epidural, paracervical and pudendal blocks,
for several days.
and local infiltration.
Barbiturates
 These blocks provide pain relief with
a. These drugs cause maternal sedation and injected anesthetic agents at sensory nerve
relaxation. pathways.
b. Maternal side effects of barbiturates  Adverse reactions may include maternal
include nausea, vomiting, hypotension, hypotension, allergic or toxic reaction,
restlessness and vertigo. respiratory paralysis, and partial or total
anesthetic failure.
c. Neonatal side effects include CNS
depression, prolonged drowsiness, and  Nursing responsibilities during
delayed establishment of feeding(poor administration of regional anesthesia
sucking reflex) include: assisting the anesthesiologist as
requested, establishing a reliable
d. The rapid transfer of barbiturates across the
intravenous line, being prepared with
placental barrier and the lack of an
medications and equipment for emergency
antagonist to counteract their effects make
situations if they arise.
them generally inappropriate during active
labor. General anesthesia
Barbiturates  General anesthesia, inhalant such as nitrous
oxide and halothane and intravenous such
Secobarbital sodium(Seconal)
as Pentothal is used during childbirth only if
Pentobarbital(Nembutal) an emergency cesarean birth becomes
necessary.
 These drugs do not relieve pain. They are
used to induce sleep, decrease anxiety, Anesthetics used in labor and birth
allow for rest and inhibit uterine
1. Type: Lumbar epidural block
contractions.
 Drug : Local anesthetic –Bupivacaine and
 Sedatives should be given in early labor,
Ropivacaine
when the birth is unlikely to occur within
12- to 24 hours.  Usual dose and route: administer for 1st
stage of labor; with continuous block,
 Sedatives may be given orally or by IM.
anesthesia will last through delivery,
 These drugs may have an effect on neonatal injected at L3-4, fentanyl or morphine
CNS, causing decreased responsiveness and possibly added
ability to suck.
 Effect on the mother: rapid onset(in
Tranquilizers minutes); lasting 60-90 minutes; loss of pain
perception for labor contractions and
a. These drugs decrease the anxiety and
delivery; possible maternal hypotension
apprehension associated with pain and
sometimes relieve the nausea associated  Effect on labor progress: slowing of labor if
with narcotic analgesics. given early; pushing feeling obliterated,
resulting in possible prolonged 2nd stage
b. Tranquilizers potentiate active sedative and
analgesic effects, decreasing the dosage of  Effect on fetus or newborn: may be some
analgesic and sedative drugs needed to differences in response in 1st few days of life
produce the desired effects.
2. Type: Pudendal block
c. Maternal side effects: hypotension,
 Drug: Local anesthetic- Lidocaine(Xylocaine)
drowsiness and dizziness.
 Usual dose and route: administer just
d. Fetal effects: tachycardia and the loss of
before delivery for perineal anesthesia;
normal beat-to beat variability on electronic
injected through the vagina
fetal heart monitoring.
  Effect on the mother: rapid anesthesia of 3. Inform all pregnant women about the
perineum benefits and management of breastfeeding.
 Effect on labor progress: none apparent 4. Help mothers initiate breastfeeding
within one hour of birth.
 Effect on fetus or newborn: none apparent
5. Show mothers how to breastfeed and
3.Type: Local infiltration of perineum
how to maintain lactation, even if they are
 Drug: Local anesthetic- Lidocaine(Xylocaine) separated from their infants.

 Usual dose and route: injected just before the 6. Give newborn infants no food or drink
episiotomy incision other than breast-milk, unless medically
indicated.
 Effect on mother: anesthesia of perineum
almost immediate 7. Practice “rooming in”—allow mothers
and infants to remain together 24 hours a
 Effect on labor progress and fetus: none
day.
apparent
8. Encourage breastfeeding on demand.
4.Type: General intravenous anesthetic
9. Give no pacifiers or artificial nipples to
 Drug: Thiopental
breastfeeding infants.
 Usual dose and route: administered IV by
10. Foster the establishment of
anesthesiologist or nurse-anesthetist
breastfeeding support groups and refer
 Effect on mother: rapid anesthesia; also rapid mothers to
recovery
them on discharge from the hospital or
 Effect on labor progress: forceps required birth center.
because abdominal pushing is no longer
Phases of the PUERPERIUM
possible
Taking-In Phase
 Effect on fetus or newborn: results in infant
being born with CNS depression  The taking-in phase is largely a time of
reflection. During this 1- to 3-day period, a
POSTPARTUM CARE
woman is largely passive. She prefers
 Post partum care refers to the medical and having a nurse attend to her needs and
nursing care given to a woman during the make decisions for her rather than do these
puerperium, which is the 6-week period things herself. This dependence results
after delivery, beginning with termination of partly from her physical discomfort because
labor and ending with the return of the of after-pains or hemorrhoids, partly from
reproductive organs to the non-pregnant her uncertainty in caring for her newborn,
state. and partly from the exhaustion that follows
childbirth.
 This period constitutes a physical and
psychological adjustment to the process of  The woman usually wants to talk about her
childbearing and is sometimes referred to pregnancy, especially about her labor and
as the 4th trimester of pregnancy. birth. Encouraging her to talk about the
birth is an important way to help her
 It is a time of maternal changes that are
integrate the experience into her total life
both retrogressive (involution of the uterus
experiences.
and vagina) and progressive (production of
milk for lactation, restoration of the normal Taking-Hold Phase
menstrual cycle, and beginning of a
 After a time of passive dependence, a
parenting role).
woman begins to initiate action (the taking-
Breastfeeding policy hold phase). She begins to take a stronger
interest in her infant and begins maternal
1. Have a written breastfeeding policy that
role behaviors.
is routinely communicated to all health care
staff.  As a rule, it is usually best to give a woman
a brief demonstration of baby care and then
2. Train all health care staff in the skills
allow her to care for her child herself—with
necessary to implement this policy.
watchful guidance—as she enters this
phase.
  Although a woman’s actions suggest greater container large enough to hold a full-term
independence during this time, she often fetus to one the size of a grapefruit, a
still feels insecure about her ability to care phenomenon that can be compared with a
for her new child. She needs praise for the rubber band that has been stretched for
things she does well, such as supporting the many months and now is regaining its
baby’s head or beginning breastfeeding to normal contour. None of the rubber band is
give her confidence. This positive destroyed; the shape is simply altered. For
reinforcement begins in the healthcare this reason, the postpartum period, like
facility and continues after discharge, at pregnancy, is not a period of illness, of
home and at postpartum and well-baby necrosing cells being evacuated, but
visits. primarily a period of healthy change.
Letting-Go Phase  The uterus: Immediately after birth, the
uterus weighs about 1,000 g. At the end of
 In this third phase, a woman finally
the first week, it weighs 500 g. By the time
redefines her new role. She gives up the
involution is complete (6 weeks), it weighs
fantasized image of her child and accepts
approximately 50 g, similar to its pre-
the real one; she gives up her old role of
pregnancy weight.
being childless or the mother of only one or
two (or however many children she had  Because uterine contraction begins
before this birth). immediately after placental delivery, the
fundus of the uterus is palpable through the
 This process requires some grief work and
abdominal wall, halfway between the
readjustment of relationships, similar to
umbilicus and the symphysis pubis, within a
what occurred during pregnancy. It is
few minutes after birth. One hour later, it
extended and continues during the child’s
will rise to the level of the umbilicus, where
growing years. A woman who has reached
it remains for approximately the next 24
this phase is well into her new role.
hours. From then on, it decreases by one
Physiologic Changes of the Postpartum Period fingerbreadth, or 1 cm, per day; for
example, on the first post-partum day, it
REPRODUCTIVE SYSTEM CHANGES - Involution is
will be palpable 1 cm below the umbilicus.
the process whereby the reproductive organs
return to their non pregnant state.  In the average woman, by the ninth or
tenth day, the uterus will have contracted
Reproductive system changes: The Uterus
so much that it is withdrawn into the pelvis
 Involution of the uterus involves two and can no longer be detected by
processes. abdominal palpation.

1. The area where the placenta was implanted  Involution will occur most dependably in a
is sealed off to prevent bleeding. The woman who is well nourished and who
sealing of the placenta site is accomplished ambulates early after birth as gravity may
by rapid contraction of the uterus play a role. Involution may be delayed by a
immediately after delivery of the placenta. condition such as the birth of multiple
This contraction pinches the blood vessels fetuses, hydramnios, exhaustion from
entering the 7-cm-wide area left denuded prolonged labor, grand multiparity, or
by the placenta and halts bleeding. With physiologic effects of excessive analgesia.
time, thrombi form within the uterine Contraction may be ineffective if there is
sinuses and permanently seal the area. retained placenta or membranes.
Eventually, endometrial tissue undermines
 The first hour after birth is potentially the
the site and obliterates the organized
most dangerous time for a woman. If her
thrombi, covering and healing the area so
uterus should become relaxed during this
completely the process leaves no scar tissue
time (uterine atony), she will lose blood
within the uterus so does not compromise
very rapidly because no permanent thrombi
future implantation sites.
have yet formed at the placental site.
2. The organ is reduced to its approximate
 In some women, contraction of the uterus
pre-gestational size. The same contraction
after birth causes intermittent cramping
process reduces the bulk of the uterus.
termed afterpains, similar to that
Devoid of the placenta and the membranes,
accompanying a menstrual period.
the walls of the uterus thicken and contract,
Afterpains tend to be noticed most by
gradually reducing the uterus from a
multiparas than by primiparas and by
 women who have given birth to large uterine contraction is decreasing, and new
babies or multiple births. In these bleeding is beginning.
situations, the uterus must contract more
 Odor: Lochia should not have an offensive
forcefully to regain its pre-pregnancy size.
odor as this suggests the uterus has become
These sensations are noticed most intensely
infected. Immediate intervention is needed
with breastfeeding, when the infant’s
to halt postpartal infection.
sucking causes a release of oxytocin from
the posterior pituitary, increasing the  Absence: Lochia should never be absent
strength of the contractions. during the first 1 to 3 weeks as absence of
lochia, like presence of an offensive odor,
 LOCHIA - The separation of the placenta
may indicate postpartal infection. Lochia
and membranes occurs in the spongy layer
may be scant in amount after cesarean
or outer portion of the decidua basalis of
delivery, but it is never altogether absent.
the uterus. By the second day after birth,
the layer of decidua remaining under the The Cervix
placental site (an area 7 cm wide) and
 Immediately after birth, a uterine cervix
throughout the uterus differentiates into
feels soft and malleable to palpation. Both
two distinct layers. The inner layer attached
the internal and external os are open. Like
to the muscular wall of the uterus remains,
contraction of the uterus, contraction of the
serving as the foundation from which a new
cervix toward its prepregnant state begins
layer of endometrium will be formed. The
at once. By the end of 7 days, the external
layer adjacent to the uterine cavity
os has narrowed to the size of a pencil
becomes necrotic and is cast off as a vaginal
opening; the cervix feels firm and nongravid
discharge similar to a menstrual flow. This
again.
flow, consisting of blood, fragments of
decidua, white blood cells, mucus, and  In contrast to the process of uterine
some bacteria, is termed Lochia. involution, in which the changes consist
primarily of old cells being returned to their
Evaluating lochia flow
former position by contraction, the process
 Amount: Lochia amount varies greatly from in the cervix does involve the formation of
woman to woman. Mothers who breastfeed new muscle cells. Because of this, the cervix
tend to have less lochial discharge than does not return exactly to its prepregnancy
those who do not because the natural state. The internal os closes as before, but
release of the hormone oxytocin during after a vaginal birth, the external os usually
breastfeeding strengthens uterine remains slightly open and appears slit-like
contractions. Lochial flow increases on or stellate (star shaped), whereas
exertion, especially the first few times a previously, it was round. Finding this
woman is out of bed but decreases again pattern on pelvic examination suggests that
with rest. Saturating a perineal pad in less childbearing has taken place.
than 1 hour is considered an abnormally
The Vagina
heavy flow and should be reported. Don’t
use tampons to halt the flow or this could  After a vaginal birth, the vagina feels soft,
lead to infection. with few rugae, and its diameter is
considerably greater than normal. The
 Consistency: Lochia should contain no
hymen is permanently torn and heals with
exceedingly large clots as these may
small, separate tags of tissue. It takes the
indicate a portion of the placenta has been
entire postpartum period for the vagina to
retained and is preventing closure of the
involute (by contraction, as with the uterus)
maternal uterine blood sinuses. In any
until it gradually returns to its approximate
event, large clots denote poor uterine
pre-pregnancy state. Thickening of the walls
contraction, which needs to be corrected.
appears to depend on renewed estrogen
 Pattern: Lochia is red for the first 1 to 3 stimulation from the ovaries.
days (lochia rubra), pinkish brown from
 Because a woman who is breastfeeding may
days 4 to 10 (lochia serosa), and then white
have delayed ovulation, she may continue
(lochia alba) for as long as 6 weeks after
to have thin-walled or fragile vaginal cells
birth. The pattern of lochia (rubra to serosa
that cause slight vaginal bleeding during
to alba) should not reverse as this suggests
sexual intercourse until about 6 weeks’
a placental fragment has been retained or
time. If a woman practices Kegel exercises,
 the strength and tone of the vagina will  The usual blood loss with a vaginal birth is
increase more rapidly. 300 to 500 ml. With a cesarean delivery, it is
500 to 1,000 ml. A 4-point decrease in
The Perineum
hematocrit (proportion of red blood cells to
 Because of the great amount of pressure circulating plasma) and a 1-g decrease in
experienced during birth, the perineum is hemoglobin value occur with each 250 ml of
edematous and tender immediately after blood lost. For example, if an average
birth. woman enters labor with a hematocrit of
37%, it will be about 33% on the first
 Ecchymosis patches from ruptured
postpartal day, and hemoglobin will fall
capillaries may show on the surface.
from 11 to 10g/dl.
 The labia majora and labia minora typically
 If the woman was anemic during pregnancy,
remain atrophic and softened after birth,
she can expect to continue to be anemic
never returning to their pre-pregnancy
afterward. As excess fluid is excreted, the
state. Mothers may experience various
hematocrit gradually rises (because of
levels of tenderness in the perineum area.
hemoconcentration), reaching
 Suggesting nonpharmacologic comfort prepregnancy levels by 6 weeks after birth.
measures such as ice or warm packs or a
 Women usually continue to have the same
gentle pillow or doughnut pad to sit on will
high level of plasma fibrinogen during the
be much appreciated by the mother.
first postpartal weeks as they did during
SYSTEMIC CHANGES POST PARTUM pregnancy. This is a protective measure
against hemorrhage. However, this high
The Hormonal System
level also increases the risk of thrombus
 Pregnancy hormones begin to decrease as formation.
soon as the placenta is no longer present.
 There is also an increase in the number of
Levels of human chorionic gonadotropin
leukocytes in the blood. The white blood
(hCG) and human placental lactogen (hPL)
cell count may be as high as 30,000
are almost negligible by 24 hours.
cells/mm3 (mainly granulocytes) compared
 By week 1, progestin, estrogen, and to a normal level of 5,000 to 10,000
estradiol are all at pre-pregnancy levels cells/mm3, particularly if labor was long or
(estriol may take an additional week before difficult. This, too, is part of the body’s
it reaches pre-pregnancy levels). defense system, a defense against infection
and an aid to healing.
 Follicle-stimulating hormone (FSH) remains
low for about 12 days and then begins to The Gastrointestinal System
rise as a new menstrual cycle is initiated.
 Digestion and absorption begin to be active
The Urinary System again soon after birth unless a woman has
had a cesarean delivery. Almost
 During pregnancy, as much as 2,000 to
immediately, the woman feels hungry and
3,000 ml of excess fluid accumulates in the
thirsty, and she can eat without difficulty
body so extensive diaphoresis (excessive
from nausea or vomiting during this time.
sweating) and diuresis (excess urine
production) begin almost immediately after  Hemorrhoids (distended rectal veins) that
birth to rid the body of this fluid. This easily have been pushed out of the rectum
increases the daily urine output of a because of the effort of pelvic stage pushing
postpartum woman from a normal level of often are present.
1,500 ml to as much as 3,000 ml/day during
 Bowel sounds are active, but passage of
the second to fifth day after birth. This
stool through the bowel may be slow
marked increase in urine production causes
because of the still-present effect of relaxin
the bladder to fill rapidly.
(a hormone which softens and lengthens
 Reassure the mother that this is normal and the cervix and pubic symphysis for
she still needs to continue drinking a preparation of the infant’s birth during
healthy amount of fluids daily, especially if pregnancy) on the bowel. Bowel evacuation
she is breastfeeding. may be difficult because of pain if a woman
has episiotomy sutures or from
The circulatory system
hemorrhoids.
The Integumentary System
  After birth, the stretch marks on a woman’s progesterone ends. The resulting decrease
abdomen (striae gravidarum) still appear in hormone concentrations causes a rise in
reddened and may be even more production of FSH by the pituitary, which
prominent than during pregnancy, when leads, with only a slight delay, to the return
they were tightly stretched. of ovulation. This initiates the return of
normal menstrual cycles.
 Excessive pigment on the face and neck
(chloasma) and on the abdomen (linea  A woman who is not breastfeeding can
nigra) will become barely detectable by 6 expect her menstrual flow to return in 6 to
weeks’ time. If diastasis recti 10 weeks after birth. If she is breastfeeding,
(overstretching and separation of the a menstrual flow may not return for 3 or 4
abdominal musculature) occurred, the area months (lactation amenorrhea) or, in some
will appear as a slightly indented bluish women, for the entire lactation period.
streak in the abdominal midline. However, the absence of a menstrual flow
does not guarantee that a woman will not
 Modified sit-ups help to strengthen
conceive during this time because she may
abdominal muscles and return abdominal
ovulate well before menstruation returns.
support to its pre-pregnant level. Diastasis
recti, however, may require surgery to Nursing Care of a Woman and Family During the
correct. First 24 Hours After Birth
PROGRESSIVE CHANGES OF THE PUERPERIUM  Skin-to-skin cuddling with the newborn
should be encouraged as well as offering
1. Lactation
the newborn the breast to try to suckle.
 Lactogenesis (human milk production)
 Provide Pain Relief for afterpains.
 Prolactin hormone is responsible for milk
 Relieve Muscular Aches.
production, and oxytocin is responsible for
the let-down reflex arch.  Administer Cold and Hot Therapy to the
perineum.
 The lactogenesis I (milk synthesis) process
begins around 16 weeks gestation as the  Promote Perineal Exercises.
glandular luminal cells in the breast begin
 Give Suture Line Care for Women With An
secreting colostrum, a thin, watery
Episiotomy.
prelactation secretion.
 Provide Perineal Care.
 Lactogenesis II is triggered at birth by the
delivery of the placenta, when the  Promote Perineal Self-Care.
progesterone hormone (prolactin is no
 Promote Rest in the Early Postpartal Period.
longer inhibited) and other circulating
pregnancy hormones suddenly decrease  Promote Adequate Fluid Intake.
and oxytocin sharply increases as a result of
 Promote Urinary Elimination.
the infant Suckling. Lactogenesis II is often
when mothers feel that their “milk has  Prevent constipation
come in” (engorgement) and occurs from
 Prevent Development of Hemorrhoids.
birth to 5 to 10 days postpartum; this is
often termed “transitional milk.”  Assess Peripheral Circulation.
 Lactogenesis III can occur from day 10 until  Promote Breast Hygiene.
weaning postpartum, when the “mature
Post-partum discharge instructions
milk” supply is now driven by the circulating
lactation hormones oxytocin and Work - All women should avoid heavy work (lifting
progesterone. or straining) for at least the first 3 weeks after
birth. Women differ in their concept of heavy work,
 Lactogenesis IV occurs after complete
so it is a good idea to explore what a woman
weaning and the breasts involute to their
considers heavy work. If she plans to do too much,
prelactation state.
you can perhaps help her to modify her plans. It is
PROGRESSIVE CHANGES OF THE PUERPERIUM usually advised that a woman not return to an
outside job for at least 3 weeks (or better, 6
2. RETURN OF MENSTRUAL FLOW
weeks), not only for her own health but also for
 With the delivery of the placenta, the enjoyment of the early weeks with her newborn.
production of placental estrogen and
Rest - A woman should plan at least one rest period symptoms of sadness last longer than 2
each day while her baby sleeps and try to get a weeks.
good night’s sleep. If she has other family members
 A woman should schedule a 4- to 6-week
dependent on her, explore the possibility of having
checkup so she can be assured involution is
a neighbor, another family member, or a person
complete and immunization if not
from a community health agency relieve her so she
previously immunized against the virus
can rest.
associated with cervical cancer (human
Exercise - A woman should limit the number of papillomavirus) can be administered and so
stairs she climbs to one flight/day for the first week reproductive life planning (if desired) can be
at home. This limitation may involve some planning discussed.
on her part, especially if her washing machine is in
The newborn’s profile
the basement or if she must go up and down stairs
to check on her baby. Help her plan for a place for 1.Weight
the baby to sleep downstairs to alleviate the
 The average birth weight (50th percentile)
second concern. She should continue with muscle-
for a mature female newborn is 3.4 kg (7.5
strengthening exercises, such as abdominal
lb) and for a mature male newborn is 3.5 kg
crunches.
(7.7 lb).
Hygiene - A woman may take either tub baths or
 During the first few days after birth, a
showers. She should continue to apply any perineal
newborn loses 5% to 10% of birth weight (6
cream or ointment. Remind her to cleanse her
to 10 oz). This weight loss occurs because a
perineum from front to back after voiding to
newborn is no longer under the influence of
prevent fecal contamination. Any perineal stitches
salt- and fluid-retaining maternal hormones.
will be absorbed within 10 days.
This causes diuresis to begin to remove a
Coitus - Coitus is safe as soon as a woman’s lochia part of the infant’s high fluid load.
has turned to alba and, if present, an episiotomy is
 If a term newborn weighs more than 4.7 kg,
healed (usually the first week after birth). Vaginal
the baby is said to be macrosomic, a
cells may not be as thick as formerly because pre-
condition that usually occurs in conjunction
pregnancy hormone balance has not yet
with a maternal illness, such as gestational
completely returned to supply lubrication. Use of a
diabetes.
contraceptive foam or lubricating jelly will aid
comfort. Be certain she knows safer sex 2. Length
precautions.
 The average birth length (50th percentile)
Contraception of a mature female newborn is 49 cm (19.2
in.).
 If desired, a woman should begin a
contraception measure with the initiation of  For mature males, the average birth length
coitus. If she wants an intrauterine device, is 50 cm (19.6 in.).
this may be fitted immediately after birth or
 The lower limit of expected birth length is
at her first postpartum checkup.
arbitrarily set at 46 cm (18 in.).
 Combination oral contraceptives are begun
 Although rare, babies with lengths as great
about 2–3 weeks after birth due to clotting
as 57.5 cm (24 in.) have been reported.
factor risks and interference with milk
production for women who are 3. Head Circumference
breastfeeding (progestin-only oral
 In a mature newborn, the head
contraceptives can be started earlier). A
circumference is usually 34 to 35 cm (13.5
diaphragm must be refitted at a 6-week
to 14 in.).
checkup. Until she returns for this checkup,
an over-the-counter spermicidal jelly and  A mature newborn with a head
condoms can provide protection. circumference greater than 37 cm (14.8 in.)
or less than 33 cm (13.2 in.) should be
Follow-up
carefully assessed for neurologic
 A woman should notify her primary care involvement, although some well newborns
provider if she notices an increase, not a have these measurements.
decrease, in lochial discharge, or if lochia
 4. Chest Circumference
serosa or lochia alba becomes lochia rubra;
if lochia has a foul odor; if she has a
temperature greater than 101°F; or if
  The chest circumference in a term newborn wrapping them and placing them in warmed cribs,
is about 2 cm (0.75 to 1 in.) less than head or drying and placing them under a radiant heat
circumference. source is an excellent mechanical measure to help
conserve heat or prevent heat loss. Perform all
 Chest circumference is measured at the
early newborn care speedily and expose the
level of the nipples. If a large amount of
newborn to cool air as little as possible. Be certain
breast tissue or edema of the breasts is
that any procedure during which a newborn must
present, this measurement will not be
be uncovered such as resuscitation or circumcision
accurate until the edema has subsided.
is done under a radiant heat source.
Temperature The temperature of newborns is
Pulse
about 99°F (37.2°C) at birth because they have
been confined in their mother’s warm and  The heart rate of a fetus in utero averages
supportive uterus. Temperature will fall almost 110 to 160 beats/min. Immediately after
immediately to below normal because of heat loss, birth, as the newborn struggles to initiate
the temperature of birthing rooms (approximately respirations, the heart rate may be as rapid
68° to 72°F [21° to 22°C), and the infant’s immature as 180 beats/min.
temperature regulating mechanisms if the baby is
 Within 1 hour after birth, as the newborn
not protected from heat loss at birth and in the
settles down to sleep, the heart rate
moments afterward.
stabilizes to an average of 120 to 140
Convection is the flow of heat from the newborn’s beats/min. The heart rate of a newborn
body surface to cooler surrounding air. Eliminating often remains slightly of the cardiac
drafts, such as from air conditioners, is an regulatory center in the medulla, and
important way to reduce convection heat loss. transient murmurs may result from the
incomplete closure of fetal circulation
Radiation is the transfer of body heat to a cooler
shunts.
solid object not in contact with the baby, such as a
cold window or air conditioner. Moving an infant as  During crying, the rate may rise again to
far from the cold surface as possible helps reduce 180 beats/min. In addition, heart rate can
this type of heat loss. decrease during sleep, ranging from 90 to
110 beats/min.
Conduction is the transfer of body heat to a cooler
solid object in contact with a baby. For example, a 3. Respiration
baby placed on the cold base of a warming unit
 The respiratory rate of a newborn in the
quickly loses heat to the colder metal surface.
first few minutes of life may be as high as
Covering surfaces with a warmed blanket or towel
90 breaths/min. As respiratory activity is
is necessary to help minimize conduction heat loss.
established and maintained over the next
Evaporation is loss of heat through conversion of a hour, this rate will settle to an average of 30
liquid to a vapor. Newborns are wet when born, so to 60 breaths/min. Respiratory depth, rate,
they can lose a great deal of heat as the amniotic and rhythm are likely to be irregular, and
fluid on their skin evaporates. To prevent this type short periods of apnea (without cyanosis),
of heat loss, lay a newborn on the mother’s sometimes called periodic respirations, are
abdomen immediately after birth and cover with a also common and normal during this time.
warm blanket for skin-to-skin contact. Respiratory rate can be observed most
easily by watching the movement of a
Newborns can conserve heat by constricting blood
newborn’s abdomen because breathing
vessels and moving blood away from the skin.
primarily involves the use of the diaphragm
Brown fat, a special tissue found in mature
and abdominal muscles.
newborns, apparently helps to conserve or produce
body heat by increasing metabolism as well as 4. Blood Pressure
regulating body temperature similar to that of a
 The blood pressure of a newborn is
hibernating animal. The greatest amounts of brown
approximately 80/46 mmHg at birth. By the
fat are found in the intrascapular region, the
10th day, it rises to about 100/50 mmHg and
thorax, and behind the kidneys.
remains at that level for the infant year.
Other ways newborns are able to increase their Because measurement of blood pressure in
metabolic rate and produce more heat include newborns is somewhat inaccurate due to
kicking and crying. the small size of their arms, it is not
routinely measured unless a cardiac
Drying and placing newborns on their mother’s
anomaly is suspected. For an accurate
abdomen (covered by a warm blanket), drying and
reading, the cuff width used must be no
 more than two thirds the length of the increased, therefore, is not evidence of
upper arm or thigh infection but reflects how stressful an event
birth is for a fetus. However, although the
PHYSIOLOGIC FUNCTIONS OF THE NEWBORN
high white blood cell count makes infection
Cardiovascular System Changes in the difficult to prove in a newborn, infection
cardiovascular system are necessary after birth must not be dismissed as a possibility if
because now, the lungs are responsible for other signs of infection such as pallor,
oxygenating blood that was formerly oxygenated respiratory difficulty, or cyanosis are
by the placenta. As soon as the umbilical cord is present.
clamped, which stimulates a neonate to take in
Blood Coagulation
oxygen through the lungs, fetal cardiovascular
shunts begin to close. Vitamin K, synthesized through the action of
intestinal flora, is responsible for the formation of
With the first breath, blood pressure decreases in
factor II (prothrombin), factor VII (proconvertin),
the pulmonary artery (the artery leading from the
factor IX (plasma thromboplastin component), and
heart to the lungs). As this pressure decreases, the
factor X (Stuart-Prower factor) in the clotting
ductus arteriosus, the fetal shunt between the
sequence. Because a newborn’s intestine is sterile
pulmonary artery and aorta, begins to close. At the
at birth unless membranes were ruptured more
same time, increased blood flow to the left side of
than 24 hours, it will take about 24 hours for flora
the heart causes the foramen ovale (the opening
to accumulate and for ongoing vitamin K to be
between the right and left atria) to close because
synthesized. This causes most newborns to be born
of the pressure against the lip of the structure
with a lower than usual level of vitamin K, leading
(permanent closure does not occur for weeks).
to a prolonged coagulation or prothrombin time.
With the remaining fetal circulatory structures
(umbilical vein, two umbilical arteries, and ductus Because almost all newborns can be predicted to
venosus) no longer receiving blood from the have this diminished blood coagulation ability,
placenta, the blood within them clots and closes vitamin K (AquaMEPHYTON) is usually administered
them, and the vessels atrophy over the next few intramuscularly into the lateral anterior thigh, the
weeks. preferred site for all injections in newborns,
immediately after birth.
The peripheral circulation of a newborn remains
sluggish for at least the first 24 hours, which can The Respiratory System
cause cyanosis in the infant’s feet and hands
A first breath is a major undertaking because it
(acrocyanosis) and for a newborn’s feet to feel cold
requires a tremendous amount of pressure (about
to the touch.
40 to 70 cm H2O) for a newborn to be able to
Blood Values - A newborn’s blood volume is 80 to inflate alveoli for the first time. The reflex to
110 ml/kg of body weight or about 300 ml total. breathe is initiated by a combination of cold
Because a newborn has more red blood cells than receptors; a lowered partial pressure of oxygen
the average adult, the hemoglobin level averages (PO2), which falls from 80 mmHg to as low as 15
17 to 18 g/100 ml of blood (the average for an mmHg before a first breath; and an increased
adult is 11 to 12 g/ml). A newborn’s hematocrit is partial carbon dioxide pressure (PCO2), which rises
between 45% and 50% (for an adult, 36% to 45%). as high as 70 mmHg before a first breath.
A newborn’s red blood cell count is about 6 million
Some fluid present in the lungs from intrauterine
cells/mm3 (for an adult, 3.5 to 5.5 million
life makes a newborn’s first breath possible
cells/mm3).
because fluid eases surface tension on alveolar
Once proper lung oxygenation has been walls and allows alveoli to inflate more easily than
established, the need for the high red cell count if the lung walls were dry. About one third of this
diminishes so, within a matter of days, red cells fluid is forced out of the lungs by the pressure of
begin to be destroyed. As these cells are broken vaginal birth. The rest of the fluid is quickly
down, bilirubin is released and the serum indirect absorbed by lung blood vessels and lymphatics
bilirubin level rises. At birth, the indirect bilirubin after the first breath.
level is between 1 and 4 mg/100 ml. Any increase
Once the alveoli have been inflated this first time,
over this amount reflects that excessive red blood
breathing becomes much easier for a baby,
cells have begun their breakdown.
requiring only about 6 to 8 cm H2O pressure.
A newborn has a corresponding high white Within 10 minutes after birth, most newborns have
blood cell count, about 15,000 to 30,000 established easy respirations as well as a good
cells/mm3 at birth (40,000 cells/mm3 if the residual volume. By 10 to 12 hours of age, vita
birth was stressful). Seeing the count capacity is established at newborn proportions (the
heart in a newborn takes up proportionately more  • Occasionally, a newborn has swallowed
space than in an adult, so the amount of lung some maternal blood during birth and
expansion space available for a large vital capacity either vomits fresh blood immediately after
is limited). birth or passes a black tarry stool after two
or more days. Whether bleeding is caused
A baby born by cesarean birth does not have as
by ingestion of maternal blood at birth or
much lung fluid expelled at birth as one born
newborn bleeding may be differentiated by
vaginally and so typically has more difficulty
a dipstick Apt- Downey test. If stools remain
establishing respiration because excessive fluid
black or tarry, this suggests newborn
blocks air exchange space. Preterm newborn
intestinal bleeding rather than swallowed
alveoli may collapse each time they exhale
blood.
(because of the lack of pulmonary surfactant). As a
result, they also have difficulty establishing  If mucus is mixed with stool or the stool is
effective residual capacity and respirations. In watery and loose, a milk allergy, lactose
these infants, because alveoli do not open well, the intolerance, or some other condition
foramen ovale and ductus arteriosus also may not interfering with digestion or absorption is
close as usual. This happens because their closure suspected.
depends on free blood flow through the pulmonary
The Urinary System
artery and good oxygenation of blood.
The average newborn voids within 24 hours after
The Gastrointestinal System
birth. A newborn who does not take in much fluid
The first stool of a newborn is usually passed within for the first 24 hours may void later than this, but
24 hours after birth. It consists of meconium, a the 24-hour point is a general rule. Newborns who
sticky, tar-like, blackish-green, odorless material do not void within this time need to be assessed for
formed from mucus, vernix, lanugo, hormones, and the possibility of urethral stenosis or absent
carbohydrates that accumulated in the bowel kidneys or ureters.
during intrauterine life. If a newborn does not pass
The kidneys of newborns do not concentrate urine
a meconium stool by 24 to 48 hours after birth, the
well, making newborn urine usually light colored
possibility of some problem such as meconium
and odorless. The infant is about 6 weeks of age
ileus, imperforate anus, or volvulus should be
before much control over reabsorption of fluid in
suspected.
tubules and concentration of urine becomes
About the second or third day of life, newborn evident.
stool changes in color and consistency. Termed a
A single voiding in a newborn is only about 15 ml
transitional stool, bowel contents appear both
and may be easily missed in an absorbent diaper.
loose and green; they may resemble diarrhea to
Specific gravity ranges from 1.008 to 1.010. The
the untrained eye.
daily urinary output for the first 1 or 2 days is about
By the fourth day of life, breastfed babies pass 30 to 60 ml total. By week 1, total daily volume
three or four light yellow stools per day that have a rises to about 300 ml. The first voiding may be pink
soft consistency. They are not foul smelling or dusky because of uric acid crystals that were
because breast milk is high in lactic acid, which formed in the bladder in utero; this looks a lot like
reduces the amount of putrefactive organisms in blood in urine but is an innocent finding. If tested
the stool. for protein, a small amount may be normally
present in voidings for the first few days of life until
 A newborn who receives formula usually
the kidney glomeruli are more mature. Diapers can
passes two or three bright yellow stools a
be weighed to determine the amount and timing of
day of soft consistency. These have a more
voiding, which is done when there is a concern.
noticeable odor, compared with those of
breastfed babies. The possibility of obstruction in the urinary tract
can also be assessed by observing the force of the
 A newborn placed under phototherapy
urinary stream in both male and female infants.
lights as therapy for jaundice will have
Males should void with enough force to produce a
bright green stools because of increased
small projected arc; females should produce a
bilirubin excretion.
steady stream, not just continuous dribbling.
 Newborns with bile duct obstruction have Projecting urine farther than normal may signal
clay-colored (gray) stools because bile urethral obstruction because it indicates urine is
pigments cannot enter the intestinal tract. being forced through a narrow channel.

 Blood-flecked stools usually indicate an The Immune System

anal fissure.
Newborns have limited immunologic protection at fetus in utero, for example, will swallow amniotic
birth because they are not able to produce fluid more rapidly than usual if glucose is added to
antibodies until about 2 months (the reason most sweeten its taste. The swallowing decreases if a
immunizations are not administered until 2 months bitter flavor is added. After birth, a baby continues
of age). Newborns are, however, born with passive to show a preference for sweet over bitter tastes.
antibodies (immunoglobulin G) passed to them
The Senses: Smell The sense of smell is present in
from their mother that crossed the placenta. In
newborns as soon as the nose is clear of lung and
most instances, these include antibodies against
amniotic fluid. Newborns probably turn toward
poliomyelitis, measles, diphtheria, pertussis,
their mothers’ breasts partly out of recognition of
chickenpox, rubella, and tetanus.
the smell of breast milk and partly as a
Newborns are routinely administered a hepatitis B manifestation of the rooting reflex.
vaccine before they leave their birth setting to
Assessments for Well-Being
promote antibody formation against this disease
(CDC, 2016). Because the newborn has little natural
immunity against herpes simplex, healthcare
personnel with herpes simplex eruptions (cold
sores) should not care for newborns until the
lesions have crusted. Without antibody protection,
herpes simplex type 2 infections can become
systemic or create a rapidly fatal form of the
disease in a newborn.
The Senses: HEARING Newborns appear to
recognize their mother’s voice almost immediately
and calm to the sound since they have heard it in
PHYSICAL ASSESSMENT OF THE NEWBORN
utero. In fact, by 25 to 27 weeks gestation, hearing
is functional and the fetus can hear the mother’s SKIN
heartbeat and voice. Hearing continues to develop
At birth: bright red, puffy, smooth
so that the fetus hears a broader range of
frequencies throughout gestation and shortly after 2nd-3rd day: pink, flaky, dry
birth. As soon as amniotic fluid drains or is
LANUGO: very thin, soft, usually unpigmented,
absorbed from the middle ear by way of the
downy hair that is sometimes found on the body of
eustachian tube within hours after birth, hearing
a fetal or new-born human appears 6 weeks of life
becomes acute. Newborns respond with
at shoulder and back
generalized activity to a sound such as a bell. They
appear to have difficulty locating where a sound is ACROCYANOSIS: blue hands and feet (peripheral
coming from. circulation is sluggish within 24 hours
The Senses: VISION A pupillary reflex or ability to CUTIS MORMORATA: transient mottling of skin
contract the pupil is present from birth. The fetus when exposed to decreased temperature
has a blink or squint reflex in response to a bright
VERNIX CASEOSA: also known as vernix or birthing
light in utero by 26 weeks gestation; newborns
custard, is the waxy white substance found coating
demonstrate they can see by blinking at a strong
the skin of newborn human babies. It is produced
light (blink reflex) or by following a bright light or
by dedicated cells and is thought to have some
toy a short distance with their eyes as soon as they
protective roles during fetal development and for
are born. Be certain parents know their newborn
few hours after birth.
cannot follow an object past the midline or appears
to lose track of objects easily. Teach also that COMMON VARIATIONS:
newborns focus best on black and white objects at
 Neonatal jaundice(physiologic jaundice)
a distance of 9 to 12 in.
after the 1st 24 hours
The Senses: Touch The sense of touch is also well
 Ecchymoses or petechial caused by birth
developed at birth. Newborns quiet down at a
trauma
soothing touch, cry at painful stimuli, and show
sucking and rooting reflexes that are elicited by  Milia: tiny white papules on cheeks, chin,
touch. nose
The Senses: Taste A newborn has the ability to  Erhythema toxicum: pink popular rash with
discriminate taste because taste buds are vesicles in thorax, back ,buttocks and
developed and functioning even before birth. A
 abdomen. Appears in 24 to 48 hours and  Bulging or depressed fontanels when quiet
subsides after several days
 Widened sutures and fontanels
 Harlequin color change: outlined color
 Craniotabes- snapping sensation along the
change as infant lies on side, lower half
lamboid suture(resembles indention of
becomes pink and upper half is pale
pingpong balls)
 Mongolian spots: irregular areas of deep
Eyes
blue pigmentation in sacral and gluteal
regions Lids usually edematous
 Telangiectatic nevi or stork bites: flat deep Color-slate gray, dark blue and brown
pink localized area on back of the neck.
Absence of tears
Disappears at 2 years of age
Corneal reflex (responses to touch)
Signs of distress(potential)
Pupillary reflex (response to light)
 Progressive jaundice within 24 hours of life
Blink reflex (response to touch or light)
 Generalized cyanosis after 24 hours:
congenital heart defect Rudimentary fixation on objects and ability to
follow to midline
 Pallor
Common variations:
 Mottling
 Epicanthal folds: oriental infants
 Grayness
 Nystagmus or strabismus
 Plethora
 Subconjunctival (scleral)hemorrhage
 Sclerema
Signs of distress(potential)
 Poor skin turgor
 Pink color of iris
 Rashes, pustules or blisters
 Purulent discharge
 Café-au-lait spots(light brown spots)
 Upward slant in non-orientals
 Nevus flammeus
 Hypertelorism (3cm greater)
 Hemorrhage, ecchymoses or petechiae that
persist  Hypotelorism
Head - Anterior fontanelle: diamond shape (2.5cm -  Congenital cataracts
4cm),closes at 12 to 18 months
 Constricted or dilated fixed pupil
Posterior fontanelle: triangular shape (0.5-1
 Yellow sclera
cm),closes at 2 months
 Absence of red reflex, papillary or corneal
Fontanelles should be flat, soft and firm. Widest
reflex
part measured from bone to bone, not suture to
suture  Inability to follow object or bright light to
midline
HEAD
 Hypertelorism is an abnormally increased
Common variations:
distance between two organs or bodily
 Molding following vaginal delivery parts, usually referring to an increased
distance between the orbits (eyes), or
 Bulging fontanelle because of crying and
orbital hypertelorism. In this condition the
coughing
distance between the inner eye corners as
 Caput succedaneum-edema of soft scalp well as the distance between the pupils is
tissue greater than normal.
 Cephalhematoma (uncomplicated)-  Hypotelorism is an abnormally decreased
hematoma between the periosteum and distance between two organs or bodily
skull bones parts, usually pertaining to the eye
sockets(orbits) also known as orbital
Signs of Distress (Potential)
hypotelorism.
 Fused sutures
  Strabismus (crossed eyes) is a common eye Other reflexes: rooting, gag and extrusion
condition among children. It is when the
Absent or minimal salivation
eyes are not lined up properly and they
point in different directions (misaligned). Vigorous cry
One eye may look straight ahead while the
Common variations:
other eye turns in, out, up, or down. The
misalignment can shift from one eye to the  Natal teeth-teeth present at birth, benign
other. but my be associated with congenital
defects
Nystagmus is a condition where the eyes move
rapidly and uncontrollably. They can move:  Epstein pearls-small, white epithelial
cysts(midline of hard palate)
• side to side (horizontal nystagmus)
Signs of distress:
• up and down (vertical nystagmus)
 Cleft lip
• in a circle (rotary nystagmus)
 Cleft palate
EARS
 Large, protruding tongue or posterior
Pinna in line with outer canthus of the eye
displacement of tongue
Pinna flexible, cartilage present
 Profuse salivation or drooling
Startle reflex is elicited by loud, sudden noise
 Candidiasis
Common variations
 Cleft lip and cleft palate, also known
 Inability to visualize tympanic as orofacial cleft, is a group of conditions
membrane(filled aural canals) that includes cleft lip, cleft palate, and both
together. A cleft lip contains an opening in
 Pinna flat against head
the upper lip that may extend into the
 Irregular shape or size nose. The opening may be on one side, both
sides, or in the middle. A cleft palate occurs
 Pits or skin tags
when the roof of the mouth contains an
Signs of distress(potential) opening into the nose. These disorders can
result in feeding problems, speech
 Low set ears and minor
problems, hearing problems, and
abnormalities(chromosomal defect and
frequent ear infections. Less than half the
kidney anomaly)
time the condition is associated with other
 Absence of startle reflex in response to loud disorders.
noises
 Cleft lip and palate are the result of tissues
NOSE of the face not joining properly
during development. As such, they are a
Nasal patency
type of birth defect. The cause is unknown
Thin white mucus in most cases. Risk factors include smoking
during pregnancy, diabetes, obesity, an
Sneezing
older mother and certain medications and
Common variations: certain medications (such as some used to
treat seizures).Cleft lip and cleft palate can
 Flattened and bruised
often be diagnosed during pregnancy with
Signs of distress(potential) an ultrasound exam.

 Non-patent canals  A cleft lip or palate can be successfully

treated with surgery. This is often done in
 Thick, bloody discharge
the first few months of life for cleft lip and
 Alae nasi (nasal flaring) before eighteen months for cleft
palate. Speech therapy and dental care may
MOUTH AND THROAT
also be needed. With appropriate
Intact, high-arched palate treatment, outcomes are good.

Uvula in midline CHEST

Sucking reflex(strong and coordinated) Anterior-posterior and lateral diameters equal

Slight sternal retractions (evident during  Sinus arrthymias: heart rate increases with
inspiration) inspiration and decreases with expiration
Xiphoid process evident  Transient cyanosis when crying or straining
Breast enlargement Signs of distress:
Common variations:  Dextrocardia-heart on right side
 Pectus excavatum (funnel chest)  Cardiomegaly
 Pectus carinatum (pigeon chest)  Displacement of apex, muffled
 Supernumerary nipples  Abdominal shunts
 Witch’s milk  Murmurs and thrills
Signs of distress:  Persistent cyanosis
 Depressed sternum  Hyperactive precordium
 Marked retraction of chest and ICS(during ABDOMEN
respiration)
Cylindrical in shape
 Assymmetric chest expansion
liver: palpable 2-3 cm below right costal margin
 Redness and firmness around nipples
Spleen: tip palpable at end of 1st week of age
 Wide-spaced nipples
Kidneys: palpable 1-2cm above umbilicus
LUNGS
Umbilical cord: bluish white at birth,2 arteries and
Abdominal respiration 1 vein
Cough reflex: absent at birth, present by 1-2 days Femoral pulses: equal bilaterally
Bilateral equal bronchial breath sounds Common variations:
Common variations:  Umbilical hernia
 Irregular rate and depth respirations  Diastasis recti-midline gap between recti
muscles
 Periodic breathing
 Wharton jelly
 Crackles shortly after birth
Signs of distress:
Signs of distress:
 Abdominal distention
 Inspiratory stridor
 Localized bulging
 Expiratory grunt and retractions
 Distended veins
 Persistent irregular breathing
 Absent bowel sounds
 Periodic breathing with repeated apneic
spells  Enlarged spleen and liver
 Seesaw respirations(paradoxical)  Ascites
 Unequal and diminished breath sounds  Visible peristaltic waves
 Persistent fine crackles  Scaphoid or concave abdomen
 Wheezing  Green umbilical cord
 Peristaltic bowel sounds on one side, with  Presence of only 1 artery in cord
diminished breath sounds on the same side
 Urine or stool leaking from cord
HEART
 Palpable bladder distention following scanty
S2 slightly sharper and higher pitch than S1 voiding
Apex: 4th to 5th ICS, lateral to left sternal border FEMALE GENITALIA
Common variations: Edematous labia and clitoris
Urethral meatus behind clitoris
Vernix caseosa between labia BACK AND RECTUM
Urination within 24 hours Spine intact, no openings, masses or prominent
curves
Common variations:
Trunk incurvation reflex
 Pseudomenstruation: blood tinged or
mucoid discharge Anal reflex
Signs of distress: Patent anal opening
 Enlarged clitoris with urethral meatus at tip Passage of meconium within 48 hours
 Fused labia Common variations:
 Absence of vaginal opening  Green liquid stools in infants
 Masses in labia ( under phototherapy)
 Meconium from vaginal opening  Delayed passages of meconium in very low-
birth-weight neonates
 Ambiguous genitalia
Signs of distress(potential)
 No urination within 24 hours
 Anal fissures or fistulas
MALE GENITALIA
 Imperforate anus
Urethral opening at the tip of glans penis
 Absence of anal reflex
Testes palpable in each scrotum
 Pilonidal cyst or sinus
Scrotum usually large, edematous, pendulous, and
covered with rugae, usually deep pigmented(dark  No meconium within 36-48 hours
skinned)
 Tuft of hair (spine)
Urination within 24 hours
 Any degree of spina bifida
Common variations:
EXTREMITIES
 Urethral opening covered by prepuce
Complete fingers and toes
 Inability to retract foreskin
Full range of motion
 Epithelial pearls(small, firm, white lesion at
Nail beds pink, with transient cyanosis
tip of prepuce)
(immediately after birth)
 Erection or priaprism
Creases on anterior 2/3 of sole
 Testes palpable in inguinal canal
Sole usually flat
Signs of distress:
Symmetry of extremities
 Hypospadias(urethral opening at ventral
Equal bilateral muscle tone
surface)
Equal bilateral brachial pulses
 Epispadias (urethral opening at dorsal
surface Common variations:
 Chordee (ventral curvature)  Partial syndactyly between 2nd and 3rd toes
 Testes not palpable in scrotum or inguinal  2nd toe overlapping the 3rd toe
canal
 Wide gap between 1st ( hallux) and 2nd toes
 No urinal within 24 hours
 Deep crease on plantar surface of foot
 Inguinal hernia between 1st and 2nd toes
 Hypoplastic scrotum  Asymmetric length of toes
 Hydrocele  Dorsiflexion and shortness of hallux
 Masses in scrotum Common variations:
 Discoloration of testes  Polydactyly
 Ambiguous genitalia  Syndactyly
  Phocomelia (hands or feet attached close to
trunk)
The sen
 Hemimilia (absence of distal part extremity of
sme
 Hyperflexibility of joints
pres
 Persistent cyanosis of nail beds in
new
 Yellowing of nail beds
ns a
 Sole covered with creases soon
the
 Simian crease
nose
 Fractures clea
lung
 Decreased or absent range of motion
and
 Dislocated or subluxated hip amn
c flu
 Limitation in hip abduction
New
 Unequal gluteal or leg folds rns
prob
 Allis or Galeazzi’s sign(unequal knees
y tur
height)
towa
 Ortolani’s sign their
mot
 Asymmetry of extremities
s’
 Unequal muscle tone or range of motion brea
part
NEUROMUSCULAR
out
Extremities maintain some degree of flexion reco
tion
Extension of extremity followed by previous
the
position of flexion
sme
Head lag while sitting, momentary ability to hold of
head erect brea
milk
Turns head from side to side (prone) and
Hold head in horizontal line with back( prone) part
as a
Common variations: man
 Quivering or momentary tremors stati
of th
Signs of distress(potential) rooti
 Hypotonia refle

 Hypertonia
 Asymmetric posturing (except tonic-neck
reflex)
 Opisthotonic posturing
 Tremors, twitches, and myoclonic jerks
 Marked head lag in all position