SESSION #12 2 Divisions of the Pelvis:

I. COMPONENTS OF LABOR FALSE PELVIS- upper half which

supports the uterus during the late
5 P’s: months of pregnancy & aids in
1. PELVIS (the PASSAGE) directing the fetus into the true pelvis
2. FETUS (the PASSENGER) for birth
3. Uterine factors (POWERS of labor) TRUE PELVIS- lower half of the
4. a woman’s PSYCHE pelvis; long, bony, curved canal
5. POSITION divided into 3 parts:
o inlet,
If the 5 components: o pelvic cavity
o outlet
(1) the woman’s PELVIS (the passage)
is adequate size & contour
(2) the FETUS (the passenger) is of  LINEA TERMINALIS or BRIM
appropriate size & in an advantageous imaginary line from the sacral
position & presentation promontory to the superior border of
(3) the uterine factors (powers of the SP which divides the pelvis into
labor) are adequate true & false pelves
(4) her (Position) is comfortable and 1. Types of Female Pelvic Shapes
facilitates the labor process
(5) the woman’s PSYCHE is preserved a. Gynecoid Pelvis “FEMALE”
so that afterward, labor can be viewed
as a positive experience Has an inlet that is well-
rounded and has a wide pubic
A. PASSAGEWAY or PASSAGE (PELVIS) arch
Ideal for childbirth
Refers to the route a fetus must
travel from the uterus through the b. Android- “MALE”
cervix & vagina to the external
perineum The pubic arch forms an
It is the mother’s bony pelvis and soft acute angle, making the lower
tissues of the cervix, pelvic floor, vagina dimensions of the pelvis
and introitus extremely narrow
A fetus may have difficulty
Functions exiting from this type of pelvis

Support & protect the reproductive & c. Anthropoid- “APE-LIKE”

other pelvic organs
Accommodation of the growing fetus Its transverse diameter is
Anchorage of the pelvic support narrow; the anteroposterior
structures diameter of the inlet is larger
than usual.
Composition Even though the inlet is large,
the shape of the pelvis does not
Anterior & lateral portion made up of 2 accommodate a fetal head as
innominate hip bones divided into 3 well as the gynecoid pelvis
parts (ilium, ischium and pubis)
d. Platypelloid – “Flattened” (oval)

It has a smoothly-curved oval

inlet, but the anteroposterior
diameter is shallow.

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 A fetal head might not be able to Measurement of the Transverse Diameter of
rotate to match the curves of the the Outlet
pelvic cavity
a. TUBERO-ISCHIAL or BI-ISCHIAL
2. ESTIMATING PELVIC SIZE (PELVIMETRY) Diameter of the Outlet

2 important pelvic measurements to It is the distance between the

determine the adequacy of the pelvic ischial tuberosities, or the
size: transverse diameter of the
- the DIAGONAL CONJUGATE outlet (the narrowest diameter
(anterior-posterior diameter of at that level, ot the one most apt
the inlet) to cause a misfit)
- the TUBERO-ISCHIAL or BI- It is made at the medial and
ISCHIAL DIAMETER lowermost aspect of the
(transverse diameter of the ischial tuberosities, at the
outlet) level of the anus
DC (Diagonal conjugate) is the Diameter of 11 cm is considered
narrowest diameter of the inlet & the adequate because it will allow
(TD) Tubero-ischial Diameter is the the widest diameter of the fetal
narrowest diameter of the outlet (11.5 head, or 9 cm, to pass freely
cm) through the outlet
TD of pelvic cavity/inter-spinous
diameter= 10 cm
TD of outlet/bi-ischial diameter= 11.5

Anteroposterior Measurements of the Inlet

a. DIAGONAL CONJUGATE= 10.5 - 11 cm.

o It is the measurement between the

anterior surface of the sacral
prominence (sacral promontory) and
the posterior surface (inferior margin)
of the symphysis pubis
o measured by internal examination; AP
diameter

b. OBSTETRIC CONJUGATE= > 10 cm.

o It is the distance between the

midpoint of the sacral promontory &
the midline of the symphysis pubis
which is ascertained by subtracting 1
to 1.5 cm from the diagonal conjugate
o OC= DC – 1 to 1.5

c. TRUE CONJUGATE/CONJUGATA VERA= >

11 cm.

o It is the distance between the midpoint

of the sacral promontory and the
upper or superior margin of the
symphysis pubis

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SESSION #13

PASSENGER (FETUS) A. SUBOCCIPITOBREGMATIC DIAMETER-

narrowest, about 9.5 cm, from the inferior
The head is the body part of the fetus aspect of the occiput to the center of the
with the largest diameter anterior fontanelle
- Its ability to fit depends on its
structure (bones, fontanelles, B. OCCIPITOFRONTAL DIAMETER- about 12
suture lines) & its alignment with cm, measured from the bridge of the nose to
the pelvis the occipital prominence
The Cranium is composed of 8 bones:
C. OCCIPITOMENTAL DIAMETER- widest
frontal, 2 parietal, occipital, sphenoid,
(Anterior Posterior (AP) diameter, 13.5 cm;
ethmoid & 2 temporal bones
measured from the chin to the posterior
Cranial sutures are fibrous joints
fontanelle
connecting the bones of the skull,
allowing the bones to move & overlap The AP diameter presented depends on the
(molding), diminishing the size of the degree of flexion of the fetal head
skull so that it can pass through the birth
canal Full flexion- head flexes sharply that the chin
o Sagittal suture- joins the 2 rests on the thorax; suboccipitobregmatic
parietal bones diameter will be presented
o Coronal suture- line of
Moderate flexion- occipitofrontal diameter is
juncture of the frontal bones presented
& the 2 parietal bones
o Lambdoid suture- juncture of Poor flexion- head is hyperextended; the
the occipital bone & the 2 largest diameter, occipitomental diameter is
parietal bones presented

ANATOMY OF THE FETAL SKULL Molding

FONTANELLES- membrane-covered  Refers to change in the shape of the

spaces found at the juncture of the fetal skull produced by the force of
main suture lines the uterine contractions pressing the
vertex of the head against the not-
ANTERIOR FONTANELLE (BREGMA)- at the yet-dilated cervix; the incompletely
junction of the coronal & sagittal sutures, ossified bones will overlap making
diamond-shaped; closes at 18 mos the head longer & narrower
POSTERIOR FONTANELLE(LAMBDA)- at the  Molding lasts only a day or 2
junction of the lambdoidal & sagittal sutures,
1. FETAL ATTITUDE
triangular and smaller than the bregma;
closes at 2-3 mos It describes the degree of flexion a
fetus assumes during labor or the
VERTEX- the space between the fontanelles
relation of the fetal parts to each
Diameters of the Fetal Skull other

It is wider in the anteroposterior A. NORMAL or GOOD ATTITUDE: the chin

diameter than the transverse touches the sternum, arms are flexed &
diameter. folded on the chest, thighs flexed onto the
To fit in the birth canal, the smallest abdomen, calves pressed against the
diameter of the skull (Transverse posterior aspect of the thighs; presents the
Diameter (TD) must present to the smallest AP diameter of the skull
smallest diameter of the pelvis

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  It refers to the relationship of the
presenting part of the fetus to the level
B. MODERATE FLEXION- chin is NOT
of the ischial spines
touching the chest but, in an alert, or
 0 station- at the level of the ischial
“MILITARY POSITION”; presents the next-
spines; synonymous to ENGAGEMENT
widest diameter, (OCCIPITO-FRONTALIS (OF)
 -1 to -4 (Minus stations)- presenting part
C. PARTIAL EXTENSION- presents the is above the ischial spines; -4 is
‘BROW’ FLOATING
 +1 to +4 (plus stations)- presenting part
D. COMPLETE EXTENSION- or poor flexion, is below the ischial spines
back arched, neck extended; OM DIAMETER  +3 or +4- presenting part is at the
(FACE presentation); in oligohydramnios or perineum & can be seen if the vulva is
neurologic abnormality (spasticity) separated; CROWNING; +4, head is at
FETAL ENGAGMENT the outlet

3. FETAL LIE

2. FETAL ENGAGEMENT

It is the settling of the presenting part

of the fetus far enough into the pelvis
to be at the level of the ISCHIAL
SPINES, a midpoint of the pelvis
widest part of the fetus (BIPARIETAL
DIAMETER in a cephalic presentation;
the INTERTROCHANTERIC
DIAMETER in a breech presentation)
has passed through the pelvic inlet;
thus, adequate for birth.
Engagement is assessed by vaginal &
cervical examination
FLOATING- if the presenting part is
not yet engaged
DIPPING- presenting part is
descending but has not yet reached
the ischial spines

STATION

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4. FETAL PRESENTATION d. Compound Presentation

 More than 1 body part presents

5. FETAL POSITION

4 quadrants according to mother’s left &

right:

o RIGHT ANTERIOR
o LEFT ANTERIOR
o RIGHT POSTERIOR
o LEFT POSTERIOR

4parts of the fetus are chosen as landmarks to

describe the relationship of the presenting part
 It is the first body part of the fetus
to 1 of the pelvic quadrants
to enter the true pelvis and also the
first body part to come out during  In vertex presentation, it is the
delivery OCCIPUT or CHIN (MENTUM); in
TYPES OF FETAL PRESENTATION breech, SACRUM, in a shoulder
a. Cephalic Presentation- most frequent presentation, SCAPULA or ACROMION
 The fetal head is the 1st body part PROCESS
that will contact the cervix  Composed of 3 letters: middle letter
 4 types: Vertex, brow, face, mentum denotes fetal landmark (O, M, Sa, A/Sc)
 Vertex presentation is the ideal because  1st letter defines whether the landmark
skull bones are capable of molding for a is pointing to the mother’s LEFT(L) or
better fit, aids in cervical dilatation, RIGHT®
prevents cord prolapse  Last letter defines whether the
b. Breech Presentation
presenting part points anteriorly (A),
 Either the buttocks or the feet are the posteriorly(P) or transversely(T)
1st body parts that will make contact  Fastest birth- ROA or LOA position
with the cervix  Labor is extended & painful- ROP or
 Good attitude- fetal knees are up LOP
against the umbilicus  POSTERIOR positions are more
 Poor attitude- knees are extended painful because rotation of the fetal
head puts pressure on the sacral
3types of breech: nerves, causing back pain
 Complete (good flexion), Types of Positions
 Frank (moderate flexion)
 Footling breech (very poor flexion)  Breech presentation (sacrum)
- LSaA, LSaP, LSaT- same with
c. Shoulder Presentation Right
 Face Presentation- (Mentum)
 In a transverse lie, presenting part is
- LMA- left mentoanterior, LMP,
1 of the shoulders (ACROMION
LMT- same w/ right
PROCESS), iliac crest, or an elbow;
 Shoulder presentation (acromion
caused by relaxed abdominal walls (in
process)
multiparity), pelvic contraction, placenta
previa
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 - LAA- left scapuloanterior, LAP,  Increased maternal BP due to
RAA, RAP increased peripheral arteriole
pressure (Check BP between
contractions for accurate results).

SESSION #14  Myometrial contractions constrict

POWERS blood vessels decreasing
uteroplacental circulation
 This is the force supplied by the  Prolonged uterine contractions
fundus of the uterus and can cause fetal hypoxia
implemented by uterine contractions  Cervical dilation during the first
which causes cervical dilatation and stage.
then expulsion of the fetus from the
uterus. EFFACEMENT- shortening & thinning of the
 After full dilatation of the cervix, the cervical canal; normally, it is 1 to 2 cm long
primary power is supplemented by use but with effacement, the canal virtually
of a secondary power source, the disappears
abdominal muscles Primiparas- effacement occurs before
 It is important for women to understand dilatation
that they should not bear down with their
abdominal muscles to push until the Multiparas- dilatation may proceed before
cervix is fully dilated. Doing so could effacement is complete but must occur
impede the primary force and cause before the fetus can be safely pushed
fetal and cervical damage.
 Contractions with pushing/bearing
1. PRIMARY POWER: Uterine Contractions down, expel the fetus and the placenta
during the second and third stages of
a. Characteristics: labor, respectively.
 Involuntary, rhythmical, regular  Contour Changes. The uterus gradually
activity of uterine musculature differentiates into 2 distinct functioning
areas. The upper portion becomes
 Occurs intermittently by allowing for
thicker & active, preparing it to be able
a period of uterine relaxation
to exert strength necessary to expel the
between contractions followed by
fetus. The lower segment becomes thin-
uterine and maternal rest and
walled, supple & passive, so that the
restoration of uteroplacental
fetus can be pushed out easily
circulation effecting sustained fetal
 Boundary between the 2 portions
oxygenation
becomes marked by a ridge on the inner
b. Purposes: uterine surface, called the
PHYSIOLOGIC RETRACTION RING
 Propel presenting part  The uterus changes from an ovoid
downward/forward structure to an elongated one with a
 Effacement of the cervix- thinning longer vertical diameter.
out, pulling up, shortening of the
cervical canal d. 3 Phases of Uterine Contractions
 Dilatation of the cervix- opening,
1. INCREMENT (CRESCENDO)- the phase of
widening, enlarging, increasing in
increasing or ‘building up’ of a contraction;
diameter of the cervical os from 0
the first phase; the longest phase
to 10 cm
2. ACME (APEX)- the height or peak of a
c. Effects of Contractions:
uterine contraction
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3. DECREMENT (DECRESCENDO)- the phase a. Maternal bearing down/ pushing-
of decreasing contraction, “letting up”; the readiness for pushing:
last or end phase
 Cervical dilatation: 10 cm; fully dilated

 Fetal station: +1; low enough to

Measuring contractions stimulate Ferguson Reflex: maternal
involuntary urge to push stimulated by
DURATION – the period from the beginning
stretch receptors in the pelvic floor.
of increment to the completion of decrement
 Correct pushing: Take a deep breath as
of the same contraction; expressed in
soon as the next contraction begins, and
seconds; the maximum normal duration is 90
then, with breath held, exert a
seconds in the transition phase
downward pressure exactly as though
FREQUENCY- The period of time from the she were straining at stool.
beginning of 1 contraction to the beginning  Discourage prolonged maternal breath
of the next contraction; expressed in “every holding of more than 6 seconds during
___ minutes.” pushing. Support involuntary pushing,
grunting, groaning, exhaling, or breath
It is the time for checking maternal BP, FHT, holding for less than 6 seconds.
delivering the fetal head in precipitate labor to  Have 4 or more pushes per contraction.
prevent lacerations; the time for maternal
sleep and relaxation during labor. b. Intra-abdominal pressure: This is another
secondary power. As the woman pushes, the
e. Intensity- refers to the strength of a uterine intra-abdominal pressure increases.
contraction during acme, can be determined
by palpation PSYCHOLOGICAL RESPONSE OF THE
MOTHER
Palpation- placing the hand lightly on the
fundus with the fingers spread; described as 1. A pregnant woman’s general behavior and
mild, moderate and strong by judging the degree influences upon her also affect labor progress.
of indentability /depressability of the uterine wall Some FACTORS make labor a meaningful,
during acme. positive or negative event:

 When the uterine fundus is very firm and a. cultural influences – how a society
cannot be indented with fingers, the views childbirth
intensity is STRONG
b. expectations and goals for the
 When the fundus is difficult to indent,
labor process; whether realistic,
the intensity is MODERATE.
achievable, ot otherwise
 When fundus is tense but can be
indented easily with fingertips, the c. feedback from other people
intensity is MILD. participating in the labor process
Intrauterine Catheter- DIRECTLY measures 2. Pregnant woman’s psychologic responses to
the strength of contractions: uterine contractions
 At ACME: intensity ranges from 30 mm  Fear and anxiety affect labor progress.
to 55 mm Hg of pressure A woman who is relaxed, aware of, and
 Resting tonus average: 10 mm Hg participating in the birth process usually
has a shorter, less intense labor
Major disadvantage: invasive and requires a
ruptured bag of waters 3. Other factors that affect the psychological
response of the mother include:
2. SECONDARY POWERS:

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 a. Childbirth preparation process station 0 or + stations, to prevent cord
(classes)- decreased need for prolapse
analgesics in labor
c. If with intravenous line, a movable pose
should be used to allow ambulation if not
contraindicated

d. No clear-cut best position; all have

b. Support system advantages and disadvantages
 The husband’s presence during labor e. In the choice of position in labor, consider the
results to less anxiety, less emotional following criteria:
tension, less pain perception
 The attending nurse should provide a  Maternal physical and psychologic
supporting and caring environment: needs
respect the client’s/family’s needs and  Fetal well-being
attitudes and provide therapeutic
communication 2. Second Stage of Labor

4. Anticipation of pain can increase emotional a. Lithotomy position: most commonly used
tension leading to increased pain perception. in the 2nd stage; favors the healthcare
provider
5. Physiologic basis for discomfort during
labor  Ensure equal height of the stirrups
 Pad the stirrups
a. 1st stage: dilatation of the cervix,  Simultaneous placement of the legs on
pain from the uterus referred to pain to the stirrups
lower abdominal wall and thE areas
 Avoid any pressure on the popliteal
over the lower lumbar region and
region
sacrum: lumbosacral pain radiating to
the abdomen

b. 2nd stage: hypoxia of the uterine

muscles during contraction

c. Stretching of the lower uterine

segment causing pressure on adjacent
structures

POSITION OF THE PARTURIENT

1. First Stage of Labor

a. Left lateral recumbent (LLR) or Left side-

lying position- most comfortable and best for
fetal well-being as this prevents SUPINE
HYPOTENSION SYNDROME (vena caval
syndrome). Avoid supine position.

b. Optimal position may vary nd may range

from sitting, to squatting, to a semi-reclined
position, or to ambulating position.

 If bag of water is intact, may ambulate

 If bag of water has ruptured, may still
ambulate provided the station is at least

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 C. FLEXION

 As the fetal head reaches the pelvic

floor, the head bends forward onto the
chest, making the smallest diameter
(SOB) to be presented
 Flexion is aided by abdominal muscle
SESSION #15 contractions during pushing

MECHANISMS (CARDINAL MOVEMENTS) of  The head flexes as it touches the pelvic

LABOR
floor & the occiput rotates about 45°
 Involves a number of different
until it is superior or just below the
position changes to keep the
smallest diameter of the fetal head (in symphysis pubis (AP diameter of the
cephalic presentation) always fetal head is now in the AP plane of
presenting to the smallest diameters them pelvis), the best relationship
of the birth canal between the head & the outlet of the
pelvis

A. ENGAGEMENT - Engagement is assessed

by vaginal & cervical examination D. INTERNAL ROTATION

FLOATING- if the presenting part is not yet  begins at the level of the ischial
engaged spine
 Head enters the pelvis with the fetal
DIPPING- presenting part is descending but AP diameter (SOB, OM, OF) in a
has not yet reached the ischial spines diagonal or transverse position
- it refers to the relationship of the presenting because the diameter at the pelvic
part of the fetus to the level of the ischial spines inlet is widest from right to left
 It brings the shoulders in the best
0 station- at the level of the ischial spines; position to enter the inlet, putting the
synonymous to ENGAGEMENT widest diameter of the shoulders
(transverse) in line with the wide
-1 to -4 (Minus stations)- presenting part is
transverse diameter of the inlet
above the ischial spines; -4 is FLOATING
 This position also aligns the fetus in
+1 to +4 (plus stations)- presenting part is below the optimum position to continue
the ischial spines descent through the pelvic outlet

+3 or +4- presenting part is at the perineum & E. EXTENSION

can be seen if the vulva is separated;
CROWNING; +4, head is at the outlet  As the occiput is born, the back of
the neck stops beneath the pubic
B. DESCENT arch & acts as a pivot for the rest of
the head
 It is the downward movement of the  The upward resistance from the
biparietal diameter of the fetal head pelvic floor causes the head to
to the pelvic inlet extend
 Full descent- when the fetal head  The head extends & the foremost
extrudes beyond the dilated cervix & parts of the head, the face & the
touches the posterior vaginal floor chin, are born.
 It is due to pressure on the fetus by the  Further descent is halted as the
uterine fundus, causing the mother to shoulders are too wide to pass
experience a pushing sensation, aided through the pelvic arch at this
by contractions position
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F. EXTERNAL ROTATION/ RESTITUTION Importance of Determining Fetal
Presentation & Position
 Almost immediately after the head is
born, the head rotates (from the AP  Presentations other than vertex- implies
position it assumed to enter the outlet) CPD, membranes rupture early,
about 45° back to the diagonal or increased risk for fetal anoxia &
transverse position of the early part of meconium staining, long labor
the labor  Presentations other than vertex- implies
 This brings the shoulder into an AP CPD, membranes rupture early,
position, best for entering the outlet with increased risk for fetal anoxia &
the face turned facing one of the meconium staining, long labor
mother’s thighs o Abdominal inspection &
 Anterior portion of the shoulder is born palpation (LEOPOLD’S
first, assisted by downward flexion of the MANEUVER),
infant’s head o vaginal examination,
o auscultation of FHT and
G. EXPULSION
o sonography
 Once the shoulders are born, the rest of
the body is born easily because of its
smaller size, signifying the end of the
2nd stage of labor

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 3. Transition Stage
SESSION #16
 Contractions reach their peak of
STAGES OF LABOR
intensity, occurring every 2 to 3 mins
A. FIRST STAGE- divided into 3 phases: with a duration of 60 to 90 secs &
latent, active & transitional causing a maximum dilatation of 8 to 10
cm
1. Latent Phase- 6 to 8 hours  If membranes have not ruptured before,
they will rupture due to full dilatation (10
 Latent or preparatory phase begins at
cm)
the onset of regular contractions & ends
 At the end of this phase, both full
when rapid cervical dilatation begins
dilatation (10 cm) & full effacement
 Contractions are mild and short (causing
(100% or full obliteration of the cervix)
mild discomfort only), lasting from 20 to
will have occurred
40 secs.
 Woman experiences intense discomfort
 Cervical effacement begins
accompanied by nausea & vomiting,
 Cervix dilates from 0 to 3 cm
feelings of loss of control, anxiety, panic
 This stage lasts about 6 hours in a or irritability
nullipara & 4.5 hours in a multipara  As the woman reaches the end at 10
 Prolonged latent phase may be due to: cm, a new sensation, the irresistible
non-ripe cervix, analgesia, CPD urge to push, occurs.
 Encourage walking and making  Frequency 2-3 minutes; duration 60-90
preparations for birth, frequent emptying secs
of the bladder, chest breathing, time the
frequency & duration of contractions B. SECOND STAGE OF LABOR/ EXPULSIVE
 Frequency q5-30 min; Duration 20-40 STAGE
secs; intensity mild to moderate
 Duration 50-90 sec; frequency q 3 to 4
2. Active Stage- 3 to 6 hours min; intensity is severe
 It is the period from full dilatation &
 Cervical dilatation is more rapid cervical effacement (unable to feel the
increasing from 4 to 7 cm cervix) to the birth of the infant
 Contractions are stronger, lasting from  With uncomplicated birth, it takes about
40 to 60secs, occurring approximately 1to 2 hours in a nullipara & minutes for
every 3 to 5 mins multiparas
 Active phase lasts about 3 hours in a  Contractions are severe at 3 to 4-min
nullipara & 2 hours in a multipara intervals lasting for 50 to 90 secs but
 Frequency is 3 to 5 min.; duration 40-60 with a decreased frequency
secs; intensity moderate  The pattern changes to an
 Show (vaginal secretions) & perhaps overwhelming, uncontrollable urge to
rupture of the membranes occur at this push or bear down with each contraction
time as if to move her bowels
 Contractions are very strong, lasts
longer, & begin to cause discomfort Ferguson reflex- the urge to bear down as
 It can be frightening & dramatic for the the presenting part presses on the stretch
woman receptors on the pelvic floor causing release
 Administration of analgesic at this stage of oxytocin
has no effect on labor progress

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  Combination of contractions & the -firm contraction of the uterus
CARDINAL MOVEMENTS of labor help
-appearance of the placenta at the vaginal
expel the fetus
opening
 As the fetal head touches the internal
side of the perineum, the perineum Placental Expulsion
begins to bulge & appear tense
 The anus may become everted & stool  After separation, the placenta is
may be expelled. delivered either by the natural bearing-
 The vaginal introitus opens & fetal scalp down effort of the mother or by gentle
appears at the opening of the vagina pressure on the contracted uterine
 At first, the opening is slit-like, then fundus by the physician or nurse
becomes oval then circular. (CREDE’S MANEUVER)
 The circle enlarges & this is called  Never apply pressure on a postpartal
CROWNING uterus in a non-contracted state
 RITGEN’S MANEUVER because it may cause the uterus to
evert & hemorrhage
 Episiotomy may be done
 If it does not deliver spontaneously, it
C. THIRD STAGE OF LABOR- 3 to 5 mins up can be removed manually
to 1 hour  After delivery, inspect the placenta to
make sure it is intact & normal in weight
 Also called PLACENTAL STAGE & appearance (15 TO 28
 It begins with the birth of the infant & COTYLEDONS)
ends with the delivery of the placenta  With the delivery of the placenta, the 3rd
 2 separate phases occur: stage is over
PLACENTAL SEPARATION &
PLACENTAL EXPULSION 2 TYPES OF PLACENTAL PRESENTATION
 After birth of the infant, the placenta is
SCHULTZE PRESENTATION (80%)
palpated as a firm, round mass just
below the level of the umbilicus.  If the placenta separates first at its
 After a few minutes of rest, contractions center & lastly at its edges, it will fold
begin again & the placenta assumes a on itself like an umbrella & present
discoid shape and retains this shape with the FETAL SURFACE, appearing
until it has separated, about 5 minutes shiny & glistening from the fetal
up to 1 hour after the birth of the infant. membranes
Placental Separation DUNCAN PLACENTA
 Active bleeding on the maternal surface  If the placenta separates with the
of the placenta begins with separation; MATERNAL SIDE (raw, red, & irregular
the bleeding helps push it away from the with the cotyledons showing)
attachment site  Shiny SCHULTZE, dirty DUNCAN
 As separation is completed, the  Normal blood loss of placental
placenta sinks to the lower uterine separation= 300 to 500 ml until the
segment or the upper vagina uterus contracts with enough force to
seal the blood collection spaces
Signs of placental separation:
 Commonly, IV Oxytocin (PITOCIN) or IM
- lengthening of the umbilical cord Methylergonovine (METHERGINE) is
given to increase contractions &
-sudden gush of vaginal blood minimize bleeding
-change in the shape of the uterus; globular D. FOURTH STAGE OF LABOR
(CALKIN’S SIGN)- 1st sign

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  Lasts from 1 to 4 hours after birth &  At end of labor, 25,000 to 30,000
initiates postpartum period cells/mm
 is a stage of recovery & bonding
3. RESPIRATORY SYSTEM
 ↑RR to supply enough O2
 Observe appropriate breathing patterns
to prevent hyperventilation
 Nursing care:
o Monitor VS q 15 mins. for 1 hour
o Offer emotional support 4. TEMPERATURE REGULATION
o Perineal care
 Slight elevation by 1°F
o Offer regular diet as soon as
 Diaphoresis occurs to prevent
she requests for food excessive warming
 Encourage full
ambulation as soon as 5. FLUID BALANCE
possible
o Comfort measures  Increase in RR and diaphoresis
o perineum for REEDA (redness, leads to insensible water loss
edema, ecchymosis, B. PSYCHOLOGICAL RESPONSES OF A
discharges, approximation) WOMAN TO LABOR
o Observe for complications:
hemorrhage, bladder distention,  PAIN- reduces her ability to cope
thrombosis  FEAR- lack of control and fear of
o Encourage voiding because a the outcome
full bladder interferes with  Cultural Influences-adapt care to
contractions woman’s specific circumstances

II. MATERNAL AND FETAL RESPONSES TO III. DANGER SIGNS OF LABOR

LABOR
A. Maternal Danger Signs:
A. PHYSIOLOGIC EFFECTS OF LABOR ON A
1. High or Low BP- systolic pressure >140 mm
WOMAN
Hg, diastolic pressure >90 mm Hg or increase of
1. CARDIOVASCULAR SYSTEM 30 mm Hg may be a sign of PIH

a. Cardiac Output- contractions -sudden drop in BP may be the 1st sign of

decrease blood flow to the uterus & intrauterine bleeding
increases blood in maternal circulation
2. Abnormal Pulse (PR = 70-80bpm)- >100
increasing peripheral resistance (↑ BP,
bpm may be a sign of hemorrhage
↑Cardiac output by 40% to 50%)
3. Inadequate or Prolonged Contractions-
-blood loss with birth (300-500ml)
uterine exhaustion
compensated by increase in blood
volume during pregnancy 4. Pathologic Retraction Rings- indentation
across a woman’s abdomen where the upper
b. Blood pressure rises by an average of
and lower segments join, may be a sign of
15 mmHg with every contraction
extreme uterine stress and possible impending
2. HEMATOPOIETIC SYSTEM rupture

 Leukocytosis- sharp increase in 5. Abnormal Lower Abdominal Contour- with

circulating WBC’s due to stress and a full bladder, a round bulge on the lower
exertion abdomen may appear

-Castillote BSN2 A10

-danger sign for 2 reasons: bladder may be  Encourage her to talk about the birth to
injured due to pressure; full bladder may prevent help her integrate it into her life
fetal head descent experience
-void every 2 hrs. during labor B. TAKING-HOLD PHASE
6. Increasing apprehension- O2 deprivation or  3rd to the 10th day
internal hemorrhage

B. Fetal Danger Signs

1. High or Low fetal Heart Rate- >160 bpm

(fetal tachycardia), < 110 bpm (fetal
bradycardia), decelerations may be a sign of
fetal distress

2. Meconium Staining

 Green color of AF due to loss of

sphincter control may be due to fetal
hypoxia

3. Hyperactivity- sign of hypoxia

4. Oxygen saturation (40% to 70%)- assessed

by a catheter inserted next to the cheek (<40%
is low); plus, acidosis (pH <7.2) suggests fetus is
being compromised

SESSION #17
 less dependent, take a strong interest in
POSTPARTAL PERIOD/ PUERPERIUM the care of her child and make her own
 Lat. Puer, “child,” and parere “to decisions but still feels insecure about
bring forth” her mothering skills
 6-week period after childbirth  give guidance and demonstrations on
how to care for her child
 retrogressive (involution of the
uterus & vagina) and progressive C. LETTING-GO PHASE
(production of milk for lactation)
 FOURTH TRIMESTER OF  10 days to 6 weeks
PREGNANCY  woman redefines her new role &
motherhood functions are established
I. PSYCHOLOGICAL CHANGES OF THE  gives up her fantasized image of her
POSTPARTAL PERIOD child and accepts her child as a unique
A. TAKING-IN PHASE person

 1st 2 to 3 days postpartum DEVELOPMENT OF PARENTAL LOVE &

POSITIVE FAMILY RELATIONSHIPS
 passive and dependent
 preoccupied with her own needs  En face position- looking directly at
 wants to talk about her pregnancy, labor her newborn’s face with direct eye
and birth contact
 Touches & explores her baby
-Castillote BSN2 A10
  Engrossment- fathers staring at the symphysis pubis, at midline or slightly to
NB for long periods of time the right.
 Complete rooming-in- mother and  1 hour after, fundus will rise to the level
child are together 24h a day of the umbilicus & remain there for 24
 Partial rooming-in- infant remains in hours. From then on, it decreases 1
the woman’s room most of the time fingerbreadth per day (1 cm).
 Sibling preparation  1st postpartal day,1 fingerbreadth below
the umbilicus; on 2nd day, 2
fingerbreadths below the umbilicus, and
so on.
 By the 9th or 10th day, it can no longer
POSTPARTUM BLUES/BABY BLUES be palpated
 A well-contracted uterus feels firm, like a
 2nd, 3rd postpartal day or within the 1st grapefruit in size & tenseness; if it is
2 weeks boggy (soft & flabby), it is not contracted
 mood swings, anger, tearfulness,
feeling let-down, anorexia, insomnia, AFTERPAINS- uterine cramps similar to
overwhelming sadness, feeling of menstrual cramps caused by intermittent
inadequacy, mood lability uterine contractions after delivery; more
 related to hormonal changes (sudden painful in breastfeeding & multiparous
decrease in E/P), fatigue & women
psychological stress related to infant
Factors that enhance involution
dependency
 Anticipatory guidance, individualized  Uncomplicated labor & delivery
support, chance to verbalize are  Breastfeeding
necessary  Early ambulation
 resolves spontaneously  Complete expulsion of placenta &
II. REPRODUCTIVE SYSTEM CHANGES membranes
 Factors that slow involution
A. The UTERUS  Prolonged labor & difficult delivery
 Anesthesia
 2 processes:
 Grand multiparity
 area where the placenta was
 Retained placental fragments
implanted is sealed off to prevent
bleeding and the  Full urinary bladder
 uterus is reduced to its approximate  Infection
pregestational size  Overdistention of the uterus

INVOLUTION- reduction in size of the uterus LOCHIA

after delivery to prepregnant size caused by  should not contain large clots
uterine contractions
 Total volume is 240 to 270 ml, gradually
 Immediately after birth, the uterus decreasing daily; increased by exertion
weighs about 1,000g; after a week, 50g; or breast-feeding
after involution is complete (6 weeks),  Unexplained increase in amount or
50g reappearance of lochia rubra is
abnormal
FUNDUS- the top portion of the uterus; an
indicator of involution TYPES OF LOCHIA

 after delivery, fundus is palpated Lochia Rubra- Dark red, bloody; fleshy,
halfway between the umbilicus & musty, stale odor that is non-offensive; may
have tiny clots/ 1 to 3 days/ Blood, mucus,

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fragments of decidua, epithelial cells, WBC’s,  hCG & HPL are almost negligible by 24
fetal meconium, lanugo, vernix caseosa hours by week 1, progestin, estrone &
estradiol are at pre- pregnancy levels
Lochia Serosa- Pink or brownish; watery;
 FSH is low for about 12 days & will
odorless/ 4 to 10 days/ Serum, RBC’s shreds
begin to rise and initiate a new
of decidua, WBC’s, cervical mucus, bacteria
menstrual cycle
Lochia Alba- Yellow to white; may have  Menstruation usually resumes in 7 to 9
slightly stale odor/ 11 to 21 days, my persist weeks in non-lactating women (90% in
for 6 weeks in lactating women/ WBC’s. 12 weeks); 1st cycle is usually
decidual cells, epithelial cells, fat cervical anovulatory
mucus, cholesterol, bacteria  Return of ovulation varies from 2 to 18
months

C. The URINARY SYSTEM

B. The CERVIX
 On palpation, a full bladder is felt as a
 Soft, irregular & edematous; may firm or hard area just above the
appear bruised with multiple small symphysis pubis
lacerations  Postpartal diuresis/Diaphoresis of 2 to 3
 Both internal & external os are open L increases the output in the 1st 12 to
 By the end of 1 week, the external os 24 hours & accounts for a 5-pound
has narrowed to the size of a pencil weight loss
opening (may admit 1 fingertip) and it
will be firm once again D. The CIRCULATORY SYSTEM
 The internal os closes as before but the
 Blood Volume returns to normal levels
external os remains slightly open and
by within 2 weeks, eliminated by
slit-like or stellate (star shaped)
diuresis
C. The VAGINA  1st 48 hours are the time of greatest risk
for complications for clients with heart
 The vagina is soft, edematous, with disease
greater diameter & multiple small  Bradycardia of 50 to 70 bpm is common
lacerations in the 1st 6 to 10 days; tachycardia is
 Low E levels postpartum lead to related to blood loss, temperature
decreased vaginal lubrication & elevation or difficult, prolonged birth
vasocongestion for 6 to 10 weeks, which  Fibrinogen remains increased for 1
can result in painful intercourse week increasing the risk for
 KEGEL’s exercises will improve the thrombophlebitis
strength & tone of the vagina  WBC count is up to 30,000/mm3
III. SYSTEMIC CHANGES especially if the labor is prolonged or
difficult; aids healing & prevents
A. The ABDOMINAL WALL infection
 Varicosities will recede but won’t
 Soft & flabby with decreased muscle disappear
tone
 Hemoglobin returns to normal in 2 to 6
 DIASTASIS RECTI- may improve weeks
depending on the physical condition,
number of pregnancies, type & amount E. The GASTROINTESTINAL SYSTEM
of exercise
 Hunger and thirst are common following
B. The HORMONAL SYSTEM birth
 Risk for constipation increases due
to decreased peristalsis, use of

-Castillote BSN2 A10

 analgesics, dehydration, decreased whether or not she plans to
mobility during labor, & fear of pain breastfeed
from having a bowel movement  Breast milk forms in response to
 Risk for hemorrhoids increases because decrease in E/P levels following delivery
of pushing during the 2nd stage of labor of the placenta (which stimulates
Prolactin release)
III. EFFECTS OF RETROGRESSIVE  Nipple stimulation leads to release of
CHANGES
OXYTOCIN from the pituitary gland; this
 Exhaustion due to pregnancy, labor & stimulates the release of PROLACTIN
delivery from the pituitary gland which causes
 Weight loss (19 lbs from delivery to the production of milk & the let-down reflex,
5th day postpartum/ initially due to release of milk by the contractions of the
diuresis, influenced by breastfeeding, alveoli of the breasts
exercise, nutrition
 Primary engorgement- 3rd or 4th day as
IV. VITAL SIGN CHANGES the supply of blood & lymph in the
breast is increased & transitional milk is
Temperature
produced; fades as effectivesucking and
 Slight increase during 1st 24 hours due emptying begins
to dehydration; relieved by adequate RETURN OF MENSTRUAL FLOW
fluid intake
 Any woman whose oral temperature  With delivery of the placenta, E/P levels
rises above 100.4°F (38°C) excluding decrease leading to ovulation
the 1st 24 hours is considered febrile  Not breastfeeding- menstrual flow
returns in 6 to 8 weeks
Pulse
 Breastfeeding- menstrual flow
 Normal postpartal range is 50 to 80 bpm returns in 3 to 4 mos (lactational
 PR is usually slightly lower than normal amenorrhea) or in some, during the
& will return to normal levels at the end entire lactation period
of the week  She may ovulate before menstruation
 A rapid & thready pulse indicates occurs
hemorrhage NURSING CARE OF A WOMAN & FAMILY
 Pulse > 100 bpm should be reported to DURING THE 1ST 24 HOURS AFTER BIRTH
the healthcare provider
POSTPARTUM ASSESSMENT
Blood Pressure
General Considerations
 Assess for orthostatic hypotension
 Monitor if woman has history of 1. Evaluate prenatal & intrapartal history
preeclampsia for complications
2. Provide privacy & encourage client to
Respirations void prior to assessment
3. Position client in bed with head flat for
 Normal range is 16 to 24 breaths per
accurate findings
minute
4. Proceed in a head-to-toe direction
V. PROGRESSIVE CHANGES 5. Vital Signs
6. Monitor breath sounds & practice deep
LACTATION breathing & coughing exercises
 Lactation or formation of breastmilk Assessment
begins in a postpartal woman
1. BREASTS

-Castillote BSN2 A10

  Determine if bottle feeding or breast  Auscultate for bowel sounds in all 4
feeding quadrants for postoperative patients
 Palpate for engorgement or tenderness
5. EPISIOTOMY OR PERINEAL
 Inspect the nipples for redness, cracks
LACERATIONS
& erectility if nursing
 Inspect the perineum for REEDA
2. UTERUS
 Episiotomy is usually 1 to 2 in long
 Gently place the non-dominant hand on  Inspect for hemorrhoids
the lower uterine segment just above
the symphysis pubis; the dominant hand 6.. LOCHIA
palpates the fundus  Inspect type, quantity, odor & color
 Palpation should not cause pain  Correlate findings with expected
characteristics of bleeding
 CS- delivered women may have less
 Determine uterine firmness, height of lochia
the fundus, & ascertain the position of
the fundus in relation to the midline of 7. HOMAN’S SIGN
the abdomen
 Pain in the calf upon dorsiflexion of the
foot is a positive sign & may indicate
 If the uterus is boggy, massage gently thrombophlebitis
using a gently, rotating motion to induce
 Inspect for pedal edema, redness, or
contraction; administer oxytocin as
warmth; if abnormal changes are
ordered
present, assess pedal pulse

 The fundal location must descend 1 cm 8. EMOTIONAL STATUS

each postpartal day
 Assess if the client’s emotions are
 Inspect any abdominal incisions, CS appropriate for the situation
delivery, or tubal ligation, for REEDA:  Determine the client’s phase of
redness, edema, ecchymosis, postpartal psychological adjustment
discharge, and approximation of the skin  Assess for postpartum blues
edges
9. BONDING

 Describe how the parents interact with

3. BLADDER
the infant
 The client should void within 6 to 8
hours after delivery; catheterization may
be necessary if delayed & bladder is IMPLEMENTATION
distended
 Assess frequency, burning or urgency, 1. PREVENT HEMORRHAGE
which could indicate UTI  Assess for risk factors
 Evaluate the ability to completely empty  Keep bladder empty
the bladder
 Gently massage fundus, if boggy; teach
 Palpate for bladder distention, if unable self-massage of uterus
to vid or complete emptying is in
 Administer OXYTOCIC medications if
question
ordered; oxytocin (Pitocin),
4. BOWEL methylergonovine maleate (Methergine),
ergonovine maleate (Ergotrate)
 Assess for passage of flatus\  Monitor for side effects of oxytocics;
 Inspect for signs of distention hypotension with rapid IV bolus of
-Castillote BSN2 A10
 Pitocin, hypertension with Methergine & -utilize well-fitting bra for support
Ergotrate
-teach breast care including no use of soap &
2. PROVIDE COMFORT air-drying nipples after feedings

 Apply ice to perineum for 20 mins on/10 -encourage nursing on demand q 2 to 3 hours,
mins off for 1st 24 hours awakening during the day 7 allowing to sleep at
 Encourage Sitz bath, warm or cool, TID night
& PRN after the 1st 12 to 24 hours
-advise mother to nurse 10 to 15 min on 1st
 Teach client perineal care after every
breast until the baby lets go of the 2nd; alternate
elimination
the breast used first & rotate positions
 Teach client to tighten buttocks, then sit
and relax muscles -suggest football hold or side-lying position for
 Apply topical anesthetics or witch hazel moms with CS or tubal ligation to avoid
compresses discomfort
 Monitor for side effects of morphine
-provide help with positioning, latching-on, &
epidural: late- onset respiratory
breaking suction when done nursing
depression (8 to 12 hours),
6. PROMOTE REST & GRADUAL RETURN TO
3. PROMOTE BOWEL ELIMINATION
ACTIVITY
 Encourage early & frequent ambulation
 Organize nursing care to avoid frequent
 Encourage increased fluids & fiber
interruptions
 Administer stool softeners; suppositories
 Plan maternal rest periods when baby is
are contraindicated is client has a 3rd-
expected to sleep
or 4th-degree perineal laceration
 Teach woman to resume activity
involving the rectum
gradually over 4 to 5 weeks; avoid
 Teach client to avoid straining; normal
lifting, stair-climbing & strenuous activity
bowel patterns return in 2 to 3 weeks
 Simple postpartal exercises may be
4. URINARY ELIMINATION started: Kegel’s exercises, raising the
chin to the chest, knee rolls, buttocks
 Encourage voiding every 2 to 3 hrs even lifts
if no urge is felt  Increases lochia indicates overexertion;
 Catheterize, as ordered, for urinary modify exercise plan
retention; Foley catheter for 12 to 24
hours after CS 7. PROMOTE ADEQUATE NUTRITIONAL
INTAKE- Add 500 kcal/day to pre-pregnancy
5. PROMOTE SUCCESSFUL INFANT diet; bottle-feedingmothers should return to pre-
FEEDING PATTERN pregnancy diet
Suppression of lactation & bottle feeding Fluid intake of 2 liters/day
-utilize snug bra or breast binder continuously Continue prenatal vitamins & iron; iron is best
for 5 to 7 days preventing engorgement absorbed in the presence of Vitamin C & may
increase constipation
-avoid heat & stimulation of breasts
8. PROMOTE PSYCHOLOGICAL WELL-
-apply ice packs for 20 min qid, if engorgement
BEING
occurs

-encourage demand feedings q 3 to 4 hours,  Encourage & support expression of

awakening during the day & allowing to sleep at feelings, positive & negative, without
night Establishment of lactation & successful guilt
breast-feeding

-Castillote BSN2 A10

  Encourage client to recount birth  Average birth weight of a matured
experience to be able to integrate female newborn 3.4 kg (7.5 lbs) and
expectations & fantasies with reality a matured male newborn is 3.5 kg
 Provide recognition & praise for self- & (7.7 lbs)
infant-care activities  A newborn loses more than 5% to
10% of birth weight (6 to 10 oz) during
9. PROMOTE FAMILY WELL-BEING the 1st few days afterbirth since the
 Encourage rooming-in, presence of newborn is no longer under the
family members & their participation influence of salt and fluid-retaining
maternal hormones and diuresis
 Advise resumption of sexual activities
begins on the 2nd to 3rd day of
after episiotomy has healed & lochia has
stopped, about 3 weeks after delivery
 Counsel the couple regarding
contraception before discharge

10. PROMOTE MATERNAL SAFETY Give

RhoGAM or RhIg to Rh (-) mom not sensitized (-
indirect Coomb’s test)

Give rubella vaccine if titer is < 1:8 (0.5 ml SC)

and advise to avoid pregnancy for at least 3
months

Teach postpartum warning signs to be reported:

-bright red bleeding saturating > 1 pad/hr or

passing of large clots

-temp > 100.4°F, chills, excessive pain,

reddened or warm areas of the breast, reddened
or gaping episiotomy, foul-smelling lochia

-inability to urinate; burning, frequency, or

urgency

-calf pain, tenderness, redness or swelling

SESSION #18  life, voiding and the passing of stool

also reduces the weight.
VITAL STATISTICS
 After the initial weight loss, the
Weight newborn has 1 day of stable weight
then begins to gain weight
 Weight depends on racial,  Breastfed newborn regains birthweight
nutritional, intrauterine & genetic within 10 days; formula-fed newborn
factors within 7 days. After this, weight gain is
 Weight in relation to gestational age 2 lbs/month
should be plotted on a standard
neonatal graph Length
 Birth weight increases with each
succeeding child in a family

-Castillote BSN2 A10

  Average matured female newborn is especially their face & hair which will not be
53 cm (20.9 in); matured male covered with clothing
newborn is 54 cm (21.3 in)
 Newborn’s lose heat easily because
Head Circumference they lack subcutaneous fat; also,
shivering is rarely seen in NB’s
 Ave: 34 to 35 cm (13.5 to 14 in)  Newborn’s conserve heat by constricting
 A mature newborn with circumference blood vessels & moving blood away
<33 cm or > 37 cm should be from the skin
investigated  BROWN FAT, a special tissue found
 HC is measured with a tape measure in mature Newborn’s, helps to
drawn across the center of the conserve heat by increasing
forehead & around the most metabolism
prominent portion of the posterior  Brown fat is found in the intrascapular
head region, thorax & perirenal area.
Chest Circumference  Mechanical measures to conserve heat:
drying & wrapping the newborn’s,
 Chest circumference is usually 2 cm placing them in a warmed crib, or drying
(0.75 to 1 in) less than head them & placing them under radiant
circumference warmers
 KANGAROO CARE- placing a
VITAL SIGNS
newborn against the mother’s skin
Temperature which helps transfer heat from the
mother to the newborn
 It is about 99°F (37.2°C) at birth  Newborn’s temperature stabilizes at
because they have been confined in 98.6°F within 4 hours after birth
an internal body organ; temperature  A newborn with a bacterial infection may
falls almost immediately because of run a subnormal temperature unlike
immature temperature-regulating adults
mechanisms
Pulse
4 Mechanisms of Heat Loss:
 In utero, PR = 120 to 160 bpm;
1. CONVECTION- flow of heat from the NB’s immediately after birth, as rapid as 180
body surface to cooler surrounding air; avoid bpm; within 1 hour, the NB settles down
drafts such as windows and air conditioners to sleep & the pulse rate stabilizes to an
2. CONDUCTION- is the transfer of body heat average of 120 to 140 bpm
to a cooler solid object IN CONTACT with the  HR is slightly irregular due to immature
baby (e.g., placing baby on a cold surface); to cardiac regulatory centers in the
avoid heat loss, cover baby with a warmed medulla
blanket or towel  Transient murmurs are common due to
the incomplete closure of the fetal
3. RADIATION- transfer of body heat to a circulation shunts
cooler solid object NOT IN CONTACT with  Femoral pulses may be palpated but
the baby such as a cold window or air radial & temporal pulses are difficult to
conditioner; move infant as far from the cold palpate
surface as possible  Absence of femoral pulses suggests
4. EVAPORATION- loss of heat through possible coarctation of the aorta
conversion of a liquid to vapor; newborn’s  Heart rate is always determined by
lose heat as amniotic fluid on their skin listening for an apical heartbeat for 1 full
evaporates; dry newborn’s as soon as possible minute

-Castillote BSN2 A10

Respiration  Vitamin K (AQUAMEPHYTON) is
administered into the vastus lateralis
 Respiratory rate in the 1st few minutes muscle immediately after birth
after birth may be as high as 80
breaths/min. As respirations stabilize, it Respiratory System
settles to 30 to 60 breaths per minute at
rest.  Initial breath is initiated by a
 Respirations are likely to be irregular, combination of cold receptors, lowered
with short periods of apnea (without partial pressure of O2 (pO2),
cyanosis) sometimes called PERIODIC INCREASED Pco2 as high as70 mm Hg
RESPIRATIONS before the 1st breath
 Breathing primarily involves the  Within 10 minutes after birth, good
diaphragm and abdominal muscles residual volume is established
 Coughing & sneezing reflexes are  10 to 12 hours after birth, vital capacity
present at birth to clear the airway is established
 Newborns are obligate nose breathers Gastrointestinal System
Blood Pressure  It is usually sterile at birth but within
24 hours, bacteria are present from
 Blood pressure is about 80/46 mm Hg at
airborne sources, vaginal secretions
birth; by the 10th day, it rises to 100/50
at birth, hospital linens, or from
mm Hg though readings are usually
contact with the mother’s breast
inaccurate
 Normal flora in the intestines are
 Blood pressure cuff width must be no
necessary for the synthesis of Vitamin K
more than 2/3 the length of the upper
arm or thigh  Stomach capacity is about 60 to 90 ml
 A newborn has limited ability to digest
PHYSIOLOGIC FUNCTION starch & fat because pancreatic
enzymes, lipase & amylase remain
Cardiovascular System
deficient for the 1st few months
 Clamping of the umbilical cord forces  Newborn regurgitates easily because of
the neonate to take in O2 through the an immature cardiac sphincter.
lungs→ ↓pressure in the chest  Immature liver function leads to lowered
promoting closure of the ductus glucose & serum protein levels
arteriosus; ↑pressure on the left side of  MECONIUM- 1st stool of NB & is
the heart closes the foramen ovale. usually passed within 24 hours after
 Umbilical vein ductus venosus and u. birth; it is tarlike, sticky, blackish green
arteries no longer receive blood, the and odorless formed from mucus,
blood within them clots & the vessels vernix, lanugo, hormones &
atrophy within the next few weeks carbohydrates accumulated in utero
 Peripheral circulation remains sluggish  If (-) stool passage by 24 to 48 hours,
for the 1st 24 hours; acrocyanosis suspect meconium ileus, imperforate
(cyanosis in the hands & feet) and cold anus, bowel obstruction
feet are common  2nd to 3rd day, TRANSITIONAL
 Prolonged coagulation or prothrombin STOOL which is green & loose, is
time due to low levels of Vitamin K passed; it resembles diarrhea
(necessary for synthesis of Factors II,  4th day, breast-fed babies pass 3 to 4
VII IX and X) light yellow stools per day which are
 It takes 24 hours for flora to accumulate sweet-smelling because breast milk
in the intestines & for Vitamin K to be is high in lactic acid
synthesized  Formula-fed babies pass 2 to 3 bright
yellow, more odorous, stools

-Castillote BSN2 A10

  Newborn under phototherapy light have  Newborns are routinely given Hepatitis
bright green stools due to increased B vaccine during the 1st 12 hours after
bilirubin secretions birth
 Clay-colored (gray) stools are  Any Health Care Practitioner with
associated with bile duct obstruction Herpes simplex eruptions should not
 Blood-flecked stools usually indicate care for newborns until the lesions have
anal fissure crusted
 If mucus is mixed with stool or the stool
Neuromuscular System
is watery & loose, a milk allergy, lactose
intolerance, or some other condition is  Newborn exhibits neuromuscular
suspected function by moving their extremities,
attempting head control, strong cry, &
newborn reflexes since the nervous
system is still immature

Urinary System Newborn Reflexes:

 The average newborn voids within 24 1. Blink Reflex

hours after birth; otherwise, should be
Purpose: to protect the eyes
examined for urethral stenosis or absent
kidneys or ureters Stimulus: shining a strong light on an eye,
 Males should void with enough force to sudden movement toward the eye
produce a small projected arc; females
should produce a steady stream. Reaction: rapid eye closure
 NB kidneys do not concentrate urine 2. Rooting Reflex.
well, producing light-colored & odorless
urine Purpose: to help the newborn find food; for
 NB single voiding is only about 15 ml, nourishment
specific gravity ranges from 1.008 to
Stimulus: cheek is brushed or stroked near the
1.010
mouth
 Daily urine output for the 1st 1 or 2 days
is about 30 to 60 ml. 1st voiding may be Reaction: the newborn will turn the head in the
pink or dusky because of uric acid direction of the stimulus
crystals formed in the bladder in utero
 Diapers can be weighed to determine *Disappears at about the 6th week of life when
the amount and timing of voiding the eyes focus steadily

Immune System 3. Sucking Reflex.

 Newborn’s have difficulty producing Purpose: to help the newborn find food
antibodies against antigens until about 2 Stimulus: When the newborn’s lips touch the
months of age & are therefore prone to mother’s breast or a bottle
infection. Thus, immunizations are not
given t infants younger than 2 months of Reaction: the baby sucks to take in food
age
*Diminishes in 6 months
 Newborns are born with passive
antibodies (Ig G) from the mother that *Disappears immediately if never stimulated (eg.
crossed the placenta (antibodies vs TEF); maintained by offering non-nutritive
polio, measles, diphtheria, pertussis, sucking such as a pacifier
chickenpox, rubella & tetanus
4. Swallowing Reflex.

Purpose: for nourishment

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Stimulus: food that reaches the posterior 10. Tonic Neck Reflex/Boxer Reflex/Fencing
portion of the tongue is automatically swallowed Reflex.

*Gag, cough, sneeze reflexes are also present In a supine position, the head is usually
to maintain a clear airway when normal turned to 1 side; the arm & the leg on the
swallowing does not keep the pharynx free of side toward which the head turns extend,
obstructing mucus and the opposite arm & leg contracts.

5. Extrusion Reflex. Purpose: stimulates eye coordination since the

extended arm moves in front of the face.
Purpose: prevents swallowing of inedible
substances *May signify handedness

Stimulus: substance placed on the anterior *Disappears on the 2nd to 3rd months of life
portion of the tongues
11. Moro Reflex/Startle Reflex.
Reaction: Newborn pushes away the substance
with the tongue Stimulus: loud noise or by jarring of the
bassinet or by holding newborn in a supine
*Disappears at 4 months of age position & allow the head drop backward 1 inch

6. Palmar Grasp Reflex Response: Newborn abducts & extends arms &
legs, fingers assume a “C” position; finally
Newborn grasps an object placed in their swinging the arms into an embrace position &
palm by closing their fingers on it pull up the legs against the abdomen
*Disappears at about 6 weeks to 3 months of (adduction)
age; grasps meaningfully at 3 months of age Purpose: like trying to ward off an attacker then
7. Step (Walk)-in-Place Reflex. covering up to protect himself

Newborn is held in a vertical position with *It is strong for the 1st 8 weeks & fades by the
their feet touching a hard surface will take a end of the 4th or 5th month at the same time as
few, quick, alternating steps. the infant can roll away from danger

*Disappears by 3 months; by 4 months, babies 12. Babinski Reflex.

can bear a good portion of their weight Stimulus: the side of the sole of the foot is
unhindered by this reflex stroked in an inverted “J” curve from the heel
8. Placing Reflex. upward

Similar to step-in-place but it is elicited by Response: Newborn fans the toes (+ Babinski
touching the anterior surface of the sign)
newborn’s leg against a hard surface such *In adults, the opposite response is normal
as the edge of a bassinet or table. (flexing of the toes)
The newborn makes a few quick, lifting motions, *It remains positive (toes fan) until at least 3
as if to step onto the table, because of the reflex months then replaced by the adult response
9. Plantar Grasp Reflex. 13. Magnet Reflex.
When an object touches the sole of the Stimulus: pressure is applied to the soles of the
newborn’s foot at the base of the toes, the feet of a newborn lying in a supine position
toes grasp n the same manner as the fingers
do. Response: Newborn pushes back against the
pressure.
* It disappears by 9 mos. in preparation for
walking

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*Magnet, Crossed Extension & Trunk -May have been seeing light & dark in utero for
Incurvation reflexes are tests of spinal cord the last few mos. of pregnancy as the as the
integrity. uterus & abdominal wall were stretched thin.

14. Crossed Extension Reflex. -demonstrates sight by blinking at a strong

light or following a bright light or toy a short
Stimulus: 1 leg of newborn lying supine is distance with their eyes; cannot follow past
extended & the sole of the foot irritated by midline & lose track of objects easily
rubbing with a sharp object such as a thumbnail
-Newborn’s focus on black or white objects best
Response: Newborn raises the other leg & at a distance of 9 to 12 inches
extends it, as if trying to push away the hand
irritating the 1st leg. -pupillary reflex or the ability to contract the pupil
is present from birth
15. Trunk Incurvation Reflex.
TOUCH.
Stimulus: Newborn lies in a prone position &
touched along the paravertebral area by a finger -well developed at birth; demonstrated by
quieting at a soothing touch & by positive
Response: Newborn flexes the trunk & swing rooting & sucking reflex & by reaction to
the pelvis towards the touch painful stimuli.
16. Landau Reflex. TASTE.
Stimulus: Newborn is held in a prone position -Newborns has the ability to discriminate
with a hand underneath, supporting the trunk taste, since tastebuds are developed &
Response: Newborn must demonstrate some functioning even before birth
muscle tone; may not be able to lift the head or - In utero, the fetus will swallow amniotic fluid
arch the back but must not sag into an inverted more rapidly if sweetened by glucose & less if
“U” position (poor muscle tone) bitter flavor is added.
17. Deep tendon Reflex. SMELL.
Stimulus: patellar reflex is stimulated by tapping -present in newborn’s as soon as the nose is
the patellar tendon with the tip of the finger. clear of mucus & amniotic fluid
Response: lower leg moves perceptively if the - Newborn’s turn toward their mother’s breast
reflex is intact; test for spinal nerves L2 through partly because of recognition of the smell of
L4 breast milk & partly as a manifestation of the
18. Biceps Reflex rooting reflex.

Stimulus: biceps reflex is stimulated by placing PHYSIOLOGIC ADJUSTMENT TO

the thumb of your left hand on the tendon of the EXTRAUTERINE LIFE
bicep’s muscles on the inner surface of the Periods of reactivity- periods of irregular
elbow; tap the thumb as it rests on the tendon. adjustment in the 1st 6 hours of life
Response: The tendon may be felt contracting (Desmond)
rather than being observed; test for spinal 1. 1st Period of reactivity- 1st phase lasting for
nerves C5 & C6 about 30 minutes; baby is alert & exhibits
The Senses- already developed at birth exploring, searching activity, often making
sounds; HR & RR are rapid
HEARING.
2. Next is a quiet, resting period- heart rate and
-A newborn is able to hear even in utero respiratory rate are slow, the newborn typically
sleeps for about 90 minutes.
VISION.
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3. 2nd period of reactivity- between the 2nd & & excretion of meconium & helps
6th weeks of life, when the baby wakes, often prevent Indirect Bilirubin build up.
gagging or choking on mucus that accumulated  Treatment for physiologic jaundice is
in the mouth; alert & responsive to the rarely necessary except for early
environment. feeding to speed passage of stool
 Some breast-fed babies may have more
 Periods of reactivity indicates that the
difficulty converting IB because breast
Nb is healthy & adjusting well to the
milk contains PREGNANEDIOL
extrauterine life.
(metabolite of progesterone) which
APPEARANCE OF A NEWBORN depresses action of glucoronyl
transferase
SKIN
PALLOR- usually the result of anemia caused
Color by:
 Most have a ruddy complexion due to (1) excessive blood loss when the cord was
increased circulation of RBCs in blood cut
vessels & decreased subcutaneous fat
 Pale & cyanotic- infants with poor (2) Inadequate flow of blood from the cord to
CNS control the infant at birth
 Gray color- indicates infection (3) fetal-maternal transfusion
 Generalized mottling of the skin, bluish
appearance of the lips, hands & feet are (4) low iron stores due to poor maternal
common from immature peripheral nutrition
circulation
(5) blood incompatibility
ACROCYANOSIS- blueness of hands & feet
 HARLEQUIN SIGN- due to immature
is normal in the 1st 24 to 48 hours after birth
circulation, a newborn lying on his or
Central Cyanosis- or cyanosis of the trunk her side appears red on the
indicates decreased oxygenation dependent side of the body & pale on
the upper side; transient only & fades
 Suction the mouth of a newborn (if the with change of position, kicking or crying
newborn does not cry or cyanotic)1st vigorously
before the nose, because suctioning the
nose 1st may trigger a reflex gasp, Birthmarks
possibly leading to aspiration if there is
 HEMANGIOMA- vascular tumor of the
mucus in the posterior throat
skin
HYPERBILIRUBINEMIA- leads to jaundice &
a. Nevus Flammeus- macular purple or dark-
occurs on the 2nd to the 3rd day of life due
red lesion (sometimes called port-wine stain)
to breakdown of fetal RBC’s (PHYSIOLOGIC
usually appearing on the face or thighs
JAUNDICE)
-those above the nose bridge tend to fade,
CEPHALHEMATOMA- collection of blood
under the periosteum of the skull bone; also -can be removed by laser therapy though they
causes release of Indirect Bilirubin may reappear
 Intestinal obstruction prevents -Stork’s beak mark- lighter pink patches at the
evacuation of stool & intestinal flora nape of the neck which do not fade
breaks down bile into its basic
components leading to release of b. Strawberry Hemangiomas- elevated areas
Indirect Bilirubin; early feeding of formed by immature capillaries & endothelial
newborn promotes intestinal movement cells; some are present at birth while some
appear up to 2 weeks after birth
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-associated with high Estrogen levels of  It usually needs no treatment
pregnancy
Milia
-may increase in size up to 1 year of age, then
they tend to be absorbed & shrink in size; by 7  Plugged or unopened sebaceous
years old, 50% to 75% have disappeared gland appearing as pinpoint white
papules appear on the cheeks or
-hydrocortisone ointment may speed the across the bridge of the nose
disappearance of the lesions  Disappear by 2 to 4 weeks of age as the
sebaceous glands mature & drain
-surgery is rarely recommended because it may
 Teach parents to avoid squeezing or
lead to secondary infection
scratching to prevent infection

Erythema Toxicum/ Flea-bite rash

c. Cavernous hemangioma- dilated vascular
spaces, usually raised, resembling  Newborn rash usually appearing in the
strawberry hemangiomas but do not 1st to 4th day of life, some up to 2 weeks
disappear with time of age.
 It begins with a papule, increases in
MONGOLIAN SPOTS- collections of pigment severity to become erythema by the 2nd
cells (melanocytes) that appear as slate-gray day & disappears by the 3rd day
patches across the sacrum or buttocks &  It is caused by the newborn’s
possibly n the arms or the legs eosinophils reacting to the
environment as the immune system
-common in Asians, S. Europeans, or Africans
matures.
-disappear by school age  It requires no treatment

Vernix Caseosa Forceps marks

 White, cream cheese-like substance  Circular or linear contusions

that serves as a skin lubricant, matching the rim of the forceps
noticeable on the skin of a newborn blades n the infant’s cheek;
 Yellow vernix- due to bilirubin disappears in 1 to 2 days along with the
 Green vernix- meconium staining edema
 Before the 1st bath, wear gloves when  Closely asses the facial nerve to
handling the NB to prevent exposure to determine any potential nerve
body fluids compression

Lanugo Skin Turgor

 Fine, downy hair that covers the  Newborn skin should feel resilient if the
shoulders, back, upper arms, underlying tissue s well-hydrated
forehead & ears of the newborn  If a fold of the skin is grasped
 Post-mature infants rarely have lanugo between the thumb & fingers, it
 It is rubbed away by the friction of should feel elastic; when released,
bedding & clothes against the skin; by 2 should fall back to form a smooth
weeks of age, it has disappeared surface
 Poor turgor is seen in those who
Desquamation suffered severe malnutrition in utero,
those with difficulty sucking at birth or
 Within 24 h after birth, skin becomes
those with metabolic disorders such as
extremelydry especially on the palms
adrenogenital syndrome
& soles resulting to areas of peeling
similar to sunburn HEAD

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  Newborn’s head is 1⁄4 of the total body  It is caused by the rupture of
length; in an adult, 1/8 of the total height periosteal capillaries due to pressure
 The fore head is large & prominent, the at birth
chin appears to recede & quivers easily.  It usually appears 24 hours after birth
 The swelling is usually severe, well-
Fontanelles
outlined as an egg shape; may be
 Anterior fontanelle is found at the discolored (black & blue) because of the
juncture of the frontal & parietal presence of coagulated blood
bones; diamond-shaped, measures 2  It is confined to an individual bone so
to 3 cm in width & 3 to 4 cm in length the swelling stops at the suture line
 Anterior Fontanelle is felt as a soft spot,  It sometimes takes weeks for the
neither indented nor bulging cephalhematoma to be reabsorbed
 Anterior Fontanelle normally closes at Craniotabes
12 to 18 months of age
 Posterior fontanelle is found at the  It is a localized softening of the
junction of the parietal bones & the cranial bones caused by pressure of
occipital bone; triangular in shape & the fetal skull against the mother’s
measures 1 cm in length pelvic bone in utero
 Posterior Fontanelle closes by the end  it is common in 1st-born infants because
of the 2nd month of the lower position of the fetal head in
the pelvis during the last 2 weeks of
Sutures pregnancy in the primiparous women
 They are the separating lines of the  the skull is so soft that the pressure of
skull and may override during the examining finger can indent it; bone
passage through the birth canal. returns to its normal shape after
 Molding subsides in 24 to 48 hours pressure is removed
 Wide separation of suture lines  The condition resolves after a few
suggests increased ICP, hydrocephalus, months
subdural hemorrhage EYES
 Fused suture lines prevent head from
expanding with growth  Lacrimal ducts are not fully mature until
3 months of age; therefore, crying is
Molding initially tearless
 Molding may be so extreme the head  Irises are gray or blue, sclera appears
appears like a dunce cap but shape blue due to its thinness; eyes assume
will be restored in a few days permanent color between 3 & 12
months of age
Caput Succedaneum  Small subconjunctival hemorrhage
sometimes appears due to pressure
 It is the edema of the scalp at the during childbirth, appearing as a red
presenting part of the head spot on the sclera usually in the inner
 The edema crosses suture lines & is aspect of the eye or as a red ring
gradually absorbed & disappears about around the cornea
the 3rd day of life & requires no  Bleeding is slight, requires no treatment
treatment & is completely absorbed within 2 to 3
Cephalhematoma weeks
 Edema around the orbit remains for the
 It is a collection of blood between the 1st 2 to 3 days until the kidneys are
periosteum of a skull bone & the capable of evacuating fluid more
bone itself efficiently

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  White pupil suggests congenital cataract  Grunting suggests respiratory distress
syndrome
MOUTH  A high crowing sound on inspiration
 NB’s mouth should move evenly; suggests stridor or immature tracheal
otherwise, check for cranial nerve injury development
 EPSTEIN’S CYST- 1 or 2 small, round, ANOGENITAL AREA
glistening, well-circumscribed cysts
on the palate, a result of the extra  Anal patency is tested by gently
load of Calcium deposited in utero; inserting the tip of the little finger, gloved
require no treatment & disappear & lubricated
spontaneously within 1 week  Anal patency is tested by gently
inserting the tip of the little finger, gloved
 THRUSH- a Candida albicans & lubricated
infection appearing as white or gray
patches on the tongue & sides of Male Genitalia
cheeks  The scrotum is edematous & has rugae,
 NATAL TEETH- evaluate for stability; deeply pigmented in dark-skinned
all teeth not covered by gum newborn’s
membrane should be removed  If 1 or both testicles are missing,
because they can loosen & may be suspect cryptorchidism; may be caused
aspirated by agenesis, ectopic testes (testes
NECK cannot enter closed scrotal sac) or
undescended testes (vas deferens or
 It is short, chubby, with creased skin artery is too short to allow testes to
folds & head should rotate freely descend)
 CONGENITAL TORTICOLLIS- caused  CREMASTERIC REFLEX- elicited by
by injury to the sternocleidomastoid stroking the internal side of the thigh
muscle during birth manifested by causing the testis on that side to move
rigidity of the neck up upward (absent in NB’s < 10 days
 In newborn’s whose membranes were old)
ruptured >24h before birth, nuchal  The penis appears small, approximately
rigidity suggests meningitis 2 cm long
 Thymus gland will triple in size by 3 yrs
EPISPADIAS- urethral opening is at the
of age & remains the same size till 10yo
dorsal side
then shrinks
HYPOSPADIAS- urethral opening is at the
CHEST
ventral side
 When 2 years old, the chest
 Circumcision should not be done if
measurement will exceed that of the
epispadias or hypospadias is present
head
(foreskin may be used in the repair)
 WITCH’S MILK- breasts secrete a
thin, watery fluid as an influence of Female Genitalia
the mother’s hormones but these
hormones clear in about 1 week  Vulva may be swollen due to maternal
 Chest circumference is approximately 2 hormones
inches smaller than the head  PSEUDOMENSTRUATION- mucus
 RR- 30 to 60 breaths per minute vaginal secretion, sometimes blood-
 SUPERNUMERARY NIPPLES- extra tinged
nipples usually found below & in line EARS
with the normal nipple

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  Pinna tends to bend easily but strong as manifested by moistness at the
enough to recoil base of the cord caused by urine flow
 The level of the top part of the external  Check for umbilical hernia; if < 2 cm, it
ear should be on a line drawn from the closes on its own by school age
inner canthus to the outer canthus of the  Newborn kidneys are the size of a
eye & back across the side of the head; walnut; right kidney is lower than the left
ears set lower are found in infants with  ABDOMINAL REFLEX- stroke each
trisomy 18 & 13 quadrant of the abdomen to cause
 Skin tags in front of the ear may be the umbilicus to wink in that direction
associated with kidney or chromosomal (not demonstrable before the 10th day of
abnormalities or of no reason at all; may life)
be removed with ligation when the child
is 1-week old BACK
 Preauricular dermal sinus appear as  Spine appears flat in the lumbar &
pinpoint-size opening directly in front of sacral areas; curves appear only after
the ear; may be removed surgically the child is able to sit & walk
when the child is near school age  SPINA BIFIDA OCCULTA or DERMAL
 Test hearing by ringing a bell held 6 in SINUS- pinpoint opening, dimpling or
from each ear; newborn blink, stop sinus tract in the skin
crying, be startled in response.  NB typically assumes its position in
NOSE utero

 Test for CHOANAL ATRESIA by closing EXTREMITIES

the mouth & compressing 1 naris at a  Arms & legs appear short, hands are
time with the fingers. Note any plump
discomfort or distress with breathing.  Fingernails are soft & smooth,
ABDOMEN sometimes extend over the fingertips
 Test upper extremities for muscle tone
 It is normally slightly protuberant by unflexing the arm for 5 seconds. If
 If scaphoid or sunken, it suggests tone is good, arm immediately returns to
missing abdominal contents or its flexed position.
diaphragmatic hernia  When the arms are at the sides, the
 Bowel sounds should be present within fingertips should cover the proximal
1 hour after birth thigh; unusually short arms may signify
 Edge of the liver is usually palpable 1 to ACHONDROPLASTIC DWARFISM
2 cm below the right costal margin; the  SIMIAN CREASE- a single crease on
spleen 1 to 2 cm below the left costal the palm (normally 3 creases) plus
margin unusual curvature of the little finger
 After cord cutting, count the cord (AVA); are associated with Down syndrome
1 artery is associated with a congenital  If arm hangs limp or is unmoving, it
heart or renal abnormality suggests birth injury (to a clavicle,
 After the 1st hour, umbilical stump brachial or cervical plexus or fracture of
begins to dry & shrink, turning brown; a long bone)
2nd to 3rd day, black  SYNDACTYLY- webbing of fingers or
 Stump falls off by day 6 to 10 leaving a toes
granulating area that heals in 1 week  POLYDACTYLY- extra digits
 Moist or odorous cord suggests  Soles of the feet are covered
infection; treat to prevent septicemia approximately 2/3 by creases; if less,
 PATENT URACHUS- a canal that suspect immaturity
connects the bladder to the umbilicus

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  In a supine position, both hips can  COGNITIVE DEVELOPMENT refers to
flexed & abducted (180°) that the knees the ability to learn or understand
touch or nearly touch the surface of the from experience, to acquire and
bed retain certain knowledge, to respond
 If hip joint locks 160 to 170°, hip to a new situation, and to solve
subluxation (shallow, poorly-formed problems (PIAGET’s COGNITIVE
acetabulum) is suggested DEVELOPMENT THEORY)
 Hold the infant’s leg with fingers on the
II. STAGES OF GROWTH AND
greater & lesser trochanters then abduct
DEVELOPMENT
the hip; if subluxation is present, a
“clunk” of the femur head striking the 1. PRENATAL PERIOD- conception to birth
shallow acetabulum CAN BE HEARD
(ORTOLANI’S SIGN).
 If the hip can be felt slipping from the
socket, this is BARLOW’S SIGN

SESSION #19

I. DEFINITION OF TERMS
 Germinal- conception to 10 days
 GROWTH- generally used to denote gestation
an increase in physical size or
 Embryonic- 10 days to 8 weeks
QUANTITATIVE CHANGE; measured
gestation
as weight and height
 Fetal- 2 months to birth
 DEVELOPMENT- is used to indicate
an increase in skill or ability to 2. INFANCY PERIOD- birth to 1 year
function (a QUALITATIVE CHANGE);
can be measured by observing a child’s  Newborn/neonatal period- birth to 1
ability to perform certain tasks (eg. How month
well a child picks up small objects such  Infancy- 1 month to 12 months
as raisins), by recording a parent’s
3. CHILDHOOD PERIOD- 1 year to 12 years
description of a child’s progress, or by
using standardized tests such as the  Toddler- 1 year to 3 years
DENVER II  Preschool- 3 years to 6 years
 MATURATION is synonymous to  Schoolage- 6 years to 10 years
development.  Puberty- 10 years to 12 years
 PSYCHOSEXUAL DEVELOPMENT is
a specific type of development that 4. ADOLESCENCE- 12 years to 19 years
refers to developing instincts or
sensual pleasure (FREUDIAN  Early adolescence- 12 years to 16
THEORY) years
 PSYCHOSOCIAL DEVELOPMENT  Late adolescence- 16 to 19 years
refers to ERIKSON’S STAGES OF III. RATES OF GROWTH
PERSONALITY DEVELOPMENT
 MORAL DEVELOPMENT is the ability 1. INFANCY- most RAPID period of growth
to know right from wrong and to
 Birth weight doubles: 6 months
apply these to real-life situations
(KOHLBERG)  Birth weight triples: 12 months

2. TODDLER- slow, plateau

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  Trunk grows faster than other tissues Ex. – Newborn can lift only the head when in
a prone position. By 2 mos., he can lift the
3. PRESCHOOLER- slow, uniform head and chest off the bed; by 4 mos., the head,
chest & part of the abdomen; by 5 mos., can
 Trunk grows faster than other tissues;
turn over; by 9 mos., can crawl; by 1 yr, can
legs also grow fast
stand or walk
4. SCHOOLER- slow, uniform growth
6. Development proceeds from proximal to
 Limbs grow most rapidly distal body parts
 Bones grow faster than muscles and
Ex. – Newborn makes little use of the arms
ligaments- tendency to fracture
and legs; by 3 to 4 mos., can support the upper
5. ADOLESCENCE- rapid growth, in spurts body weight onthe forearms and can scoop up
both in height & weight objects with the hand; 10 mos., pincer-like grasp
to pick up small objects
 Trunk grows faster than other tissues
 Girls are ahead by 2 years in growth 7. Development proceeds from gross to
spurt refined skills
 Growth spurt lasts for 3 years Ex. – 3 yo colors with a large crayon; 12-year-
 At age 9, boys and girls are the same in old can write with a fine pen
size; at 12, girls are bigger than the
boys 8. There is an optimum time for initiation of
experiences or learning
IV. PRINCIPLES OF GROWTH AND
DEVELOPMENT Ex. – cannot learn tasks until nervous system is
mature enough to allow that particular learning
1. Growth and development are continuous
processes from conception until death -those not given the opportunity to learn
tasks at target times may have more
Ex. – at all times a child is growing now cells difficulty than the usual child learning the
& learning new skills task later on (child in a body cast at 12 mos.
old) because the child has passed the time of
- BW triples and height increase by 50% at 1
optimal learning
year-old
9. Neonatal reflexes must be lost before
2. Growth and development proceed in an
development can proceed
orderly sequence
Ex. – infant cannot grasp with skill until the
Ex. – growth in height proceeds in only 1
grasp reflex has faded nor stand steadily until
sequence- from smaller to larger
the walking reflex hasfaded
- development proceeds in a predictable
-neonatal reflexes are replaced by purposeful
order (sitting before creeping then stand
movements
before walking and then proceed to running)
-A great deal of skill and behavior is learned by
3. Different children pass through the
practice
predictable stages at different rates
V. Measurement Tools to Assess progress of
Ex. – some walk at 9 mos. while some at 14
growth and development
mos. (all stages have a range of time)
A. Chronological age: assessment of
4. All body systems do not develop at the
developmental tasks related to birth date
same rate
B. Mental age: assessment of cognitive
5. Development is cephalocaudal
development

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1. measured by a variety of standardized others but tend to advance faster
intelligence tests (IQ) in skills
o Sometimes, the child with high
2. results from at least 2 separate testing
intelligence falls behind in physical
sessions needed before an assessment is made
skills because he/she spends more
3. uses toys and language based on mental time with books or mental games
rather than chronological age
2. TEMPERAMENT
C. Denver Developmental Screening Test
 It is the usual reaction pattern of an
(DDST)
individual, or an individual’s
1. Generalized assessment tool; measures characteristic manner of thinking,
gross motor, fine motor, language; and behaving, or reacting to stimuli in the
personal-social development from newborn- 6 environment
years  It is an inborn characteristic set at birth

2. does not measure intelligence Reaction Patterns (Chess and Thomas)

D. Growth parameters a. Activity Level- some are constantly

on the go while others move little and
1. Bone age: X-ray of tarsals and carpals; are docile
determines degree of ossification
b. Rhythmicity- rhythms or schedules
2. Growth charts: norms are expressed as in physiologic functions; some are
percentile of height, weight, head circumference predictable while some have erratic
for age; any child who crosses over multiple routines
percentile line needs further evaluation
c. Approach- refers to a child’s
VI. FACTORS INFLUENCING GROWTH AND response on initial contact with a new
DEVELOPMENT stimulus; some are unruffled, others
1. GENETICS demonstrate withdrawal, are fussy and
react fearfully
 eye color, height potential, learning
d. Adaptability- it is the ability to
style, temperament
change one’s reaction to stimuli over
a. GENDER time

o girls are usually born lighter and e. Intensity of Reaction- some react
shorter; by pre-puberty, girls with their whole being (tantrums)
surge ahead (puberty is 6 mos. to while some have a mild or low-
1 yr. earlier than boys); by the intensity reaction
end of puberty (14 to 16 yrs.),
f. Distractability- those who can
boys again tend to be taller and
easily shift attention to a new
heavier
situation are easily managed; some
b. HEALTH cannot be distracted, stubborn, willful or
unwilling to compromise
o Those who inherit a genetically-
transmitted disease may not grow g. Attention Span and persistence-
as rapidly or develop as fully as a ability to remain interested in a
healthy child particular project or activity;
persistence means they keep trying to
c. INTELLIGENCE perform an activity even when they fail
o Children with high intelligence do
not generally grow faster than
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 h. Threshold of response- intensity  Children learn by watching other
level of stimulation that is necessary children so an only child or an eldest
to evoke a reaction child may not excel in other skills
i. Mood Quality- one who is always d. HEALTH
happy and laughing has a positive
mood quality  Diseases from environmental sources
can influence G&D
Categories of Temperament  RHD, decrease in hearing for infants
cared for in the NICU (exposed to loud
1. The Easy Child
noises)
-easy to care for” with predictable rhythmicity,
4. NUTRITION
approach and adapt to new situations readily,
have a mild to moderate intensity of reaction,  The quality of a child’s nutrition during
have an overall positive mood quality; 40% to the growing years (including prenatally)
50% has a major influence on his/her health
and stature
2. The Difficult Child
 Poor maternal nutrition may limit growth
- “difficult” with irregular habits, negative mood & intelligence potential.
quality, withdraw rather than approach new  Children with inadequate nutrient intake
situations; 10% show inadequate physical growth and
prevents them from learning at their best
3. Slow-To-Warm-Up Child
intellectual level
-overall, fairly inactive, respond mildly and adapt  Those who eat too many carbohydrates
slowly to new situations, and have a general tend to be obese and develop motor
negative mood skills more slowly
 Nutrition influences susceptibility to
3. ENVIRONMENT diseases and development of chronic
a. SOCIOECONOMIC LEVEL illness

VII. SIGNIFICANT PERSONS

 Health care and nutrition are affected
1. INFANCY: MOTHER, mother-substitute or
b. PARENT-CHILD RELATIONSHIP
primary caregiver
 Children who are loved thrive better
2. TODDLER: PARENTS; mother and father
than those who are not
 Quality time spent is more important 3. SCHOOLER: teacher, peers of the same
than quantity sex, neighbors, classmates
 Loss of love and care may interfere with
a child’s desire to eat, improve and 4. ADOLESCENCE: PEERS (greatest
advance determinant/influencing factor of his behavior),
models of leadership. Partners of same &
c. ORDINAL POSITION IN THE FAMILY OPPOSITE SEX, adults other than parents are
idolized, sexual models
 The position of the child and the size of
the family have some bearing on the VIII. FEARS OF CHILDREN
growth and development of the child
A. INFANCY: fear of STRANGERS; starts at 6
 An only child or the eldest generally
mos when infant recognizes parents; peaks at 7-
excels in language development
8 mos
because conversations are mainly with
adults B. TODDLERS: Fear of SEPARATION

Stages of separation anxiety:

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1. PROTEST- cries loudly  PRESCHOOLER (PHALLIC PHASE)-
stage of the SUPEREGO;
2. DESPAIR- less active, monotonous voice
masturbation is common,
3. DENIAL- silent, difficulty forming close exhibitionism
relationships o OEDIPAL COMPLEX- son’s
attachment to mother and
C.PRESCHOOLER: jealousy towards the father
CASTRATION/MUTILATION o ELECTRA COMPLEX-
*Illogical fears: GHOSTS, INANIMATE objects, daughter’s
DARK (universal fear of children)  SCHOOL-AGE (LATENT PHASE)-
strict SUPEREGO; libido is diverted
D. SCHOOLER: Fear of into concrete thinking
DISPLACEMENT/REPLACEMENT, disease &  ADOLESCENT (GENITAL PHASE)- it
DEATH (permanent separation from loved ones) is the establishment of new sexual
aims and the finding of new love
E. ADOLESCENCE: Fear of losing Identity:
objects
acne, obesity, body odor, homosexuality,
fear of the UNKNOWN, disease and death X. ERIKSON’S THEORY OF PSYCHOSOCIAL
(altered identity); unfulfilled dreams; fears DEVELOPMENT- ERIK ERIKSON (1902-1996)
death the most
 It stresses the importance of culture
IX. FREUD’S PSYCHOANALYTIC & society in the development of
THEORY/PSYCHOSEXUAL THEORY personality
(Sigmund Freud 1856-1939)  A person’s social view of himself is
more important than instinctual
 Described adult behavior as being the
drives in determining behavior.
result of instinctual drives that have a
 At each stage, there is a conflict
primarily sexual nature (LIBIDO) from
between 2 opposing forces. The
within the person and the conflicts that
resolution of each conflict, or
develop between these instincts
accomplishment of the developmental
(represented in the individual as ID),
task or that stage, allows the individual
reality (the EGO), and society (the
to go on to the next phase of
SUPEREGO)
development
 He described child development as a
 INFANT (TRUST VS. MISTRUST)-
series of (PSYCHOSEXUAL STAGES)
infants whose needs are met as they
in which a child’s sexual gratification
arise, cuddled played with view the
becomes focused on a body part
world as a safe place; if care in
 INFANT PERIOD (ORAL phase)- stage
inconsistent, inadequate or rejecting, it
of ID (biologic pleasure principle);
fosters a basic mistrust; this task arises
infants suck for enjoyment or relief
again at each successive stage of
from tension and for nourishment:
development
o 0-6 mos- oral passive
 TODDLER (AUTONOMY VS. SHAME
o 7-18 mos- oral aggressive
OR DOUBT)- autonomy builds on new
(teething)
motor & mental abilities; toddlers need
 TODDLER (ANAL PHASE)- stage of to do what they are capable of doing, at
the EGO; focus on anal region as they their own pace and time; if they are not
begin toilet training; children find allowed to do things they want to do,
pleasure in both retention and they will doubt their ability and stop
defecation trying
o part of toddler’s self-discovery,
 PRESCHOOLER (INITIATIVE VS.
exertion of independence GUILT)- it is learning how to do
things on their own and not merely
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 respond to or imitate the actions of breastfeeding provides more stimulation due to
others. Encourage opportunities for increased effort
motor play, answer questions
(intellectual initiative), do not inhibit Toddler: ANAL Stage: learns to control
fantasy or play activity. Those who do urination & defecation: Help achieve toilet
not develop initiative may later have training without undue emphasis on its
limited brainstorming and problem- importance; continue when hospitalized
solving skills, waiting for clues or Preschooler: PHALLIC Stage: learns sexual
guidance from others before acting identity through awareness of genital area:
 SCHOOLAGE CHILD (INDUSTRY VS. Accept sexual interest like fondling of genitals,
INFERIORITY)- The task is how to do as normal; help parents answerquestions about
things well; success or failure in birth or sexual differences
school or community settings have a
lasting impact School-age: LATENT Stage: child’s personality
 ADOLESCENT (IDENTITY VS. ROLE development appears to be nonactive or
CONFUSION)- they must bring dormant: Help child have positive experiences
everything they have learned about so self-esteem continues to grow & child
themselves and integrate these prepares for the conflicts of adolescence
different images into a whole that
Adolescent: GENITAL Stage: adolescent
makes sense
develops sexual maturity & learns to establish
 YOUNG ADULT (INTIMACY VS. satisfactory relationships with the opposite sex:
ISOLATION)-intimacy is the ability to Provide opportunities for the child to relate with
relate well with other people, not only opposite sex; allow child to verbalize feelings
the opposite sex but also with one’s about new relationships
own sex to form lasting friendships
 MIDDLE-AGED ADULT ERIKSON’S STAGES
(GNERATIVITY VS. STAGNATION)-
extend their concern from just TRUST VS MISTRUST-learns to love & be
themselves and their families to the loved; Provide primary caregiver, experiences
community and the world, become that add to security like touch, soft sounds,
politically active, work to solve provide visual stimulation
environmental problems, participate AUTONOMY VS. SHAME – learns to be
in far-reaching communities or world- independent; Provide opportunities for
based problems; those without decision-making by offering choices of clothes to
generativity stagnate and become self- wear or toys; praise for ability to make decisions
absorbed with a narrow perspective and rather than the correctness of the decision.
lack ability to cope
 OLDER ADULT (INTEGRITY VS. INITIATIVE VS. GUILT- learns how to do
DESPAIR)- those with integrity feel things (basic problem-solving) & that doing
good about their life choices; those things is desirable; Provide opportunities for
with despair wish life would begin exploring new places or activities; use clay,
again so things could turn out water, finger paints
differently
INDUSTRY VS INFERIORITY- child learns
SUMMARY OF FREUD’S AND ERIKSON’S how to do things well; Provide opportunities
THEORIES OF PERSONALITY such as allowing child assemble & completea
DEVELOPMENT short project so that child feels rewarded for
accomplishment
FREUD’S STAGES
IDENTITY VS. ROLE CONFUSION- learn who
Infant: ORAL stage: explores the world by they are and what kind of person they will be
using mouth, esp the tongue: Oral stimulation by adjusting to a new body image, seeking
using pacifiers; don’t discourage thumbsucking;
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emancipation from parents, choosing a though physical properties change) or
vocation, & determining a value system; REVERSIBILITY (ability to retrace steps) as in
Provide opportunities to discuss feelings about pouringbeads into differently-sized containers
events important to him/her. Offer support & wherein they conclude that there is a change in
praise for decision making the amount of beads

XI. PIAGET’S THEORY OF COGNITIVE -role fantasy (how children would like
DEVELOPMENT-JEAN PIAGET (1896-1980) something to turn out)

4 stages of development, within each stage -assimilation (taking in information and

are finer units or schemas changing it to fit their existing ideas)

1. INFANT 0 to 2 yrs (SENSORIMOTOR -magical thinking- personification of nonliving

STAGE)- practical intelligence, at first things
through their senses, using reflex behavior;
later, they learn people are entities separate -egocentrism- perceiving one’s thoughts are
from objects; primary refers to activities related better or more important than those of others
to a child’s own body while circulatory reaction 4. SCHOOL-AGE CHILD (CONCRETE
shows repetition of behaviors OPERATIONAL THOUGHT)- discover
-secondary refers to activities separate from a concrete solutions to everyday problems ad
child’s body (hitting a mobile, making it move); recognize cause and effect relationships; as
infant also learns permanence (peek-a-boo, early as 7 yo
search for hidden objects, parent is the same -inductive reasoning- from specific to general
regardless of outfit, learn where their body stops (toy is broken; toy is made of plastic; all plastic
and their bed, parent or toy begin toys break easily)
-final phase of infant year (coordination of 5. ADOLESCENT (FORMAL OPERATIONAL
secondary reactions)- exhibit goal-directed THOUGHT)
behavior
-capable of thinking in terms of possibility- what
2. TODDLER (TERTIARY CIRCULAR could be (ABSTRACT THOUGHT)-rather than
REACTION & INVENTION OF NEW MEANS & being limited to what already is (CONCRETE
START OF PREOPERATIVE PERIOD) THOUGHT)
-tertiary circular reaction- use trial and error to -able to use scientific reasoning
discover characteristics of objects and events
-Understands deductive reasoning (from general
-invention of new means- able to think through to specific)- plastic toys break easily; this toy is
actions or mentally project solutions to a plastic; it will break easily
problem

-preoperational thought- relearn on a

conceptual level some lessons mastered as
infants; using symbols to represent objects;
draw conclusions only from obvious facts they
see (Daddy is shaving therefore going to work
just like yesterday)

3. PRESCHOOLER

-intuitive thought (substage of preoperational

thought)-tend to look at an object and see only 1
characteristics or centering (banana is yellow,
medicine is bitter) which contributes to lack of
CONSERVATION (ability to discern truth,
-Castillote BSN2 A10
  CV System- HR slows from 120- 160
bpm to 100-120 bpm by the end of the
1st year
 Kidneys remain immature and not as
efficient at eliminating body wastes as in
the adult
 Immune system becomes functional by
at least 2 months of age
 The ability to adjust to cold is mature by
6 months of age

F. Teeth
SESSION #20
 1st baby tooth/ milk tooth/deciduous
GROWTH AND DEVELOPMENT OF AN
teeth (lower central incisor) erupt at 6
INFANT
months of age
I. Physical Growth  12 months: have 8 teeth, lower &
upper central and lateral incisors
A. Weight  24 months: 16 teeth
 During the 1st 6 months, the infant  2 1⁄2: with complete milk teeth- 20 teeth
typically averages a weight gain of 2  Late preschool: eruption of 1st
lbs./month permanent teeth (first molars)
 During the 2nd 6 mos., weight gain is 1  6 years: brags about DANCING TEETH
lb/month  12 YEARS: with all permanent teeth
except FINAL MOLARS (27-28 teeth)
B. Height  17-21 years: complete permanent
teeth: 32
 Infants increase in height during the
 SCHOOL AGE: to be checked for
1st year by 50% or grows from an
loose teeth before any surgery
average birth length of 20 in to 30 in
 CARE of teeth:
 Infant growth is most apparent in the
1. brush & floss (with parent’s help)
trunk during the early months; during the
2x a day
2nd half, it becomes more apparent as
2. limit concentrated sweets
lengthening of the legs
3. if H2O is not fluorinated,
C. Head Circumference supplements can be given 0.25 to
0.5 mg/day
 HC increases rapidly reflecting rapid 4. Don’t allow a bottle of milk or juice
brain growth. By the end of the 1st to bed-BOTTLE MOUTH CARIES
year, the brain has reached 2/3 of its 5. 1ST DENTAL VISIT AS SOON AS
adult size ALL PRIMARY TEETH ARE OUT (2
1⁄2 years)
D. Body Proportion
 PERMANENT TEETH
 Chest circumference is less than that 1. 6-7 yrs.: 4 “six-year-molars”
of the head by about 2 cm 2. 12-13 yrs.: 4 additional molars
 Cervical, thoracic and lumbar vertebral 3. 17-21 yrs..: 4 molars (“wisdom
curves develop as infants hold up their teeth”)
head, sit, and walk
II. PLAYS AND GAMES IN CHILDREN
E. Body Systems
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A. INFANT Accidents are a leading cause of death in
children from 1 month through 24 years of age
1. Solitary play- plays with body or toys
1. Aspiration Prevention
2. Toys: rattles, crib mobiles, teether, pacifier,
squeeze toys, musical boxes, large, cuddly toys,  Round, cylindrical objects are more
colorful balls dangerous (carrot, pea, hotdog)
because it can totally obstruct the
B. TODDLER
airway
1. Parallel play- plays alone in the presence  Do not prop feeding bottles
of other children: no sharing  Children < 5 should not be offered
peanuts or popcorn
2. Toys:

a. push and pull toys (BEST)

2. Fall Prevention- 2nd major cause of infant
b. Play telephone- age of language training accidents
c. outlets for aggressive behavior: play hammer,  Do not leave infant unattended on a
drum, pots & pans, balls raised surface
d. throwing and retrieving games (ball)  Be prepared for infant to roll over at 2
months
e. building blocks: build tower of 2 blocks at 12-  Crib rails should be 2 3/8 inches apart,
18 mos., narrow enough so a child cannot put his
head between them
4 blocks at 18 mos. to 2 yrs.., and 8 blocks at 2
1⁄2 years 3. Car Safety
C. PRESCHOOLER  Infants up to 20 lbs. should be placed in
a rear- facing seat in the back seat
1. COOPERATIVE PLAY: plays with others,
because an inflating air bag could
can be with large group of boys & girls
suffocate them
2. TOYS: play house, coloring books, clay,
4. Safety with Siblings
cutting & pasting tools, superheroes, costumes,
dress-up dolls, ball (throws and catches balls at  Do not leave infants unattended with
5 yrs.; rides tricycle at 3, bicycle at 7 yrs.) children < 5 yrs. of age
D. SCHOOLER 5. Bathing & Swimming safety
1. COMPETITIVE PLAY: plays with peers of  Do not leave infant unattended in a tub
the same sex; games have rules where
winning is desired 6. Childproofing

2. TOYS: Quiet games like reading, painting,  Check for possible sources of lead
radio listening, TV watching; table games: (paint) since infants begin teething at 5
scrabble, chess; bicycle (at 7 yrs.); handicrafts to 6 months
(late schoolers), school sports  Remove all poisonous substances from
bottom cupboards
E. ADOLESCENCE
IV. PROMOTING NUTRITIONAL HEALTH
1. Leisure, recreation activities: parties, outings,
picnics, movies, fantasy, DAYDREAMING,  The best food during the 1st 12 months
telephone conversation, reading romance of life (and the only food necessary for
novels, sports games, hobbies the 1st 6 months) is breast milk
III. PROMOTING INFANT SAFETY
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  Due to extremely rapid growth, high -offer 3 meals & healthy snacks
protein, high calorie intake is needed
-begin to wean from bottle & begin table foods
 Breast fed infants gain less weight than
formula-fed infants -avoid fruit drinks & flavored milk
A. Introduction of Solid food -allow infant to feed self with spoon
 Delaying feeding of solid foods until 4 to B. Sequence of Introducing Solids
6 months prevents the kidneys from
being overwhelmed by the high solute 1. RICE CEREALS
load
 Hypoallergenic, easy to digest
 Extrusion reflex fades by 3 to 4 mos. In
 Do not give it from the bottle to prevent
preparation for the introduction of solid
aspiration and allow learning to eat with
food.
a spoon

Schedule for introducing solid food

2. VEGETABLES (7 mos.)
0 to 3 mos.
 Iron content is higher than fruits and
-Feeding only breast milk or formula for 1st year therefore given before fruits

-Hold infant when feeding & never prop bottle 3. FRUITS

when feeding
 Offered 1 month after beginning
-limit water intake to 1⁄2 oz. to 1 oz. at a time vegetables (8 mos.)
 Offer a selection so infant is exposed to
-avoid use of honey or corn syrup different tastes & textures
-allow non-nutritive sucking 4. MEAT (9 MOS)
4 to 6 mos.
 Beef & pork have more protein than
-introduce solid foods without salt or sugar & chicken; offer them first
iron-fortified cereal, 1 food at a time  meat is usually added as part of the
evening meal in place of cereals
-avoid use of juice or sweetened drinks
5. EGG YOLKS (10 mos.)
-feed from a spoon only
 the yolks contain the bulk of iron in eggs
7 to 9 mos.  may be prepared by hard-boiling then
-introduce finger foods & cup when infant is able mashing; soft-boiling is not
to sit up recommended because Salmonella may
not be killed and thorough cooking
-have infant join family at mealtimes makes it easier to digest
 whole eggs are given at 12 mos.
-allow self-feeding, with observation to prevent
choking 6. TEETHING FOODS (6 to 7 mos.)
-offer fluids after solids C. Establishing Healthy Eating Patterns and
Promoting Development in Daily Activities
-introduce limited amounts of diluted juice in a
cup 1. WEANING
-avoid sugary desserts & soda  infant can drink from a cup at 9 mos.
 Sucking reflex begins to diminish at 6 to
10 to 12 mos.
9 mos., the right time to wean the infant
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  Choose 1 feeding a day to introduce 3. USE of PACIFIERS
weaning
 Parents should attempt to wean a child
2. SELF-FEEDING from a pacifier any time after 3 mos. of
age
 At 6 mos. of age, introduce the use of a  Use of pacifiers has been linked to
spoon increased incidence of otitis media
3. BATHING  Be vigilant to prevent strangulation from
the strap or aspiration
 The frequency of bathing depends on
the weather 4. HEAD BANGING
 Some need frequent washing of the  It is normal if it begins during the 2nd
scalp to prevent SEBORRHEA (cradle half of the 1st year through to the
cap) preschool period, associated with
naptime or bedtime and lasts under 15
minutes
4. DIAPER –AREA CARE
5. SLEEP PROBLEMS
 Change diapers frequently, about every
2 to 4 hours; wash the skin & allow to For eliminating or coping with night waking:
dry and apply ointment  Delay bedtime by 1 hour
5. CARE OF TEETH  Shorten afternoon naps
 Do not respond immediately to infants at
 Use toothpaste after the tooth eruption night so they can have time to fall back
 Initial check-up is made at 2 or 2.5 years to sleep on their own
of age & continues at 6-month intervals  Provide soft toys or music to allow them
to play quietly alone
6. SLEEP
6. CONSTIPATION
 Most require 10 to 12 hours of sleep at
night and 1 or several naps during the  Foods with bulk such as fruits or
day vegetables, apple juice or prune juice,
add more fluids
V. PARENTAL CONCERNS AND PROBLEMS
 If it persists, check for other possible
RELATED TO NORMAL INFANT
conditions
DEVELOPMENT
7. LOOSE STOOLS
1. TEETHING
 Infants with associated signs such as
 High fever, seizures, vomiting or
fever, cramping, vomiting, anorexia,
diarrhea and earache are NEVER
decrease I voiding and weight loss must
normal signs of teething
be evaluated
 Teething rings may be refrigerated to
provide soothing coolness against 8. COLIC
tender gums
 Colic is a paroxysmal abdominal pain
2. THUMBSUCKING that occurs generally in infants < 3 mos.
of age
 The sucking reflex peaks at 6 to 8
 The infant cries loudly, pulls up the legs
months, whereas thumb-sucking peaks
against the abdomen, face flushed, fists
at about 18 mos.
clench and the abdomen become tense
 Thumb sucking is normal, does not
deform the jaw line as long as it stops
by school age.
-Castillote BSN2 A10
  The cause is unclear, maybe from 13. OBESITY IN INFANTS
overfeeding or swallowing too much air
or the formula is hard to digest  Obesity is a weight greater than the 90th
to 95th percentile on a standardized
 Assess the feeding patterns, the diet
height/weight chart
and bottle-feeding methods
 It occurs when there is an increase in
 Give small, frequent feedings, bubble
the number of fat cells due to excessive
frequently
calorie intake
 In most infants, it disappears at 3 mos.
 Formula should not be more than 32 oz
because it is easier to digest food &
daily; add a source of fiber to the diet;
easier to maintain an upright position
avoid refined sugars
9. SPITTING UP

 Formula-fed babies do it more often

than breastfed babies
 Spitting up (rolling down the chin) 2 to 3
times a day is normal
 Burp baby thoroughly, sit infant on an
infant chair for 30 mins after feeding to
decrease spitting up

10. DIAPER DERMATITIS

 Diaper rash occurs if the diaper change

is infrequent causing irritation from
stools and from the ammonia in urine
 Change diapers frequently, apply A & D
or Desitin ointment, and exposing the
diaper to air

11. MILIARIA

 Prickly heat rash occurs often in warm

weather or when babies are
overdressed or sleep in overheated
rooms
 They appear as clusters of pinpoints,
reddened papules with occasional
vesicles and pustules surrounded by
erythema appearing on the neck first
spreading upward to the ears and face
and downward to the trunk
 Bathe 2x a day during hot weather,
eliminate sweating to prevent further
eruption

12. BABY-BOTTLE SYNDROME

 Decay occurs because while an infant

sleeps, liquid from the propped bottle
continuously soaks the upper front teeth
and the lower back teeth (lower front
teeth are covered by the tongue)
 Never put the baby to sleep with a bottle
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 C. Psychosocial Development

 AUTONOMY VS SHAME & DOUBT

 PRE-CONCEPTUAL PHASE (2-4 yo)-
 animism, magical thinking, concrete,
literal
 Vague idea about GOD
 REWARD & PUNISHMENT
 DIFFERENTIATION- separate
individual
 Withstand DELAYED GRATIFICATION
 TRANSITIONAL OBJECT

D. NUTRITION

 PHYSIOLOGIC ANOREXIA-picky,
fussy
SESSION #21  GRAZING, NIBBLING
 RITUALISTIC- use same plate,
GROWTH AND DEVELOPMENT OF A
utensils
TODDLER
 CHOKING- avoid large, round foods
 SQUAT, “POT-BELLIED” appearance  FOOD JAGS- make food appealing,
because of less well-developed offer variety
abdominal muscles & short legs
E. Parental Concerns During the Toddler
A. Anthropometric Measurements Years

1. WEIGHT:  Toilet training

 Ritualistic behavior
 Weight gain= 1.8-2.7kg (4-6 lbs.)/year
 Negativism
 Average weight (2yo) = 12 kg (27 lbs.)
 Discipline
 Birth weight X 4 at 21/2 yrs. Old
 Separation anxiety
2. HEIGHT:  Temper tantrums

 increase of 3 inches/yr. (mainly in the F. Nursing Diagnoses: Toddler Growth and

LEGS Development
 Ave height at 2 yrs. old = 34 in (50%
 Deficient knowledge related to best
adult height)
method of toilet training
3. HC (Head Circumference) = CC (Chest  Risk for injury related to impulsiveness
Circumference) by 1 to 2 yrs old of toddler
 Interrupted family process related to
4. CC > HC during toddler years need for close supervision of 2-year-old
B. Distinct Characteristics and Traits of  Readiness for enhanced family coping
Toddlers related to parents’ ability to adjust to
new needs of child
 NEGATIVISM: “NO”
GROWTH AND DEVELOPMENT OF A
 Development of EGO
PRESCHOOL CHILD
 TEMPER TANTRUMS
 RITUALISM BIOLOGIC DEVELOPMENT
 DAWDLING
 EGOCENTRICITY/SELFISHNESS  Average weight (3 years old) = 14.6 kg
(32lbs.)
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  Average weight gain = 5 lbs./yr. o Height & weight increase is
 Average HEIGHT INCREASE= 6.75-7.5 SLOW& STEADY
cm (2.5-3 in)/yr. o Proportional changes: slimmer,
 PHYSICALPROPORTIONS: slender, longer legs, varying proportion &
sturdy, graceful, agile, posturally-erect lower center of gravity; posture
improves, fat diminishes & is
SOCIAL/MORAL DEVELOPMENT redistributed
 ASSOCIATIVE PLAY o UGLY DUCKLING STAGE –
 IMAGINARY PLAYMATES early years
o PREADOLESCENCE- from
 SEX Education at 5yo from parents
middle of childhood to 13yo
 Fear of the DARK; SLEEP TERRORS
o PUBERTY- 10 in girls, 12 in
 LYING, TELLS TALES
boys
 Stuttering
SOCIAL/MORAL DEVELOPMENT

 LATENCY (FREUD)
EMOTIONAL DEVELOPMENT

 Oedipus and Electra complexes

 Gender roles
 Socialization

Nursing Diagnoses for Preschoolers

 Health-seeking behaviors related to

developmental expectations
 Risk for injury related to increased
independence outside the home
 Delayed growth and development
related to frequent illness
 Risk for imbalanced nutrition, more than
body requirements, related to fast food
choices
 Risk for poisoning related to
maturational age of child
 Parental anxiety related to lack of
understanding of childhood
development

SESSION #22

GROWTH AND DEVELOPMENT OF A

 INDUSTRY VS INFERIORITY- positive
SCHOOL-AGE CHILD
reinforcement
BIOLOGIC DEVELOPMENT  PEER GROUP- secret codes, rules
 BEST FRIENDS
 The school age child is a sturdy,  BULLYING
complicated individual with the ability
 Not yet ready to abandon parental
to communicate, conceptualize in a
control; parents as ADULTS, not PALS
limited way & become involved in
 COMPETITIVE PLAY
complex social & motor behavior.

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  QUIET GAMES- collecting, reading, o Assure children they are safe.
handicraft, board games, computer o Observe for signs of stress.
games, music, sports o Do not allow children or
 EGO mastery through play adolescents to view footage of
traumatic events repeatedly.
MORAL & SPIRITUAL DEVELOPMENT
o Watch news programs with
 REWARD AND PUNISHMENT children; explain the situation
 Concepts of Heaven & Hell portrayed.
 Concept of punishment to fit the crime o Prepare a family disaster plan;
designate a “rally point” to meet
COGNITIVE DEVELOPMENT if ever separated.
CONCRETE OPERATIONS Recreational drug use
 From making judgments from what  Suspect if child regularly appears
they see (Perceptual Thinking) to irritable, inattentive, or drowsy.
making judgments based on what  Counsel against use of steroids;
they reason (CONCEPTUAL highlight future cardiovascular
THINKING) irregularities, uncontrollable
 CLASSIFICATION aggressiveness, and possible cancer.
 ORDERING  Teach to recognize tobacco advertising
 REVERSIBILITY-refers to the ability manipulation; caution against
to recognize that numbers or objects experimenting with smokeless tobacco.
can be changed and returned to their  Role model excellent nonsmoking health
original condition. For example, during behavior.
this stage, a child understands that a
favorite ball that deflates is not gone but PROBLEMS OF SCHOOLERS
can be filled with air again and put back
 STEALING/SHOPLIFTING (7years)-
into play
 CHEATING
 CONSERVATION is the concept of
 HANDEDNESS- established at 6 years
things staying the same even though
old
other elements change, which is
 SPEECH DIFFICULTIES
based on rational thinking.
 PREPARATION FOR PUBERTY
DEVELOPMENTAL CONCERNS:  SEX Education- HCP as resource
person
 CHEATING
 DRUG EXPERIMENTATION
 STEALING/SHOPLIFTING- 7 years-old
 SCHOOL STRESS
 Early childhood stealing is best
handled without a great deal of Nursing Diagnoses: School-Age Children
emotion.
 Shoplifting must be taken seriously  Health-seeking behaviors related to
by parents. normal school-age growth and
 Parents should set good examples development
 Readiness for enhanced parenting
 HANDEDNESS- established at 6
related to improved family living
years-old
conditions
 SPEECH DIFFICULTIES
 Anxiety related to slow growth pattern of
 PREPARATION FOR PUBERTY
child
 SEX Education- HCP as resource
 Risk for injury related to deficient
person
parental knowledge about safety
 SCHOOL STRESS
precautions for a school-age child
 Violence or terrorism
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  Easily influenced into forming concept of
self; choose ROLE MODELS & avoid
Labeling
 PEER GROUP influence
 Vacillates between considerable
maturity &childlike behavior
 MOOD SWINGS
 AMBIVALENCE bw independence &
fear of responsibilities

COGNITIVE DEVELOPMENT

 ABSTRACT THINKING- no longer

restricted to the real & actual
(CONCRETE) but also considers the
possibilities
 FORMAL OPERATIONAL AGE
 Scientific reasoning
 Can imagine thinking other than their
own
SESSION #23

GROWTH AND DEVELOPMENT OF AN

ADOLESCENT MORAL DEVELOPMENT

DEFINITIONS:  INTERNALIZED SET OF MORAL

PRINCIPLES- refers to moral code
ADOLESCENCE- begins with gradual
appearance of 2ary sex characteristics at 11 to SEXUAL MATURATION IN GIRLS
12 years old & ends with cessation of body
 THELARCHE- breast development (9-
growth at 18 to 20 yrs old
13 1⁄2)
PUBERTY- the maturational, hormonal & growth  ADRENARCHE- pubic hair
processes that occur when the reproductive  MENARCHE- ist menstruation 2 yrs
organs begin to function & the secondary sex after changes (9 1⁄2 to 12 years old)
characteristics begin to develop (3 stages)  OVULATION- 6 to 14 mos after
MENARCHE
PREPUBESCENCE- 2 years before puberty
 Growth spurt
PUBERTY- sexual maturity is achieved;  Widening of the hips
menarche  Vaginal secretions increase
 Axillary hair
POSTPUBESCENCE-1-2 yrs after puberty
SEXUAL MATURATION IN BOYS
3 PHASES OF ADOLESCENCE:
 enlargement & thinning, reddening &
EARLY ADOLESCENCE- 11-14 yrs old
increasing looseness of scrotum (9
MIDDLE ADOLESCENCE- 15 to 17 yrs old 1⁄2-14 yo)
 Pubic hair, axillary & facial hair
LATE ADOLESCENCE- 18 to 20 yrs old  Penile enlargement
SOCIAL DEVELOPMENT  Increasing muscularity
 Voice changes
 IDENTITY VS ROLE CONFUSION  GYNECOMASTIA
 Growth spurt

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  NOCTURNAL EMISSIONS
 SPERMATOGENESIS

PHYSICAL GROWTH

 ACNE
 APOCRINE SWEAT GLANDS active
 GROWTH SPURT- extremities & neck
first

PLAYS AND GAMES

 LEISURE/RECREATIONAL
ACTIVITIES
 PARTIES, OUTING, PICNICS, MOVIES
 FANTASY & DAYDREAMING
 TELEPHONE CONVERSATIONS
 COMPUTER GAMES
 READING ROMANCE NOVELS
 SPORTS
 HOBBIES

PROBLEMS WITH ADOLESCENTS CAUSES OF INJURIES

 Fatigue, poor posture  MOTOR VEHICULAR ACCIDENTS
 ACNE VULGARIS  SPORTS ACCIDENTS
 SUICIDE  DROWNING
 DRUG EXPERIMENTATION  ALCOHOL
 ALCOHOLISM  DRUGS
 SUICIDE
 TEENAGE PREGNANCY

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