NCM107 1

NCM 107 – CARE OF MOTHER, CHILD, ADOLESCENT (WELL CLIENTS)
CONCEPT OF PROCREATION In male: strong rhythmic muscular contraction of the

PROCREATION epididymis, prostate, vas deferens, seminal vesicle,
- Creation of a new human person, by the act of sexual ejaculatory ducts and penis resulting to the ejaculation
intercourse, by a man and a woman of semen
In women: strong rhythmic contractions of the
THEORY RELATED TO PROCREATION orgasmic platform, uterus and anal sphincter muscles
Evolutionary theory releasing mucoid fluid from the vagina.
- All things came about by the repeated random actions
of natural selection, whereby: 4. Resolution phase: follows the orgasm in both
- Life came into existence male and female
- Primitive life evolved into more and more complex Characteristics: In male – penis returns to non-erect
organisms, and eventually producing mankind state, testes lower and return to normal size
In female – vagina and labia return to normal, lowering
PROCESS OF HUMAN REPRODUCTION of the cervix, clitoris and size of breast
HUMAN REPRODUCTION Both: general muscle relaxation occurs; flushing
 A long process, starting with sexual intercourse, disappears, heart rate & BP return to normal, external
followed by nine months of pregnancy before and internal genital organs return to an unaroused
childbirth. Many years of parental care is required state, with a desire to sleep. Takes approx. 30 minutes
in order to finish with a mature human being. for both men and women.
5. Refractory phase – only in male; period during
1. HUMAN SEXUAL INTERCOURSE which no amount of stimulation can cause another
- Human reproduction takes place as internal erection. Not manifested in women because females
fertilization by sexual intercourse are MULTI-ORGASMIC. This phase lengthens with
- Upon successful fertilization and implantation, age.
gestation of the fetus then occurs within the female's
uterus, called pregnancy 2. PREGNANCY
- Carrying of one or more offspring, known as a fetus
Human Sexual Response (EPOR) or embryo, inside the uterus of a female. In a
1. Excitement phase: pregnancy, there can be multiple gestation
Duration: a few minutes to a few hours - The period of time during which the fetus develops
Stimulation: sensory stimuli such as touch, sight, - Gestation is 40 weeks
sound, smell or active imagination
Purpose: to prepare both sexes physically and 3. BIRTH
emotionally for the act. - When the fetus is sufficiently developed, chemical
Characteristics: Female: vaginal lubrication in female; signals start the process of birth
nipples become erect, breast size increases. - The newborn should typically begin respiration on its
Male: there is penile erection due to vasocongestion. own shortly after birth.
HR, RR, BP increases. Childbirth
- also called labor, birth, partus or parturition
2. Plateau phase: starts upon insertion of penis into - the culmination of a human pregnancy or gestation
the vagina and active intercourse starts period with birth of one or more newborn
Characteristics: generalized muscle tension, - childbirth is categorized in three stages of labor:
hyperventilation, increase BP, HR, respiration, flushing dilatation stage, birth of the infant, and birth of the
may spread to abdomen, thighs, and back. placenta
In women: formation of orgasmic platform - retraction - Childbirth is achieved through caesarean section or
of clitoris beneath the prepuce, opening of vagina vaginal birth.
narrows
In men: full distention of the penis, testes become 4. PARENTAL CARE
enlarges and elevated toward the body - Babies and children are nearly helpless and require
high levels of parental care
3. Orgasmic phase: - One important type of parental care is the use of
Duration: the shortest stage (few seconds) in the the mammary glands in the female breasts to
sexual response cycle in which the body suddenly nurse the baby
discharges accumulated sexual tension; accompanied
by an intense pleasure affecting the whole body. Risk Factors related to Development of Genetic
*It is the climax or orgasm of sexual excitement Disorders
involving the release of sexual tension - Maternal age > 35
Characteristics: - Paternal age > 50
- Recurrent previous spontaneous abortions
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- Chromosomal abnormality in a previous child 7. Done to determine chromosomal abnormalities but

- Parental chromosomal disorder doesn’t reveal extent of spinal cord abnormalities
- Ethnic background or race
- History of metabolic disorders 5. AMNIOCENTESIS
- Family history of chromosomal disorders or birth  Withdrawal of amniotic fluid thru the abdominal
defects wall for analysis
Genes: basic units of heredity that determine both the  Done as early as 12th week or at 14-16th week
physical and cognitive characteristics of people. It  2ml-5ml of A.F.
consists of strands DNA that are woven in the nucleus Procedure:
to produce chromosomes.  Local anesthesia will be given
A person with normal genome has either 46XY (Male)  May feel a sensation of pressure as the needle is
or 46XX (Female). Chromosomal aberration exists if inserted
there is a missing or extra chromosome.  Spinal needle gauge 20-22 is used
 Needle is inserted abdominally & fluid is aspirated
COMMON TESTS FOR DETERMINATION OF  Skin cells in A.F. are karyotyped
GENETIC ABNORMALITIES
 Level of AFP is analyzed
1. KARYOTYPING
Nursing Management:
 Visual presentation of chromosome pattern
 Observe for 30 minutes for (-) labor contractions
 Sample: peripheral venous blood or buccal & fetal heart rate within normal
membrane
 Deep breath & holding it is discouraged
 Any additional, lacking or abnormal chromosomes
 UTZ will be done
can be visualized
Complications:
• Hemorrhage from penetration of placenta
2. BARR BODY DETERMINATION
• Infection of A.F.
 Evaluate whether the child has 2 X chrom.
• Puncture of fetus
 Sample cells: buccal membrane of inner surface
of cheeks
6. PERCUTANEOUS UMBILICAL BLOOD
 Presence of black dot (barr body) on the edge of
SAMPLING
the nucleus confirms that the child is female
 Karyotyping is done after  Removal of blood from umbilical cord (u. vein)
using amniocentesis technique
3. ALPHA-FETOPROTEIN ANALYSIS  To ensure blood is obtained from fetus, it is
submitted to Kleihauer-Betke test
 AFP--produced by the fetal liver
 RhIG is given to Rh negative mom
 Present in amniotic fluid or maternal serum
 Serum test done at 15th week of pregnancy Nursing Management:
 If the result is abnormal (+): A.F. is assessed • Monitor fetus
 Elevated—spinal cord or abdominal defect • Uterine contractions
 Decreased—chromosomal disorder (trisomy 21) • Signs of bleeding by UTZ
 Confirmatory test if elevated serum AFP: UTZ or
amniocentesis 7. SONOGRAPHY
 Assess fetus for generalized size & structural
4. CHORIONIC VILLI SAMPLING disorders of internal organs, spine & limbs
 Can be done as early as 5th week; 10-12 weeks  Used to discover complications of pregnancy &
 More commonly done 8-10th week fetal anomalies
 Sample cells: trophoblast cells or chorion cells  Maintain full bladder
 Thin catheter is inserted vaginally or biopsy needle  Can be done using intravaginal technique or on
inserted abdominally or intravaginally abdomen
Risks:  A gel or lubricant is applied on abdomen
• Excessive bleeding leading to pregnancy loss  Then a transducer on abdomen
• Missing limbs
Report the following: 8. FETOSCOPY
1. Fever  Insertion of fetoscope thru a small incision in
2. Chills mom’s abdomen into the uterus & membranes
3. Uterine contractions  Inserted by amniocentesis technique
4. Vaginal bleeding  Done as early as 16th-17th week
5. Women receive rhogam after the procedure
 Local anesthesia injected into abdominal skin
6. Cells are karyotype or submitted for DNA analysis
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Risk: place) and round ligaments (from sides of the uterus

 Amnionitis to the mons pubis)
 Premature labor - Abundant blood supply from uterine and ovarian
 Used to inspect fetus for gross abnormalities arteries
Other uses: - Organ of menstruation; site of implantation,
 Confirm UTZ findings retainment and nourishment of the products of
conception.
 Remove skin cells for DNA analysis
- Composed of 3 muscle layers: perimetrium,
myometrium and endometrium
9. PRE-IMPLANTATION DIAGNOSIS
- Consists of three parts:
 Fertilized embryo is removed from the uterus by 1. Fundus - upper portion; site of implantation
lavage before implantation
2. Corpus (body)- middle portion
 Cells from zona pellucida removed & biopsied for 3. Isthmus – lower uterine segment; adjacent
DNA analysis
to Cervix – lower cylindrical portion
 Ovum would be reinserted or not
3. Fallopian Tubes – 4 inches long from each side of
UTILIZATION OF NURSING PROCESS IN THE the fundus; widest part (called ampulla) spreads into
PREVENTION OF GENETIC DISORDERS finger-like projections (called fimbriae). Responsible
A. History for transport of mature ovum from ovary to
Family history uterus; fertilization takes place in its outer third or
1. Mother’s age outer half
2. Ethnic background Parts:
3. Cases of spontaneous miscarriage 1. Infundibulum: adjacent to uterus;
4. Environmental conditions 2. Ampulla: Widest part; site of fertilization
Family pedigree 3. Interstitial: narrowest portion; most
- attempt to diagnose the pattern of inheritance dangerous site of ectopic pregnancy
B. Physical assessment
4. Ovaries – almond-shaped, dull white sex glands
 Pay attention to space bet the eyes; height, near the fimbriae, kept in plact by ligaments. Produce,
contour & shape of ears; no. of fingers & toes; mature and expel ova and manufacture estrogen and
presence of webbing progesterone.
 Dermatoglyphics - study of surface markings of
the skin THE PELVIS – although not a part of the female
reproductive system but of the skeletal system, it is a
C. Interventions very important body part of pregnant women.
 Obtain a detailed history & P.E. of client & spouse
 Review mode of transmission & chances of A. Structure
acquiring disease Two os coxae/innominate bones – made up of:
 Prepare for genetic counseling o Ilium – upper extended part; curved upper
 Provide emotional support & guidance border is the iliac crest.
 Assist couples in values clarification, planning & o Ischium – under part; when sitting, the body
decision making based on test results rests on the ischial tuberosities; ischial spines are
important landmarks.
ANATOMY AND PHYSIOLOGY OF THE o Pubes – front part; join to form an articulation of
REPRODUCTIVE SYSTEM the pelvis called the symphysis pubis.
A. FEMALE REPRODUCTIVE SYSTEM o Sacrum – wedge-shaped, forms the back part of
THE INTERNAL RERODUCTIVE ORGANS the pelvis. Consists of 5 fused vertebrae, the first
having a prominent upper margin called the sacral
1. Vagina – a 3-4-inch-long dilatable canal located
promontory.
between the bladder and the rectum; contains rugae
o Coccyx – lowest part of the spine; degree of
(which permit considerable stretching without tearing);
movement between sacrum and coccyx made
organ of copulation; passageway for menstrual
possible by the third articulation of the pelvis
discharges and fetus.
called sacroccygeal joint which allows room for
delivery of the fetal head.
2. Uterus
- Hollow pear-shaped fibromuscular organ 3 inches
B. Divisions – set apart by the linea terminalis, an
long, 2 inches wide, 1 inch thick and weighing 50-60g
imaginary line from the sacral promontory to the ilia on
- Held in place by broad ligaments (from sides of uterus
both sides to the superior portion of the symphysis
to pelvic walls; also hold Fallopian tubes and ovaries in
pubis.
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1. False pelvis – superior half formed by the Female Reproductive System

ilia. Offers landmarks for pelvic measurements;
supports the growing uterus during pregnancy;
and directs the fetus into the true pelvis near the
end of gestation.
2. True pelvis – inferior half formed by the pubes in
front, the iliac and the ischia on the sides and the
sacrum and coccyx behind. Made up of three
parts:
3. Inlet – entranceway to the true pelvis. Its
transverse diameter is wider than its ANALOGOUS STRUCTURES IN THE MALE AND
anteroposterior diameter. Thus: FEMALE REPRODUCTIVE SYSTEM
Transverse diameter = 13.5 cm. MALE FEMALE
Anteroposterior diameter (AP) = 11 cm.
spermatozoa ovum
Right and left oblique diameter = 12.75 cm.
glans penis glands clitoris
4. Cavity – space between the inlet and the
scrotum labia majora
outlet. Contains the bladder and the rectum, with
penis vagina
the uterus between them in an anteflexed position
testes ovaries
towards the bladder.
vas deferens fallopian tubes
5. Outlet – inferior portion of the pelvis, bounded on
prostate glands skene’s glands
the back by the coccyx, on the sides by the ischial
Cowper’s glands Bartholin’s glands
tuberosities and in front by the inferior aspect of
the symphysis pubis and the pubic arch. Its AP
diameter is wider than its transverse diameter. THE MAMMARY GLANDS
External structures
C. Types/Variations 1. Nipple or Papillae - located on the surface of each
1. Gynecoid – “normal” female pelvis. Inlet is well breast
rounded forward and back. Most ideal for 2. Areola - surrounds the nipple; pigmented
childbirth. 3. Montgomery Tubercles - glands that secrete oily
2. Anthropoid – transverse diameter is narrow; AP substance to lubricate areola and nipples
diameter is larger than normal. Internal structures
3. Platypelloid – inlet is oval, AP diameter is 1. Lobes: 15 to 20 lobes/breast
shallow 2. Lobules: composed of acini cells
4. Android – “male” pelvis. Intel has a narrow, 3. Acini cells: secretes milk d/t prolactin
shallow posterior portion and pointed anterior 4. Lactiferous Ducts: stimulates development of the
portion. ductile structures of the breast
5. Lactiferous Sinus: reservoir of milk.
D. Measurements
1. External – suggestive only of pelvic size: Know your HORMONES!
o Intercristal diameter – distance between the EStrogen - responsible for Secondary Sex
middle points of the iliac crests. Average = 28 cm. characteristics; telarche
o Interspinous diameter – distance between the Progesterone - develops acinar structures
anterosuperior iliac spines. Average = 25 cm. during Pregnancy
o Intertrochanteric diameter – distance between the HPL: breast enlargement during pregnancy
trochanters of the femur. Average = 31 cm. Oxytocin: “Oozing”; Milk let-down reflex
o External conjugate / Baudelocque’s diameter – Prolactin: Production of milk
distance between the anterior aspect of the
symphysis pubis and depression below B. MALE REPRODUCTIVE SYSTEM
L5. Average = 18-20 cm. I. EXTERNAL ORGANS
2. Internal – give the actual diameters of the inlet 1. Penis: consists of two corposa cavernosa and one
and outlet corposa spongiosum
o Diagonal conjugate – distance between the sacral - organ of copulation
promontory and inferior margin of the symphysis - urination
pubis. Average = 12.5 cm. Important 2. Scrotum: hanging sac-like structure; contains
measurement because it is the diameter of the testes
pelvic inlet. Average = 10.5 – 11 cm.
o Bi-ischial diameter/tuberischii – transverse II. INTERNAL ORGANS
diameter of the pelvic outlet. Is measured at the 1. Testes: descends in the scrotum after 28 weeks
level of the anus. Average = 11 cm. AOG
o - produces testosterone (spermatogenesis)
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Parts: Purpose:
A. Seminiferous tubules: site of spermatogenesis (176  To bring an ovum to maturity
sperm/day)  To prepare uterus for pregnancy
B. Leydig/Interstitial cells: produce testosterone
C. Sertoli Cells: supports sperm transport Terminologies:
Menarche - first mentrual period
Common Disorders: Thelarche - budding of the breasts
*Cryptorchidism: undescended testes; remains in the Adrenarche - development of body hair
abdominal cavity Menopause/ Climacteric - cessation of
- non-palpable testes in the scrotum menstruation (45-55 years of age)
- Mgt: Surgery > orchiopexy - physician stitches the
testes into the scrotum Structures involved:
- Post - op mgt:  Hypothalamus
 Anterior Pituitary Gland
2. Epididyms: passageway of sperm  Ovaries
 Uterus
3. Vas deferens: propels sperm during ejaculation HORMONES FUNCTION/ PURPOSE
GnRh Signals pituitary to release
4. Ejaculatory Duct: it connects the seminal vesicles (Hypothalamus) FSH and LH
to the urethra. For follicle maturation
Causes hypertrophy of
myometrium
FSH
Triggered by a decrease in
(A. Pituitary Gland)
estrogen
↓Estrogen = ↑FSH
; ↑Estrogen = ↓FSH
Stimulates ovulation
LH
Suppressed by Progesterone
(APG)
Develops the corpus luteum
Secreted by Graafian follicles
Takes over proliferative
phase
Estrogen Thickens the endometrium
III. ACCESSORY ORGANS Responsible for secondary
- Seminal Vesicle sex characteristics
- Prostate Gland Hormone of women
- secretes alkaline fluid Corpus Luteum hormone
- Cowper’s/Boulburethral Gland Prepares uterus for
implantation
*Seminal Fluid or Semen-mixture of secretions from Progesterone
Hormone of pregnancy
the seminal vesicles, prostate gland,Cowper’s gland, Most important hormone
ejaculatory duct and sperm cells. during the secretory phase
Did you know? PHASES OF THE MENSTRUAL CYCLE (28-day

1 ejaculation is equivalent to 3-5 ml of semen cycle)
with 20-50 million of sperm I. UTERINE CYCLE
1. MENSTRUAL PHASE
 day 1-5
 shedding of endometrium (2/3)
 uterus lining is in its thinnest
 total blood loss:30-80 ml (Average: 50 ml)
 iron loss: 12 to 29mg
 estrogen is LOW; cervical mucus is opaque and
viscous
2. PROLIFERATIVE PHASE
MENSTRUAL CYCLE (follicular, postmenstrual and estrogenic phase)
- is a cyclic uterine bleeding in response to hormonal  day 6-13 (Lasts 8-10 days)
changes; start counting from the first day of your last  stimulated by ↓ estrogen = APG releases FSH
menstruation up to the first day of the next  ↑ FSH = maturation occurs: from Primordial
menstruation follicle to Graafian follicle
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 Graafian follicle produces increasing amount of Management:

follicular fluid that is high in ESTROGEN 1. Estrogen Replacement Therapy
***Estrogen increases = thickening of endometrium 2. Engage in regular exercise
 ↑ estrogen = ↓ FSH 3. Calcium supplementation
4. Avoid smoking and alcohol
3. SECRETORY PHASE
 day 13-25 FETAL CIRCULATION
 ↑ estrogen, ↓FSH Shunts:
 ↓ progesterone = hypothalamus releases LHRF to 1. Ductus Venosus: between umbilical vein and vena
stimulate APG to release LH cava, bypasses liver
 ↑ LH = ovulation (ovum can only lasts for 24-48 2. Ductus Arteriosus: between pulmonary artery and
hrs) aorta
 Graafian follicle becomes the corpus luteum 3. Foramen Ovale: between two atria
 after ovulation, Graafian follicle is now the Corpus **PLACENTA works as RESPIRATORY SYSTEM
Luteum (life span: 10-12 days) **shunts are closed during the first breath/cry**
-endometrium appears spongy 1. Ductus Venosus = Ligamentum Venosum
**following ovulation, estrogen drops sharply 2. Ductus Arteriosus = Ligamentum Arteriosum
3. Foramen Ovale = Fossa Ovale
4. ISCHEMIC PHASE
 release of prostaglandins =arteriolar spasm →
necrosis → rupture of blood vessels
 uterine cramping occurs
 beginning of another cycle
II. OVARIAN CYCLE

1. FOLLICULAR PHASE (DAYS 10-14)
- a primordial follicle matures under the influence of
FSH and LH up to the time of ovulation
2. LUTEAL PHASE (DAYS 15-28) FETAL DEVELOPMENT

- Mature ovum leaves the graafian follicle A. First 12-14 days = zygote
- the empty cavity will become corpus luteum B. From 15th day up to the 8th week = embryo
C. From 8th week up to the time of birth = fetus
COMMON MENSTRUAL PROBLEMS
1. Dysmenorrhea: painful menstruation Cytotrophoblast – the inner layer.
Primary dysmenorrhea: no known cause Syncytiotrophoblast – the outer layer containing
*management: give analgesics as prescribed finger-like projections called chorionic villi, which
: offer warm compress differentiate into:
: provide emotional support A. Langhan’s layer – believed to protect the fetus
Secondary dysmenorrhea: common causes against Treponema Pallidum (etiologic agent of
are PID, endometriosis, uterine prolapse, polyps syphilis). Present only during the second trimester of
*management: treat the cause pregnancy.
2. Amenorrhea: absence of menses B. Syncytial layer – gives rise to the fetal
3. Oligomenorrhea: infrequent menstrual flow membranes:
4. Hypomenorrhea: scanty menstrual flow 1. Amnion – inner membrane which gives rise to
5. Menorrhagia / hypermenorrhea: heavy and 1.1 Umbilical cord/funis – contains
prolonged menses two arteries and one vein, which are
6. Metrorrhagia: bleeding in between menses supported by the Wharton’s jelly.
7. Polymenorrhea: bleeding at frequent intervals 1.2 Amniotic fluid
8. Menopause: Climacterium - cessation of menses - Clear, albuminous fluid in which the baby floats.
*Perimenopause: hormones become imbalanced (34- - Begins to form at 11-15 weeks gestation.
36 years old) - Approximates water in specific gravity (1.007-
*Menopause: end of reproductive age 1.025) and is neutral to slightly alkaline (pH =
*Post-menopause: year after; loss of estrogen 7.0-7.25). Note: the higher the pH, the more
Signs and symptoms: hot flushes, sweating even when alkaline; the lower the pH, the more acidic
it is cold, insomnia, forgetfulness, atrophy of - Near term is clear, colorless, containing little
reproductive organ, dyspareunia, loss of breast mass white specks of vernix caseosa and other solid
particles.
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- Produced at a rate of 500 ml in 24 hours and 3. Placenta - formed from the chorionic villi and
fetus swallows it at an equally rapid rate. By the decidua basalis
4th lunar month, urine is added to the amount of - reaches maturity at 12 weeks AOG and begins to
amniotic fluid. Amniotic fluid, therefore, is degenerate
derived chiefly from maternal serum and fetal - weight/size: 500 grams at term with a diameter of
urine. Implication: a case of 15-20 cm and about 3 cm thick
polyhydramnios)=more than 1500 ml of amniotic -placental barrier: maternal and fetal blood do not mix
fluid) stems from the inability of the fetus to although the oxygen and nutrient supply of the fetus
swallow amniotic rapidly, as in comes from the mother. Fetal and maternal circulation
tracheoesophageal fistula; while oligohydramnios is separated by cytotrophoblasts, syncytium and walls
)=amniotic fluid less than 500 ml) is due to the of fetal blood vessels. The exchange of substances
inability of the kidneys to add urine to the between the mother and the fetus is regulated by the
amniotic fluid, as in congenital renal anomaly. following processes:
- Also known as bag of water (BOW), it serves the 1. Diffusion - used in the passage of carbon
following purposes: dioxide, oxygen, fetal waste products, sodium,
 Protestion – shields the fetus against blows or chloride and fat-soluble vitamins
pressures on the mother’s abdomen; against 2. Facilitated Diffusion - Used in the passage of
sudden changes in temperature because glucose
liquid changes temperature more slowly than 3. Active Transport - used by amino acids, water
air; and from infections soluble vitamins, iron, calcium and iodine
 Diagnosis – as in amniocentesis; meconium- 4. Pinocytosis - at the end of pregnancy,
stained amniotic fluid means fetal distress antibodies such as IgG cross the placenta
 Aids in descent of the fetus during active labor which provide natural passive immunity after
birth.
2. Chorion – together with the deciduas basalis,
gives rise to the placenta, which starts to form at FETAL MILESTONES
8th week gestation. Develops into 15-20 subdivisions A. First Lunar Month
call cotyledons. Placenta serves the following 1. Germ layers differentiate by the 2nd week: (in
purposes: cases of multiple congenital anomalies, the
2.1 Respiratory system – exchange of gases takes structures that will be affected are those that arise
place in the placenta, not in the fetal lungs out of the same germ layer).
2.2 Renal system – waste products are being  Entoderm – develops into the lining of the
excreted through the placenta (Note: it is the GIT, the respiratory tract, tonsils, thyroid (for
mother’s liver which detoxifies the fetal waste basal metabolism), parathyroid (for calcium
products). metabolism), thymus gland (for development
2.3 Gastrointestinal system – nutrients pass to the of immunity), bladder and urethra
fetus via the placenta by diffusion through the  Mesoderm – forms into the supporting
placental tissues structures of the body (connective tissues,
2.4 Circulatory system – feto-placental circulation is cartilage muscles and tendons); heart,
established by selective osmosis circulatory system, blood cells, reproductive
2.5 Endocrine system – it produces the following system, kidneys and ureters
important hormones (before 8 weeks gestation, the  Ectoderm – responsible for the formation of
corpus luteum is the one producing these hormones): the nervous system, the skin, hair and
 Human chorionic gonadotropin nails, and the mucous membrane of the anus
(HCG) “orders” the corpus luteum to keep on and mouth.
producing estrogen and progesterone, that is 2. Fetal membranes (amnion and chorion) appear by
why menstruation does not take place during the second week.
pregnancy. 3. Nervous system very rapidly develops by the
 Human placental lactogen (HPL) or 3rd week. (Dizziness is said to be the earliest sign of
human chorionic somatomammotropin – pregnancy because as the fetal brain rapidly develops,
promotes growth of mammary glands glucose stores of the mother are depleted, thus
necessary for lactation. Also has growth- causing hypoglycemia in the latter).
stimulating properties. 4. Fetal heart begins to form as early as the 16 th day
 Estrogen and Progesterone of life. (To the question, “When does the fetal heart
2.6 Protective barrier – inhibits the passage of same begin to beat?”, the answer is first lunar month. But
bacteria and large molecules to the question, “When can fetal heart tones to first
heard?” the answer is fifth month.)
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5. The digestive and respiratory tracts exist as a single COMMON TERATOGENS AND SIDE EFFECTS
tube until the 3rd week of life when they start to (ToRCH and other Factors)
separate.  Toxoplasmosis: protozoan infection; spread
through uncooked meat or contaminated soil or
B. Second Lunar Month cat litter
1. All vital organs are formed by the 8th week; S/sx: malaise, lymphadenopathy
placenta develops fully : can cause CNS damage to infant
2. Sex organs (ovaries and testes) are formed by the Mngt: SULFONAMIDES (Pyrimethamine)
8th week. (To the question, “When is sex  Rubella: most dangerous; can cause
determined?” the answer is “At the time of microcephaly, glaucoma, cataract and mental
conception”). retardation
3. Meconium (first stools) are formed in the o advice mother to get vaccinated but NO
intestines by the 5th – 8th week. PREGNANCY within 3 months
 Cytomegalovirus: herpes virus; causes CNS
C. Third Lunar Month damage
1. Kidneys are able to function – urine is formed by  Herpes Simplex Virus: can cause severe
the 12th week. congenital anomalies or abortion
2. Buds of milk teeth form  Chickenpox: HIGH IMMUNITY in the first 7
3. Beginning bone ossification months; can have vaccine after delivery
4. fetus swallows amniotic fluid  Alcohol - can cause fetal alcohol syndrome
5. Feto-placental circulation is established by (mentally deficient, congenital abnormalities, low
selective osmosis; no direct exchange between birth weight); can also cause abortion and
fetal and maternal blood. prematurity
 Smoking - Nicotine can cause vasoconstriction
D. Fourth Lunar Month
resulting in decreased blood flow to the placenta
1. Lanugo appears
which in turn diminishes oxygen supply to the
2. Buds of permanent teeth form
fetus. Fetal hypoxia leads to low birth weight
3. Heart beats maybe audible with fetoscope
 Drugs - Advise woman not to use or take any
over-the-counter drugs
E. Fifth Lunar Month
Drugs Teratogenic Effects
1. Vernix caseosa appears
2. Lanugo covers entire body Androgen, estrogen, Masculinization of female
3. Quickening (fetal movements) felt progesterone infants
4. Fetal heart beats very audible Pocomelia, cardiac and lung
Thalidomide
defect
F. Sixth Lunar Month Cleft lip and palate,
Anticonvulsant (Dilantin)
1. Skin markedly wrinkled congenital heart diseases
2. Attains proportions of full-term baby Lithium Congenitsl Heart defects
Yellow staining of teeth,
Tetracycline
G. Seventh Lunar Month – alveoli begin to form inhibit bone growth
(28th weeks of gestation is said to be the lower limit of Vitamin K hyperbilirubinemia
prematurity because if baby is delivered at this time, Salicylates Neonatal bleeding, IUGR
will cry and breathe but usually dies) Sodium bicarbonate Fetal metabolic alkalosis
Streptomycin Nerve deafness
H. Eighth Lunar Month Vitamin A CNS Defects
1. Fetus is viable Iodides Goiter, Mental retardation
2. Lanugo begins to disappear Steroids Cleft lip and Palate
3. Nails extend to ends of fingers Barbiturate Bleeding disorders
4. Subcutaneous fat deposition begins
NORMAL CHANGES DURING PREGNANCY
I. Ninth Lunar Month
EMOTIONAL ADAPTATIONS OF MOTHER
1. Lanugo and vernix disappear
DURING PREGNANCY
2. Amniotic fluid volume somewhat decreases
1. Acceptance of Pregnancy (1st tri)
2. Acceptance of the Fetus (2nd tri)
J. Tenth Lunar Month – all characteristics of the
3. Acceptance of motherhood (3rd tri)
normal newborn.
8
SYSTEMIC CHANGES d) There is increased level of circulating fibrogen, that

1. Circulatory/Cardiovascular is why pregnant women are normally safeguarded
a) Beginning the end of the first trimester there is a against undue bleeding. However, this also
gradual increase of about 30% - 50% in the total predisposes them to formation of blood clots
cardiac volume, reaching its peak during the (thrombi). The implication is that pregnant women
6th month. This causes a drop in hemoglobin and should not be massaged since blood clots can be
hematocrit values since the increase is only in the released and cause thromboembolism.
plasma volume = physiologic anemia of
pregnancy. Consequences of increased total 2. Gastrointestinal changes
cardiac volume are: o Morning sickness – nausea and vomiting during
o Easily fatigability and shortness of breath the first trimester is due to increased human
because of increased workload of the heart chorionic gonadotropin (HCG). It may also be due
o Slight hypertrophy of the heart, causing it to to increased acidity or even to emotional
be displaced to the left, resulting in torsion factors. Management: Eat dry toast or crackers 30
on the great vessels (the aorta and minutes before arising in the morning (or dry, high
pulmonary artery). carbohydrate, low fat and low spices in the diet).
o Systolic murmurs are common due to o Hyperemesis gravidarum = excessive nausea and
lowered blood viscosity vomiting which persists beyond 3 months; results
o Nosebleeds may occur because of marked in dehydration, starvation and
congestion of the nasopharynx as pregnancy acidosis. Management: D10NSS 300 ml in 24
progresses. hours is the priority treatment; complete bed rest
is also important.
b) Palpitations are due to: o Constipation and flatulence are due to
o Sympathetic nervous system stimulation displacement of the stomach and intestines, thus
during the first half of pregnancy slowing peristalsis and gastric emptying time. May
o Increased pressure of uterus against the also be due to increased progesterone during
diaphragm during second half of pregnancy pregnancy. Management:
o Because of poor circulation resulting from  Increase fluids and roughage in the diet
pressure of the gravid uterus on the blood  Establish regular elimination time
vessels of the lower extremities:  Increase exercise
o Edema of the lower extremities  Avoid enemas
occurs. Management legs above hip  Avoid harsh laxatives like Dulcolax; stool
level. Important: Edema of the lower softeners, e.g. Colace, are better
extremities is normal during pregnancy; it is  Mineral oil should not be taken because
not a sign of toxemia it interferes with absorption of fat-soluble
o Varicosities of the lower extremities can also vitamins.
occur. Management:
o Hemorrhoids are due to pressure of enlarged
1. Use/wear support hose or elastic
uterus. Management: cold compress with witch
stockings to promote venous flow, thus hazel or Epsom salts.
preventing stasis in lower extremities o Heartburn, especially during the last trimester, is
2. Apply elastic bandage – start at the distal due to increased progesterone which decreases
end of the extremity and work toward the gastric motility, thereby causing reverse peristaltic
trunk to avoid congestion and impaired waves which lead to regurgitation of stomach
circulation in the distal part; do not wrap contents through the cardiac sphincter into the
toes so as to be able to determine esophagus, causing irritation. Management:
adequacy of circulation (Principle behind  Pats or butter before meals
bandaging: blood flow through tissues is  Avoid fried, fatty foods
decreased by applying excessive  Sips of milk at frequent intervals
pressure on blood vessels)  Small, frequent meals taken slowly
3. Avoid use of constricting garters, e.g.,  Bend at the knees, not at the waist
knee-high socks  Take antacids (e.g. milk of Magnesia) but
never sodium bicarbonate (e.g. Alka
c) Because of poor circulation in the blood vessels of Seltzer or baking soda) because it
the genitalia due to the pressure of the gravid uterus, promotes fluid retention.
varicosities of the vulva and rectum can
occur. Management: side-lying position with hips 3. Respiratory changes – shortness of breath
elevated on pillow and modified knee-chest position. Causes:
 Increased oxygen consumption and production of
carbon dioxide during the first trimester.
9
 Increased uterine size causes diaphragm to be - Moderate enlargement of the thyroid gland due to
pushed or displaced, thus crowding the chest hyperplasia of the glandular tissues and increased
cavity. vascularity. Could also be due to increased basal
Management: Lateral expansion of the chest to metabolic rate to as much as +25% because of the
compensate for shortness of breath increases oxygen metabolic activity of the products of conception.
supply and vital lung capacity. - Increased size of the parathyroid, probably to satisfy
the increased need of the fetus for calcium.
4. Urinary changes - Increased size and activity of the adrenal cortex, thus
 Urinary frequency, the only sign in pregnancy seen increasing the amount of circulating cortiso,
during the first trimester disappears during the aldosterone and ADH, all of which affect carbohydrate
second and reappears during the third and fat metabolism, causing hyperglycemia.
trimester. Early in pregnancy is due to increased - Gradual increase in insulin production but the body’s
blood supply to the kidneys and to the uterus sensitivity to insulin is decreased during pregnancy.
rising out of the pelvic cavity; in the last trimester
is due to pressure of enlarged uterus on the 8. Weight (Table 5)
bladder, especially with lightning (descent of the 8.1 During the first trimester, weight gain of 1.5-3 lbs
fetus into the pelvic brim). is normal
 Decreased renal threshold for sugar due to 8.2 On 2nd and 3rd trimesters, weight gain of 10-11
increased production of glucocorticoids which lbs. per trimester is recommended.
cause lactose and dextrose to spill into the urine; 8.3 Total allowable weight gain during entire period
also, an effect of the increased of pregnancy, therefore, is 20-25 pounds (10-12 kgs).
progesterone. (implication: it would be difficult to 8.4 Pattern of weight gain is more important than the
diagnose diabetes in pregnancy based on the urine amount of weight gained.
sample alone because a pregnant woman has
sugar in their urine.)
Fetus 7lbs.
5. Musculoskeletal changes Placenta 1 lb.
 Because of the pregnant woman’s attempt to Amniotic fluid 1 ½ lbs.
change her center of gravity, she makes Increased weight of uterus 2 lbs.
ambulation easier by standing more straight and Increased weight of the breasts 1/1 – 3 lbs.
taller, resulting in a lordotic position (“pride of Weight of additional fluid 2 lbs.
Fat and fluid accumulation 4-6 lbs.
pregnancy”)
Characteristics of pregnancy
 Due to increased production of the hormone Total 20-25 lbs.
relaxin, pelvic bones become more supple and
movable, increasing the incidence of accidental
falls due to the wobbly gait. Implication: Advise
use of low-heeled shoes after the first trimester
Distribution of Weight Gain During Pregnancy
 Leg cramps
Causes
9. Emotional responses
1. Increased pressure of gravid uterus on lower
 First trimester. The fetus is an unidentified
extremities
concept with great future implications but without
2. Fatigue
tangible evidence of reality. Some degree of
3. Chills
rejection, disbelief, even
4. Muscle tenseness
depression. (Implication: when giving health
5. Low calcium, high phosphorus intake
teachings, emphasize the bodily changes in
Management
pregnancy).
1. Frequent rest periods with feet elevated
 Second trimester: fetus is perceived as a separate
2. Wear warm, more comfortable clothing
3. Increase calcium intake (calcium tablets and diet) entity. Fantasizes appearance of the baby.
4. Do not massage – blood clots can cause embolism.  Third trimester: has personal identification with a
real baby about to be born and realistic plans for
5. Most effective treatment: Press knee of the
future childcare responsibilities. Best time to talk
affected leg and dorsiflex the foot.
about layette and infant feeding method. Fear of
6. Temperature – slight increase in basal
death, though is prominent (To allay fears, let
temperature due to increased progesterone, but
pregnant woman listen to the fetal heart sounds.)
the body adapts after the 4th month
7. Endocrine changes- Addition of the placenta as an
LOCAL CHANGES
endocrine organ, producing large amounts of
1. Uterus- Weight increases to about 1000 grams at
HCG, HPL, estrogen and progesterone.
full tern; due to increase in the amount of fibrous
and elastic tissues.
10
- Change in shape from pear-like to ovoid; enormous  Avoid intercourse to prevent reinfection
change in consistency of lower uterine segment causes
extreme softening, known as Hegar’s sign, seen at - Candida albicans, a fungus or yeast. The condition is
about the 6th week called Moniliasis or Candidiasis. Fungus also thrives in
- Mucous plugs in the cervix, called operculum, are an environment rich in carbohydrates (that is why it is
produced to seal out bacteria. common among poorly-controlled diabetics) and in
- Cervix becomes more vascular and edematous, those on steroid or antibiotic therapy when acidic
resembling the consistency of an earlobe, known as environment is altered. Moniliasis is seen as oral
Goodell’s sign. thrush in the newborn when transmitted during
delivery through the birth canal of the infected mother.
2. Vagina Symptoms
- Increased vascularity causes change in color from  White, patchy, cheese-like particles that adhere to
light pink to deep purple or violet known as Chadwick’s vaginal walls
sign.  Irritatingly itchy and foul-smelling vaginal
 To prevent confusion as to pregnancy signs, discharges
arrange the body parts from “out to in” and the Management
different signs alphabetically. Thus:  Mycostatin/Nystatin p.o. or vaginal
Vagina – Chadwick’s sign suppositories/peccaries (100,000 U) twice a day
Cervix – Goodell’s sign for 15 days
Uterus – Hegar’s sign  Gentian violet swab to vagina (use panty shields
 Due to increased estrogen, activity of the to prevent staining of clothes or underwear)
epithelial cell increases, thus increasing amount  Correct diabetes
of vaginal discharges called leucorrhea. As long  Avoid intercourse
as the discharges are not excessive, green/yellow  Acidic vaginal douche
in color, foul-smelling or irritatingly itchy, it is
normal. Management: maintain or increase 3. Abdominal Wall
cleanliness by taking twice daily shower baths Striae gravidarum – increase uterine size results in
using cool water. rupture and atrophy of connective tissue layers, seen
as pink or reddish streaks (gently rubbing oil on the
- The pH of the vagina changes from normally acidic skin helps prevent diastasis) and umbilicus pushed out
(because of the presence of Dederlein bacillie) to
alkaline (because of increased estrogen). Alkaline 4. Skin
vaginal environment is supposed to protect against Linea nigra – brown line running from umbilicus to
bacterial infection; however, there are two symphysis pubis
microorganisms which thrive in an alkaline Melasma or chloasma – extra pigmentation on
environment. cheeks and across the nose due to increased
- Trichomonas, a protozoa or flagellate. The condition production of melanocytes by the pituitary gland
is called trichomonas vaginalis or trichomonas vaginitis Sweat glands unduly activated
or trichomoniasis.
Signs and symptoms of Trichomoniasis 5. Breasts – all changes due to increased estrogen
1. Frothy, cream-colored, irritatingly itchy, foul-  Increase in size due to hyperplasia of mammary
smelling discharges alveoli and fat deposits. Proper breast support
2. Vulvar edema and hyperemia due to irritation from with well-fitting brassiere necessary to prevent
the discharges sagging
Management  Feeling of fullness and tingling sensation in the
 Flagyl for 10 days p.o. or vaginal suppositories of breasts
trichomonicidal compounds. (e.g., Tricofuron,  Nipples more erect. For mothers who intend to
Vagisec or Devegan). breastfeed, advise:
 Is carcinogenic during the first trimester - Nipple rolling
 Treat male partner also with Flagyl. - Drying nipples with rough towel to help
 Avoid alcoholic drinks when taking Flagyl – can toughen the nipples.
cause Antabuse – like reactions: vomiting, flushed - Not to use soap or alcohol as this can cause
face and abdominal cramps. drying which could lead to sore nipples.
 Dark brown urine a minor side effect – no need to  Montgomery glands become bigger and more
discontinue the drug. protruberant
 Acidic vaginal douche (1 tbsp. white vinegar in 1  Areola becomes darker and diameter increases
quart of water or 15 ml. white vinegar in 1000 ml.  Skin surrounding areolae turns dark
of water) to counteract alkaline – preferred
environment of the protozoa.
11
 By the fourth month, a thin, watery, high protein 3. Hyperemesis Gravidarum - Persistent vomiting
fluid, called colostrums, is formed. It is the beyond first trimester-
precursor of breast milk. 4. Abdominal pain
Early pregnancy – crampy with bleeding – abortion
6. Ovaries – no activity whatsoever since ovulation Low quadrant pain radiating to shoulder – ectopic
does not take place during pregnancy
pregnancy. Progesterone and estrogen are being Hard, boardlike painful abdomen – abruption placenta
produced by the placenta Sudden, sharp abdominal pain – uterine rupture
5. Vaginal bleeding
SIGNS AND SYMPTOMS OF PREGNANCY 1st trimester – Abortion
PRESUMPTIVE
PROBABLE 3rd trimester – Placenta previa
SIGNS POSI+IVE DANGER SIGNS
SIGNS (QUELNACS)
(PUGO HUB) SIGNS (FUX F2) -refer 6. Dysuria with burning sensation - UTI
-subjective -objective
7. Severe, persistent headache with vomiting
Quickening Positive pregnancy FHT - vaginal bleeding
Urinary frequency test UTZ of any amount 8. Swelling of hands and face
Easy fatigabilty Uterine growth X-ray - persistent 9. Dimness, blurring and doubling of vision
Leukorrhea Goodel’s sign vomiting
Nausea and Vomiting Outline of the Funic Souffle - chills and fever # 7, 8, and 9 = signs of PIH
Amenorrhea fetus Fetal movement - sudden escape of 10. Fetal distress - Marked change in intensity &
Chadwick’s Sign felt by the fluid from the
Skin changes Hegar’s sign examiner vagina frequency of fetal movement or absence of movement
Uterine souffle - swelling of face (6-8 hours) after quickening
Ballotement and fingers
- visual
disturbances LABORATORY EXAMS
- painful urination
or dysuria 1. Blood studies
- abdominal pain 1. Blood Typing
- severe or
continuous 2. Complete blood count, including Hgb and Hct,
headache
to determine anemia
3. Serological tests (VDRL and Kahn
DISCOMFORTS & DANGER SIGNS (PREGNANCY) Wasserman) to diagnose for syphilis
S/SX CAUSE MANAGEMENT 2. Urine examinations
FIRST TRIMESTER
- Heat and acetic acid test to determine
-offer dry crackers or
toast albuminuria. Any sign of albumin in the urine should
N&V Hcg -no oily, greasy food be reported immediately because it is a sign of toxemia
-drink fluids between - Benedict’s test for glycosuria, a sign of possible
meals
gestational diabetes. Urine should be collected before
Empty bladder as
Urinary frequency Pressure of fundus breakfast to avoid false positive results. Should not be
needed
Breast tenderness ↑ E and P Wear a well-fitting bra more than +1 sugar.
Keep it dry - Determination of pyura. Urinary tract infection has
Leukorrhea ↑ mucus production Refer if infection is
been found to be a common cause of premature
suspected
Ptyalism Offer hard candy delivery.
Rise slowly; assume
SOB
Semi-Fowler’s position PRENATAL EXERCISES
SECOND TRIMESTER Exercise
-assume SF position
- Strengthens muscles used during delivery process
-refrain from lying down
after meals
Pyrosis D/t esophageal reflux
-offer sips of warm Principles of exercise
water - Done in moderation
-AVOID ANTACIDS
Elevate legs
- Must be individualized
Ankle Edema D/t venous stasis Left side lying position
Weakening of faulty Elevate feet 1. Walking – best exercise
Varicosities Use support hose
valves 2. Squatting – strengthen muscles of perineum.
Eat high fiber diet
↑ OFI
Increase circulation to perineum. Squat – feet flat on
Hemorrhoids/ D/t constipation floor
Stool Softeners as
prescribed (Colace) 3. Tailor Sitting – 1 leg in front of other leg (Indian
Lumbosacral seat) Raise buttocks 1st before head to prevent
Backache Pelvic tilting
pressure
Tailor sitting;
postural hypotension, dizziness when changing
Leg cramps Losing Calcium
dorsiflexion of foot position, shoulder circling exercise- strengthen chest
muscles, pelvic rocking/pelvic tilt- exercise – relieves
DANGER SIGNS OF PREGNANCY low back pain & maintain good posture
1. Chills and fever - suspect for infection arch back- standing or kneeling. 4 extremities on floor
2. Escape of fluid from vagina - PROM
12
4. Kegel Exercise – strengthen pulococcygeal muscles oxytocin from the posterior pituitary gland. Oxytocin
- as if hold urine, release 10x or muscle contraction causes contraction of the smooth muscles of the body,
5. Abdominal Exercise – strengthens muscles of e.g., uterine muscles.
abdomen, done as if blowing a candle C. Progesterone Deprivation theory –
progesterone, being the hormone designed to promote
CHILDBIRTH PREPARATION pregnancy, is believed to inhibit uterine motility. Thus,
Overall goal: to prepare parents physically and if its amount decreases, labor pains occur.
psychologically while promoting wellness behavior that D. Prostaglandin theory – initiation of labor is said
can be used by parents and family thus, helping them to result from the release of arachidonic acid produced
achieved a satisfying and enjoying childbirth by steroid action on lipid precursors. Arachidonic acid
experience. is said to increase prostaglandin synthesis which, in
turn, causes uterine contractions.
A. Psychophysical
1. Bradley Method – Dr. Robert Bradley – advocated Theory of Aging Placenta – because of the decrease
active participation of husband at delivery process. in blood supply, the uterus contracts
Based on imitation of nature.
Features: Essential Factors of Labor: Passageway and
1.) darkened room Power
2.) quiet environment PASSAGES/PASSAGEWAY
3.) relaxation tech o Serves as birth canal
4.) closed eye & appearance of sleep o It proves attachment to muscles, fascia and
ligaments
2. Grantly Dick Read Method – fear leads to tension o Supports uterus during pregnancy
while tension leads to pain o It provides protection to the organs found within
the pelvic cavity
B. Psychosexual
1. Kitzinger method – pregnancy, labor & birth &
care of newborn is an important turning patient in
woman’s life cycle
- Flow with contraction than struggle with contraction
C. Psychoprophylaxis – prevention of pain

1. Lamaze by Dr. Ferdinand Lamaze
Requirement: disciple, conditioning & concentration. Gynecoid – normal female type of pelvis
Husband is coach - most ideal for childbirth
Features: - round shape, found in 50% of women
1. Conscious relaxation Android – male pelvis
2. Cleansing breathe – inhale nose, exhale mouth - presents the most difficulty during childbirth
3. Effleurage – gentle circular massage over - found in 20% of women
abdominal to relieve pain Platypelloid – flat pelvis, rarest, occurs to 5% of women
4. imaging – sensate focus Anthropoid – apelike pelvis, deepest type of pelvis
found in 25% of women
Different Methods of delivery:
1. Birthing Chair – bed convertible to chair; woman DIVISION OF PELVIS
is placed in semi fowlers 1. False Pelvis – “provide and direct”
2. Birthing Bed – dorsal recumbent position 2. True Pelvis – “the tunnel”
3. squatting – relieves low back pain during labor A. Inlet or Pelvic Brim – entrance to true pelvis
pain ANTEROPOSTERIOR DIAMETER
4. Leboyer – warm, quiet, dark, comfy room; after 1. Diagonal Conjugate – midpoint of sacral
delivery, baby gets warm bath. promontory to the lower margin of symphysis pubis
5. Birth Under H20 – bathtub – labor & delivery – (12.5 cm)
warm water, soft music. 2. Obstetric Conjugate – midpoint of sacral
promontory to the midline of symphysis pubis (11 cm)
Theories of Labor Onset 3. True Conjugate – midpoint of sacral promontory
A. Uterine Stretch Theory – any hallow body to the upper margin of symphysis pubis (11.5 cm)
organ when stretched to capacity will necessarily B. Pelvic Canal – situated between inlet and outlet
contract and empty. - designed to control the speed of
B. Oxytocin theory – labor, being considered a descent of the fetal head
stressful event, stimulates the hypophysis to produce C. Outlet – most important diameter of the outlet.
13
POWERS PASSENGER
Involuntary – not within the control of the parturient FETAL HEAD
Intermittent – alternating contraction and relaxation - Biggest part of the fetal body
Involves discomfort (compression, stretching and - Olways the presenting part
hypoxia) - Turn to present smallest diameter
PHASES OF UTERINE CONTRACTIONS CRANIAL BONES (1 FOSE, 2 PaTe)

1. Increment/Crescendo – “ready, get set” 1 frontal bone 2 parietal bone
2. Acme/Apex – “go” 1 occipital bone 2 temporal bone
3. Decrement/Decrescendo – “stop” 1 sphenoid bone
INTENSITY - strength of uterine contraction 1 ethmoid bone
1. Mild – slightly tensed fundus
2. Moderate – firm fundus SUTURE LINES – allow skull bones to overlap
3. Strong – rigid, board like fundus (molding) and for further brain development
FREQUENCY – rate of uterine contraction 1. Sagittal Suture – between 2 parietal bones
- measured from the beginning of a contraction to 2. Frontal Suture – between 2 frontal bones
the beginning of the next contraction 3. Coronal Suture – between frontal and parietal
DURATION – length of uterine contraction 4. Lamdiodal Suture – between parietal andoccipital
- measured from the beginning of a contraction to
the end of the same contraction FONTANELS – intersection of suture lines
INTERVAL – measured from the end of contraction to 1. Anterior Fontanel or Bregma – intersection of SFC
the beginning of the next contraction - diamond shaped, closes b/n 12 – 18 months
- 3 x 4 cm
ASPECTS OF CONTRACTION 2. Posterior Fontanel or Lambda – triangular shaped,
A. Blood Pressure – should not be taken during a closes b/n 2 – 3 months
contraction as it tends to increase. Because no blood
supply goes to the placenta during a contraction, all of DIAMETERS OF THE FETAL HEAD
the blood is in the periphery that is why there is AP > T (fetal head)
increased BP during uterine contractions. 1.Tranverse Diameters (BBB)
 BP readings should be taken at least every half Biparietal – most important TD
hour during active labor - greatest diameter presented to the pelvic inlet’s AP
 When a woman in labor complains of a headache, and at the outlet’s TD
the first nursing action is to take BP. If it is - average measurement is 9.5 cm
normal, it is only stress headache; if the BP is Bitemporal – average measurement is 8 cm
increased, refer immediately to the doctor (it could Bimastoid – average measurement is 7 cm
be a sign of toxemia)
B. Fetal heart rate (FHR) – should not be mistaken 2. Anteroposterior Diameters (SOO)
for uterine soufflé (synchronizes with maternal pulse Suboccipitobregmatic – smallest APD
rate) - fully flexed (presenting part)
 Normally 120 to 160 per minute - measured from the inferior aspect of occiput to the
 Should not be taken during a uterine contraction anterior fontanel
because it tends to decrease. Compression of the - average measurement is 9.5 cm
fetal head when the uterus contracts stimulates Occipitofrontal – head partially extended and
the vagal reflex which, in turn, causes bradycardia presenting part is the anterior fontanel
 Should be taken every hour during the latent - average size is 12. 5 cm
phase of labor, every half hour during the active Occipitomental – head is extended and the
phase and every 15 minutes during the transition presenting part is the face
period - measured from the chin to the posterior fontanel
 For any abnormality in FHR, the initial nursing - average size is 13.5 cm
action is to change the mother’s position
Signs of fetal distress

1. Bradycardia (FHR less than 100/minute) or
tachycardia (FHR more than 180/minute)
2. Meconium – stained amniotic fluid in non – breech
presentation
3. Fetal thrashing – hyperactivity of the fetus as it
struggles for more oxygen
Essential Factors of Labor: Passenger and Psyche
14
FETAL LIE – relationship of the long axis of the Causes: Very poor
1. relaxed Frank breech - hips flexion
fetus to the long axis of the mother abdominal wall flexed and legs
Longitudinal Lie – “parallel” 2. placenta extended (MOST
Transverse Lie – “right angle/lying crosswise” previa COMMON) Flexion
Oblique Lie – “slanting”
Footling Breech –
FETAL ATTITUDE/ HABITUS– degree of flexion or one or both feet are
relationship of the fetal parts to each other. the presenting parts
Shoulder
FETAL PRESENTATION- refers to the part of your Presentation – fetus
baby's body that is closest to the birth canal is lying
perpendicular to the
FETAL POSITION - relationship of the fetal long axis of the
mother
presenting part to a specific quadrant in the mother’s - vaginal delivery is
pelvis NOT POSSIBLE
The pelvis is divided into four quadrants:
1. Right anterior
2. Left anterior
3. Right posterior *Compound
4. Left posterior Presentation – when
there is prolapsed of
Posterior positions result in more backaches because the fetal hand
of pressure of the fetal presenting part on the maternal alongside the vertex,
sacrum breech or shoulder.
Points of direction in the fetus:
1. Occiput – in vertex presentations POSSIBLE FETAL POSITIONS
2. Chin (mentum) – in face presentations Vertex
3. Sacrum – in breech presentations o LOA – left occipitoanterior (most common and
4. Scapula (acromio) – in horizontal presentations favorable position at birth)
o LOP – left occipitoposterior
FETAL STATION - relationship of the presenting part o LOT – left occipitotransverse
of the fetus to the ischial spine of the mother. o ROA – right occipitoanterior
Minus (-) station – presenting part is above the ischial o ROP – right occipitoposterior
spine o ROT – right occipitotransverse
Zero (0) station – presenting part is at the level of the Breech
ischial spine o LSA – left sacroanterior
Positive (+) station – presenting part is below the level o LSP – left sacroposterior
of the ischial spine o LST – left sacrotransverse
FLOATING – head is movable above the pelvic inlet o RSA – right sacroanterior
+1 station – fetus is engaged o RSP – right sacroposterior
+2 station – fetus is in midpelvis o RST – right sacrotransverse
+4 station – perineum is bulging Face
o LMA – left mentoanterior
LIE PRESENTATION ATTITUDE o LMP – left mentoposterior
A. Longitudinal Vertex – most ideal Complete o LMT – left mentotransverse
Lie - flexion
1. suboccipitobregmatic
o RMA – right mentoanterior
Cephalic (head) is presented (9.5 o RMP – right mentoposterior
cm) o RMT – right mentotransverse
Moderate
Shoulder
Brow – flexion
occipitomental is o LADA – left acromiodorsoanterior
presented (13.5 cm) Partial flexion o LADP – left acromiodorsoposterior
(military o RADA – right acromiodorsoanterior
Sinciput – position)
occipitofrontal is
o RADP – right acromiodorsoposterior
presented (12.5 cm) Extension
2. Breech (butt) PSYCHE/PERSON
Face presentation Hyperextended FACTORS affecting labor:
Chin presentation Good flexion — Perception & meaning of childbirth
— Readiness & preparation for childbirth
Complete breech - Moderate — Coping skills
feet & legs flexed on flexion
the thighs and the
— Past experiences
B. Transverse thighs are flexed on — Cultural & social background
Lie the abdomen — Presence of significant others and support system
15
SIGNS OF LABOR C. Uterine Changes

 Weight Loss – 2-3 pounds (progesterone) 1. The uterus is gradually differentiated into two
 Ripening of the Cervix – “soft” distinct portions
 Increased Braxton Hicks – “irregular, painless” - Upper uterine segment – becomes thick and active to
 Show – “ruptured capillaries + operculum = expel out fetus
pinkish color” - Lower uterine segment – become thin-walled, supple
 Lightening – “the baby dropped”; settling of and passive so that fetus can be pushed out easily.
presenting part into the pelvic brim
2. Physiological retraction ring is formed at the
- 2 weeks (primi) and before or during (multi)
boundary of the upper and lower uterine
— Relief of respiratory discomfort
segments. In difficult labor when the fetus is
— Increased frequency of urination
larger than the birth canal, the round ligaments of
— Leg pains
the uterus become tense during dilatation and
— Muscle spasms
expulsion, causing an abdominal indentation
— Increased vaginal discharge
called Bandl’s pathological retraction ring, a
— Decreased fundal height
danger sign of labor signifying impending rupture
 Increased Level of Activity – large amount of of the uterus if the obstruction is not relieved.
epinephrine (AG)
 Rupture of Membranes – gush or steady FIRST STAGE OF LABOR
trickle of clear fluid STAGE 1– DILATATION STAGE
Starts from first true uterine contraction until the cervix
FALSE LABOR
is completely effaced and dilated.
 Contraction disappears with ambulation
○ Dilatation – widening of cervical os to 10 cm
 Absence of cervical dilation
○ Effacement – thinning to 1- 2 cm
 No ↑ DIF (duration, intensity, frequency)
CAUSES:
 Discomfort @ abdomen
1. Pergusion Reflex
 Absence of show
2. Fetal head and intact BOW serves as a wedge to
 Contraction stops when sedated
dilate the cervix
PHASES OF STAGE 1 with NURSING CARE:
TRUE LABOR 1. LATENT PHASE
 Contraction persists when sedated ○ Cervical Dilation: 0 – 4 cm
 Uterine contraction ↑ DIF (duration, intensity,
○ Nature of Contraction: Duration: < 30 secs
frequency) Interval: 3 – 5 mins
 Progressive cervical dilation
○ Length of Latent Phase: Primis – 6 hours
 Presence of show Multis – 4 – 5 hours
 Ambulation increase contractions
○ Attitude of mother: feel comfortable, walking and
 Discomfort radiates to lumbosacral area
sitting at this time
FALSE LABOR PAINS TRUE LABOR PAINS
Nsg Responsibilties:
1. May be slightly irregular at
1. Encourage walking - shorten 1st stage of labor
first but become regular and 2. Encourage to void q 2 – 3 hrs – full bladder inhibits
1. Remain irregular predictable in a matter of contractions
hours.
3. Breathing – chest breathing
2. First felt in the lower back
2. Generally confined to the and sweep around to the
abdomen abdomen in a girdle-like 2. ACTIVE PHASE
fashion. ○ Cervical Dilation: 4 – 7 cm
3. No increase in duration, 3. Increase in duration,
frequency and intensity frequency and intensity.
○ Nature of contractions: Duration: 30 – 50 secs
4. Often disappears if the 4. Continue no matter what the Intensity: moderate to strong
woman ambulates woman’s level of activity is. ○ Length of Active Phase: Primis – 3 hours
5. Absent cervical changes 5. Accompanied by cervical
Multis – 2 hours
effacement and dilatation (the
most important difference) ○ Attitude of mother: prefer to stay in bed, withdraws
from her environment and self – focused
Differences Between False and True Labor Pains Nsg Responsibilities:
A. Effacement – shortening and thinning of the 1. M – edications – have meds ready
cervical canal as distinct from the uterus. It is 2. A – ssessment include: vital signs, cervical dilation
expressed in percentage. and effacement, fetal monitor, etc.
B. Dilatation – enlargement of the external cervical 3. D – dry lips – oral care (ointment) dry linens
os up to 10 cm primarily as a result of uterine 4. B – abdominal breathing
contractions and secondarily as a result of
pressure of the presenting part and the BOW.
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3. TRANSITION PHASE o Danger of serious intrauterine

○ Cervical Dilatation: 8 – 10 cm infection if delivery does not occur in
○ Nature of Contractions: Duration: 50 – 60 secs 24 hours
Interval: 2 -3 mins
Intensity: moderate to strong 1. NITRAZINE PAPER TEST
○ Length of Transition Phase: - used to assess whether membrane ruptured or not.
Primis – 1 hour (baby delivered within 10 contractions Procedure: “Insert and Touch”
or 20 mins)  Yellow – intact BOW
Multis – 30 mins (baby delivered within 10 contractions  Blue – ruptured
or 20 mins) Normal Color of AF – clear, colorless to straw colored
○ Attitude of mother: feel discouraged, ask Green tinged – meconium stain (fetal distress in non –
midwife/nurse repeatedly when labor will end, not in breech presentation)
control of her emotions and sensations, irritated, may Yellow/Gold – hemolytic disease
not want to be touched Gray/Cloudy – infection
○ There is an uncontrollable urge to push with Pinkish/Red stained – bleeding
contractions, a sign of impending second stage of Brownish/Tea Colored/Coffee Colored – fetal death
labor. Profuse perspiration and distention of neck veins
are seen. 2. OTHER TEST TO DETERMINE STATUS OF
○ Nausea and vomiting is a reflex reaction due to AMNIOTIC FLUID
decreased gastric motility and absorption.  Ferning pattern of cervical mucus
Nsg Responsibilities: RRE  (“swab – dry – view”)
1. Reassure woman that labor is nearing end & baby  Nile blue sulfate staining of fetal squammous cells
will be born soon
2. Reinforce breathing and relaxation techniques FETAL ASSESSMENT DURING LABOR
3. Encourage fast-blow breathing to remove the urge (FHT Monitoring)
to bear down FHT Monitoring
4. Emotional support — Latent Phase – every hour
— Active Phase – every 30 minutes
MATERNAL ASSESSMENT DURING FIRST STAGE — Second Stage of Labor – every 15 minutes
OF LABOR: *FHT is taken more frequently in high – risk cases
 Check V/S q 4hrs during the first stage Normal FHT Pattern
BT - temp q hour if membranes are already ruptured — Baseline rate: 120 – 160 bpm
(risk of infection) — Early Deceleration – FHT @ contraction, Normal
BP - BP b/n contractions, in left lateral pos, q 15 – 20 @ end of contraction (head compression)
mins after giving anesthesia — Acceleration - FHT when fetus moves
PR - a rapid pulse indicates hemorrhage & dehydration Abnormal FHT Pattern
 Uterine contraction — Bradycardia – 100 – 119 bpm – moderate
Manual: fingers over fundus, you feel it about 5 secs - below 100 bpm – marked
before the client feels it Causes:
Techniques: 1. fetal hypoxia (analgesia & anesthesia)
1. assess contraction (DIIF) 2. maternal hypotension
2. check contraction q 15 – 30 mins during the first 3. prolonged cord compression
stage Mgt:
3. refer immediately if: 1. place mother on left side
o duration more than 90 secs 2. assess for cord prolapse
o interval less than 30 secs 3. administer oxygen
o uterus not relaxing completely after each — Tachycardia – 161 – 180 bpm – moderate
contraction - above 180 bpm – marked
 Show – slightly blood-tinged mucus discharge Causes:
 Internal Examination – to assess status of 1. maternal fever, dehydration
amniotic fluid, consistency of cervix, 2. drugs (atrophine, terbutaline, ritodrine, etc.
effacement/dilatation, presentation, station and Mgt:
pelvic measurement. 1. D/C oxytocin, position on LLP
- do it during relaxation 2. give 02 at 8 – 10 lpm
- less IE done once membrane have ruptured 3. prepare for birth if no improvement
- start with middle finger then index finger *Other Nursing Care for 1st Stage of Labor
 Status of Amniotic Fluid (if ruptured) CARE OF THE BLADDER – encourage the woman to
o Danger of cord prolapse if fetal head is void q 2 hrs to:
not yet engaged. o Delay fetal descent
17
o Increases the discomfort of labor 3. Flexion – the chin of the fetus touches his chest
o Predispose to UTI enabling the smallest diameter (suboccipitobregmatic)
o Can be traumatized during labor to be presented to the pelvis for delivery
FOODS & FLUIDS – NPO on active phase 4. Internal Rotation – when the head reach the level
o Clear fluids on latent phase of the ischial spine, it rotates from transverse diameter
POSITIONING – LLP - best position to AP diameter so that its largest diameter is presented
o Relieves pressure – IVC to the largest diameter of the outlet. This movement
o Improves urinary function allows the head to pass through the outlet.
o Prevent hypotensive syndrome 5. Extension – the head of the fetus extend towards
o Encourage anterior rotation of the fetal head the vaginal opening. As the head extend, the chin is
o Squatting is ideal position – directs presenting lifted up and then it is born.
part towards the cervix promoting dilatation 6. External Rotation – when the head comes out,
AMBULATION – during the latent phase to shorten the the shoulder which enters the pelvis in transverse
first stage, to decrease the need for analgesia, FHT position turns to anteroposterior position for it become
abnormalities & to promote comfort in line with the anteroposterior diameter of the outlet
o NO WALKING IF BOW IS RUPTURED & pass through the pelvis.
IV FLUIDS – reasons: 7. Expulsion – when the head is born, the shoulder &
o Prevent dehydration/fluid & electrolyte the rest of the body follows without much difficulties.
imbalances
o Life – line for emergencies B. Duration of Second Stage:
o Usually required before administration of A/A 1. Primis – 50 mins
o Administration of oxytocin after delivery to
2. Multis – 20 mins
prevent atony
PERINEAL PREP
C. Assessment: monitor FHT q 15 mins in normal
o Clean & disinfect the external genitalia
case and every 5 mins in high risk cases if not yet
o Provide better visualization of the perineum
ENEMA – emptying the colon of fecal matters to: delivered
○ Prevent infection
○ Facilitate descent of fetus D. Transfer to the DR:
○ Stimulate uterine contractions 1. Primis – cervix fully dilated
2. Multis – cervix is 8 cm dilated
○ CONTRAINDICATIONS:
E. Delivery Position
1. Not given during active phase
2. If premature labor because of danger of cord 1. Lithotomy – used when forcep delivery &
prolapse episiotomy are to be performed.
3. Rupture of BOW 2. Dorsal Recumbent – head of the bed is 35 – 45˚
4. Vaginal bleeding elevated, knees are flexed & feet flat on bed. This
5. Abnormal fetal presentation & position position facilitates the pushing effort of the mother.
6. Abnormal fetal heart rate pattern 3. Left Lateral Position – indicated for woman with
heart disease.
SECOND STAGE OF LABOR
A. MECHANISM OF LABOR: EDFIRE ERE NURSING CARE: ASSISTING THE MOTHER IN
THE DR
1. Coach the mother to push effectively
2. Instruct the woman to pant
3. Dorsiflex the affected foot and straigthen the leg
until the cramps disappear
4. Perform ironing on vaginal orifice if the presenting
part moves towards the outlet
5. When the head is crowning, instruct the mother
to pant.
6. Perform Ritgen’s Maneuver while delivering the
fetal head to:
1. Slows down delivery of the head
2. Lets the smallest diameter of the head to be born
3. Facilitates extension of the head
1. Engagement 7. Just after delivery, immediately wipe the nose &
2. Descent – entrance of the greatest biparietal mouth of secretions then suction.
diameter of the fetal head to the pelvic inlet 8. Take note of the exact time of baby’s birth
9. Immediately after delivery, the newborn should be
held below the level of the mother’s vulva for a few
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minutes to encourage flow of blood from the placenta FOURTH STAGE OF LABOR
to the baby. The infant is held with is head in a - Puerperium
dependent position (head lower thatn the rest of the MANAGEMENT:
body) to allow for drainage of secretions. Remember: 1. Repair of lacerations.
never stimulate a baby to cry unless you have drained CLASSIFICATION OF PERINEAL LACERATIONS
him out of his secretions. First degree – involves the vaginal mucous
10. Place the infant over the mother’s abdomen to help membranes and perineal skin
contract the uterus. Second degree – involves not only the muscles,
11. Clamping the cord: vaginal mucous membranes and skin, but also the
— After the pulsation stops muscles.
— Clamp the cord twice and cut in between 8 – 10 Third degree – involves not only the vaginal mucous
inches from umbilicus membranes and skin, but also the external sphincter of
— After cutting the cord, look for 2 arteries & 1 vein the rectum
12. Wrap the infant. Remember: Chilling increase the Fourth degree – involves not only the external
body’s need for oxygen sphincter of the rectum, the muscles, vaginal mucous
membranes and skin, but also the m mucous
THIRD STAGE OF LABOR membranes of the rectum.
A. METHODS OF PLACENTAL SEPARATION: 2. Assist the doctor in doing episiorrhaphy repair
1. Schultz Mechanism –if placenta separates first at of episiotomy or lacerations). In vaginal
its center and last at its edges, it tends to fold on itself episiorrhaphy, packing is done to maintain
like an umbrella and presents the fetal surface which is pressure on the suture line, thus prevent further
shiny (“Shiny” for Schultz); 80% of placentas separate bleeding. Note: Vaginal packs have to be removed
in this manner. after 24 – 48 hours
2. Duncan Mechanism – if placenta separates first at 3. After repair of lacerations & episiotomy, perineum
its edges, it slides along the uterine surface and is cleansed, the legs are lowered from stirrups at
presents with the maternal surface which is raw, red, the same time.
beefy, and irregular and “dirty” (“Dirty” for Duncan). 4. Make mother comfortable by perineal care and
Only about 20% of placentas separate this way. applying clean sanitary napkin snugly to prevent
B. NURSING MANAGEMENT: its moving forward from the anus to the vaginal
1. Watchful waiting. opening. Soiled napkins should be removed from
a) Do not hurry the expulsion of the placenta by front to back.
forcefully pulling out the cord or doing vigorous 5. Position the newly – delivered mother flat on bed
fundal push as this can cause uterine inversion. Just without pillows to prevent dizziness due to
watch for the signs of placental separation. decrease in intraabdominal pressure.
b) Wait for signs of placental delivery 6. Check V/S of the mother every 15 mins for the first
o Calkin’s sign – uterus is firm, globular & rising hour & every 30 mins for the next 2 hours until
to the level of umbilicus; earliest sign of stable.
placental separation 7. Check uterus & bladder q 15 mins. A full bladder
o Sudden gush of blood from vagina is evidenced by a fundus which is to the right of
o Lengthening of the cord the midline and dark – red bleeding with some
c) Tract the cord slowly, winding it around the clots. Will prevent adequate uterine contraction.
clamp until the placenta spontaneously comes out, 8. Fundus – should be checked every 15 minutes for
slowly rotating it so that no membranes are left inside 1 hour then every 30 minutes for the next 4 hours.
the uterus, a method called Brandt – Andrews Fundus should be firm, in the midline, and during
maneuver. the first 12 hours postpartum, is a little above the
d) Inspect for completeness of cotyledons; any umbilicus. First nursing action for a non-
placental fragment retained can also cause severe contracted uterus: massage.
bleeding and possible death. 9. Perineum – is normally tender, discolored and
e) Palpate the uterus to determine degree of edematous. It should be clean, with intact sutures.
contraction. If relaxed boggy or non - contracted, 10. Blood pressure and pulse rate may be slightly
first nursing action is to massage gently and properly. increased from excitement and effort of delivery,
An ice cap over the abdomen will also help contract but normalize within one hour.
the uterus since cold causes vasoconstriction.
2. Inject oxytocin (Methergine = 0.2 mg./ml. or GENERAL CONCEPTS OF POSTPARTUM CARE
Syntocinon = 10U/ml) IM to maintain uterine Essential concepts:
contractions, thus prevent hemorrhage.  Postpartum care refers to the care given to a
Note: oxytocins are not given before placental delivery. woman during the puerperium, which is the 6-
3. Never leave the client unattended. week period after delivery, beginning with
4. Oxygen & emergency equipment made available.
19
termination of labor and ending with the return of - Fibrinogen and thromboplastin remains elevated until
the reproductive organs to the nonpregnant state. the 3rd postpartum week.
- increased leukocyte sedimentation rate.
 This period constitutes a physical and C. Vital signs:
psychological adjustment to the process of - Physiologic bradycardia – 40-50 bpm for first 24-28
childbearing and is sometimes referred to as the hrs
fourth trimester of pregnancy. - Orthostatic hypotension – first 48 hours.
 During this period, the uterus undergoes 2. Integumentary System

involution – the progressive changes in the uterus - Chloasma, palmar erythema, linea nigra and skin
after delivery leading to its return to near- changes during pregnancy gradually disappear during
prepregnant size and condition. the postpartum period.
- Striae gravidarum do not disappear and assumes a
Goals: silvery white appearance.
 Promote normal uterine involution and return to - Hyperpigmentation of the areola may not disappear
the nonpregnant state. completely. Some women are left with a wider and
 Prevent or minimize postpartum complications.  darker areola after pregnancy.
 Promote comfort and healing of pelvic, perianal,
and perineal tissues. 3. Gastrointestinal System
 Assist in restoration of normal body functions. - Many women are hungry after delivery because of
 Increase understanding of physiologic and foods and fluids restriction during labor, diaphoresis
psychological changes. and the strenuous labor they just went through.
 Facilitate newborn care and self-care by the new - Bowel movement may be delayed for days after
mother. delivery resulting in constipation. This is caused by:
 Promote the newborn’s successful integration into - Decreased muscle tone during labor and puerperium
the family unit. - Lack of food during labor
- Dehydration
 Support parenting skills and parent-newborn
attachment. - Perineal pain caused by episiotomy, hemorrhage,
laceration
 Provide effective discharge planning, including
appropriate referral for home care follow-up. 
4. Urinary System
Physiologic Adaptations During Delivery - Diuresis begins 12 hours after delivery and extends
1. Cardiovascular System up to the 5th day as the body gets rid of extracellular
A. Blood Volume fluid accumulated during pregnancy. The woman loses
- blood loss in vaginal del – 500 ml; CS delivery – 500- up to 9 lbs. weight from the excretion of these fluids
1000 ml and electrolytes.
- blood loss and diuresis in the postpartum period - Acetone in the urine and lactosuria during the first
contribute to reduction in blood volume week is normal.
- The 40% increase in BV during pregnancy enters the - The bladder and urethra are traumatized by the
maternal circulation within 5-10 mins after placental pressure exerted by the fetal head as it passes through
delivery making this period very critical to the birth canal. Trauma to bladder results in loss of
gravidocardiacs because their damage heart may not bladder tone, edema and hyperemia. As a result, the
be able to handle this sudden increase in cardiac woman experiences decreased bladder tone that
workload. results in increased bladder capacity. Decreased
- Blood volume returns to non-pregnant levels 1-2 bladder tone causes decreased sensation to the filling
weeks after delivery resulting in a decline in cardiac and distention of the bladder, the woman may not
output by 30%. experience the urge to void even if her bladder is
B. Blood Components: already distended with urine which predisposes to
- Hematocrit – rises in the first 3-7 days due to infection.
hemoconcentration caused by excretion of large - Generally, bladder tone is regained after 1 week and
amount of fluid in the urine (diuresis during the first normal kidney function, after one month.
few days after delivery). Hct level returns to normal on - To avoid distention, the bladder is assessed every
the 4th to 5th postpartum week. time fundus is checked.
- Leukocytosis of 20,000-30,000 (normal: 5,000- - Effects of bladder distention:
10,000) during the first 12 days characterized by o Hemorrhage – distended bladder displaces the
uterus resulting in uterine relaxation.
increased neutrophils and eosinophils and decreased
o Infection – stasis of urine promotes bacterial
lymphocytes.
growth.
o Increase discomfort to the woman.
20
o Atony of bladder wall is caused by elevated estrogen levels. The sudden

o Overflow incontinence withdrawal of estrogen and progesterone after delivery
o Signs of full bladder: result in atrophy of myometrial cells, and eventually a
o Suprapubic swelling with resonant sound on decrease in uterine weight.
percussion - In the surface of the uterus within a few days after
o High fundus delivery, the remaining decidua differentiates in two
o Increase lochia – displacement of the uterus layers. The outer superficial layer undergoes necrosis
interferes with effective uterine contractions and is eventually sloughed off. The next layer, the
basal layer, regenerates and gives rise to the new
4.1. Measures to Induce Voiding endometrium. The endometrial lining rapidly
The woman is expected to void withing 6-8 hrs after regenerates, so that by the 7th day, the endometrial
delivery. After the initial voiding, encourage the woman glands are already evident. By the 16th day, the
to void every 3-4 hrs. endometrium is restored throughout the uterus, except
o Provide privacy at the placental site. The entire endometrium heals in
o Open faucet and allow woman to listen to running 3 weeks.
water - The uterus does not return to its original nonpregnant
o Pour warm water over the perineum condition, uterine size is slightly increased after each
o Assist woman to the bathroom if the woman can pregnancy.
get out of bed or offer bedpan. Warm bedpan first. - Weight of the uterus:
o Place woman’s hand on warm water. o Right after delivery: 1,000 grams
o Encourage woman to practice Kegel’s exercise o One week after delivery: 500 grams
several times a day to hasten return of o 2 weeks after delivery: 300 grams
pubococcygeal muscle tone. o 6 weeks after delivery: 50-60 grams
o Liberal fluid intake to prevent urinary stasis and
dehydration. B. Promotion of Uterine Involution
o Catheterization 1. BREASTFEEDING – release of oxytocin speeds
up involution
4.2. Measures to Prevent Infection -stimulation of the nipple when the infant suckles
o Flush perineum with warm water after each results in the release of oxytocin. The uterus decreases
voiding, wipe with clean tissue from front to back.
in size as it contracts.
o Apply perineal pad from front to back 2. Administration of oxytocin as ordered
o Liberal fluid intake 3. Early ambulation reduces the incidence of
o Decoction of guava leaves for perineal flushing
complications secondary to prolonged bedrest:
promotes healing
 Thrombophlebitis
o Perilight for 15-20 minutes promotes healing by
promoting blood flow.
 Pneumonia
o Instruct about signs and symptoms of UTI that  Subinvolution of the uterus
must reported immediately to physician. 4. Regular voiding as a full bladder displaces the
-frequency of urination/urgency of urination uterus, thus delaying the normal involutionary process
-painful urination 5. Proper postpartum diet high in protein, vitamins,
-suprapubic pain minerals with emphasis on iron and calories
- Placental Site: heals in 6 weeks
Bleeding maternal vessels in the placental site are
5. Reproductive System Changes
sealed off by thrombosis and uterine contractions.
Changes in Uterus, Cervix, Vagina and Perineum
Healing is achieved by exfoliation. This process of
healing involves complete regrowth of endometrium so
5.1. Uterus that no scar tissue is formed in the area formerly
A. Uterine Involution – return of the uterus to its occupied by the placenta. The remaining decidual
pre-pregnant size, shape, and function. Most of the lining undergoes necrosis, is sloughed off and is shed
reduction in size and weight occurs in the first 2 weeks. in the lochia.
- The uterus contracts firmly after delivery of the
newborn reducing its size by more than half. It remains C. Lochia
this size for about two days, then decreases size
– uterine discharge after delivery consisting of blood,
(involution) and descends about one fingerbreadth per mucus, epithelial cells, leukocytes and bacteria.
day. - It is never absent regardless of the method of
- The diminution of the uterine size is due to a
delivery. However, less lochia is expected in women
decrease in size of myometrial cells not a decrease in
who delivered by CS, ambulate early, and those who
their number. During pregnancy, increased collagen breastfeed their babies.
formation and uterine weight is caused by raised
1. Lochia rubra – first 3 days after delivery, bright red
progesterone levels and increased myometrial cell size
in color, fleshy odor, may contain small clots;
21
epithelial cells, erythrocytes, leukocytes, and 5.4. Perineum

deciduas. - Traumatized. It is often swollen, discolored,
2. Lochia serosa – 4 to 10 days, pink to brownish painful after delivery, often with lacerations and
discharge. It contains decidua, erythrocytes, episiotomy.
leukocytes, cervical mucus, and microorganisms. - Perineum is observed for signs of infection
It has a strong odor. (edema, redness, purulent discharge, gaping at
3. Lochia alba – 10-14 days and even upto 3 weeks suture line) and trauma
after delivery, is an almost colorless to creamy - Discomfort does not last for more than 1 week
yellowish discharge. It contains leukocytes, because perineal area heals rapidly. Non-
deciduas, epithelial cells, fat, cervical mucus, absorbable suture is removed on the 5th and
cholesterol crystals, and bacteria. Lochia alba 6th day. Absorbable sutures are not removed and
should have no odor. are absorbed within 7-10 days.
- Amount of lochial flow should be similar to - Perineal muscle tone is regained by 6 weeks.
menstrual flow. Expect flow to increase
temporarily during ambulation. 6. Breast Changes
- Check the perineal pad and estimate amount of a. Rapid drop in estrogen and progesterone levels
blood loss based on how much saturated it is: occurs, with an increase in secretion of prolactin after
o I inch stain after 1 hour: scant amount delivery.
o 2-4 inches stain after 1 hour: light amount b. Colostrum is present at the time of delivery.;
o 4-6 inches stain after 1 hour: moderate breastmilk is produced by the third or fourth
amount postpartum day.
o Fully soaked or saturated after 1 hour: heavy c. Larger and firmer breasts occur with lactation
amount (primary engorgement). Congestion subsides in 1 or 2
- Presence of Clots: in the first few days after days.
delivery, it is normal for lochia rubra to contain The average amount of milk produced in 24 hours
some small clots but never large ones. The increases with time.
presence of large clots indicates retained placental (1) First week – 6-10 oz
fragments. (2) 1-4 weeks – 26 oz
- Smell: Lochia should smell like menstrual (3) After 4 weeks – 30 oz
discharge. A foul-smelling lochia is a sign of
infection. 7. Endocrine System
1. estrogen and progesterone levels decrease rapidly
5.2. Cervix
after delivery. This rapid drop in estrogen and
- Soft, edematous and relaxed right after delivery. progesterone after delivery of the placenta is
- It regains its pre pregnant firmness after the responsible for many of the anatomic and physiologic
1st week postpartum but the external os does not changes during the puerperium.
return to its original pre pregnant condition as it is 2. Ovulation and resumption of menstruation are
lacerated during delivery. After childbirth, the influenced by whether or not the client breast feeds.
internal os assumes a slit-like appearance. a. 45% of lactating women resume menstruation
- By the end of the first week, the external os is by 12 weeks. 80% have one or more anovulatory
closed and will not admit a finger. cycles before the first ovulation.
b. 40% of nonlactating women resume menstruation
5.3. Vagina by 6 weeks after delivery. 65% by 12 weeks; and 90%
- Right after childbirth, the vagina is a smooth and by 24 weeks. 50% ovulate during the first cycle.
swollen passage.
- Lacerations and episiotomy are usually healed PSYCHOLOGICAL ADAPTATIONS DURING
after 2 weeks. PREGNANCY
- After 3-4 weeks, rugae re-appear, but not as A. Provide emotional support – the psychological
numerous as before pregnancy. phases during the postpartum period are:
- The vagina returns to its pre pregnant condition 1. Taking – in phase – first 1 – 2 days postpartum
after 6-8 weeks but does not regain its original when mother is passive and relies on others to care for
virginal state. her and her newborn. She keeps on verbalizing her
- The hymen is converted to mytiformes caruncles. feelings regarding the recent delivery for her to be able
- Resolution of the vagina to its pre pregnant to integrate the experience into herself.
condition is delayed in women who are
breastfeeding because of the persistent low 2. Taking hold phase – begins to initiate action and
estrogen levels. Prolactin inhibits estrogen make decisions. Postpartum blues (an
production. overwhelming feeling of sadness that cannot be
accounted for) may be observed. Could be due to
22
hormonal changes, fatigue or feeling of inadequacy in 4. Fourth degree - + mucous membrane of

taking care of a new baby. Management: explain that rectum
it is normal; crying is therapeutic, in fact.
3. Vital Signs
3. Letting-go phase - interdependent; refining new a. Vital signs:
roles - Every 15 mins – for first hour
- Every 30 mins – 2nd hour
CARE OF THE PARTURIENT DURING THE - Every hour – until transferred to the RR or
FOURTH STAGE private room
1. Care for the - Every 2-4 hrs. – once mother is stable.
Uterus/FundusFundus: Body Temperature:
- The fundus is assessed frequently for firmness, *Provide extra blanket to keep patient warm. Chilling
position, and height. The fundus should be called postpartum tremors is common at this period
checked after the bladder is emptied. A full and is due to the circulatory changes that occurred
bladder displaces the uterus upwards and to the after delivery.
sides, therefore, it is easier and more accurate to *Temperature may increase because of the
examine the fundus when the bladder is empty. dehydrating effects of labor. Implication: any increase
- Check for consistency every 15 mins during the in body temperature during the first 24 hours
first hour or until it no longer tends to relax. postpartum is not necessarily a sign of postpartum
- Massage the fundus every 15 mins during the
1st hour, every 30 mins during the next hour, and 4. Perineal Care/ Perineal Pain Relief Measures
then every hour. *Clean the perineum with an antiseptic solution and
- Locate fundal height: apply a sterile sanitary pad on the perineum. An ice
o immediate after placental delivery – located pack may be applied to the perineum to reduce
between the umbilicus and symphysis pubis, swelling from episiotomy.
it gradually rises to the level of umbilicus * Ice packs are applied to the perineum during the first
afterwards. 24 hrs. and lessen discomfort by providing anesthesia.
o Position of mother: dorsal recumbent *Lower legs from stirrups at the same time and remove
o palpate the fundus by placing a hand at the soiled drapes and linens. Change mother into clean
umbilicus and pressing it downward while the gown
other hand is placed just above the symphysis *Strict Asepsis in pericare
to support the lower segment of the uterus - Wash hands and put gloves
(to prevent uterine inversion)
- Observe front to back technique of flushing and
o fundus descends into the pelvic cavity by one
removal of peripads
cm or one fingerbreadth a day until it is non-
- Supine position – remove perineal pad from front
palpable at 10-14th day.
to back
- Use clean gauze square or clean portion of wash
UTERINE ATONY
cloth with soap and water for each stroke, always
Causes of uterine atony:
1. Multiparity washing from front to back.
- Rinse the area in the same manner and dry it.
2. Overdistended uterus (Polyhydramnios, DM,
Multiple gestation)
Pain in perineal region may be relieved by:
Management of Uterine atony:
- Sim’s Position – minimizes strain on the suture
1. Massage the uterus gently in circular motion
line
2. Breastfeeding
- Perineal heat lamp or warm Sitz baths twice a day
3. Administer oxytocin as ordered or increase
– vasodilatation increases blood supply and,
infusion
therefore, promotes healing
1. Perineal lamp – used to promote vasodilation
2. Lacerations
o Dorsal recumbent, drape legs, place lamp
Lacerations (uterus feels firm but there is continuous between the legs
oozing of bright red blood) o Use a perineal lamp. Use 25-40 watts bulb,
Management: repair (episiorrhapy) should be positioned 12-18 inches away from
Classifications of Perineal lacerations: the perineum, adjust the distance if it is too
1. First degree – involves fourchette, vaginal hot.
mucous membrane, perineal skin o Use for 20 mins 3 times a day
2. Second degree - + muscles of the perineal 2. Sitz Bath
body o Promote circulation by vasodilation, thereby
3. Third degree - + anal sphincter promoting healing.
23
o Perineal area is immersed in 4-6 inches of 7. Diet

water with temperature of 102-105 deg - Provide diet that is high in protein (60-70g daily),
Celsius for 3-4 times a day for no more than calories (+500 for lactating), vitamins and
20 minutes each time. minerals especially vitamin C and Iron
o Application of topical analgesics or
administration of mild oral analgesics as 8. Coitus/ Sexual Activity and Menstruation
ordered - Maybe resumed by the 3rd or 4th week postpartum
if bleeding has stopped and episiorrhappy has
5. Promote Bowel and Bladder Function healed. Decreased physiologic reactions to sexual
- Prevent constipation stimulation are expected for the first 3 months
- Adequate fluid intake postpartum because of hormonal changes and
*Some newly delivered mothers may complain of emotional factors.
frequent urination in small amounts; explain that this - Consider: MATERNAL COMFORT
is due to urinary retention with overflow. Other, - - Episiotomy wound may cause bleeding and may
on the other hand, may have difficulty voiding because predispose to infection
of decreased abdominal pressure or trauma to the - Coitus is safe as soon as a woman’s lochia has
bladder. Voiding may be initiated by: turned to alba and episiotomy is healed (usually
1. Pouring warm and cold water alternately over abt the 1st wk after birth but it will fully heal in 6
the vulva weeks).
2. Encouraging the client to go the comfort room - Bleeding and infection are less likely to occur once
3. Let her listen to the sound of running water 14 postpartum days have passed.
4. If these measures fail, catheterization, done - Perineal swelling – after 6 weeks
gently and aseptically, is the last resort on doctor’s - Personal desire to have sex
order. (if there is resistance to the catheter when it
reaches the internal sphincter, ask patient to Menstruation – if not breastfeeding, return of
breathe through the mouth while rotating the menstrual flow is expected within 8 weeks after
catheter before moving it inward again). delivery. If breastfeeding, menstrual return is expected
in 3-4 months; in some women, no menstruation
6. Exercises occurs during the entire lactation period.
Abdominal breathing (important: amenorrhea during lactation is no
- Started on the 1st day after birth – easy guarantee that the woman will not become pregnant.
- Lying flat on her back or sitting, a woman should She may be ovulating the absence of menstruation
breathe slowly and deeply in and out 5 times, may her body’s way of conserving fluids for lactation.
using abdominal muscles. Implication: she should be protected against a
Chin to chest subsequent pregnancy by observing a method of
- Excellent for 2nd day. contraception, except the pill).
- Lying on back without pillow, woman raises her
head and bends her chin forward on her chest 9. Promote Breastfeeding and Bonding
without moving any other part of her body while - Encourage BF
exhaling. - Promote rooming-in
- Should star gradually repeating it no more than 5 1. Start Early
times the first time and then increasing it 10 – 15 2. Empty the breasts each feeding time. This stimulates
times in succession. milk production:
- Can be done 3 – 4 x a day o 200-300 ml/day by day 4
Perineal contraction o 600 ml/day by about 6 weeks
- Tighten and relax her perineal muscles 10 – 25 3. Allow the NB to nurse in short frequent periods:
times in succession as if she were trying to stop o 2-3 mins- 1st day
voiding. o Increasing gradually to 10 mins on each
- Kegel's Exercise breast in later days
Arm raising 4. Provide a relaxed, warm and supportive
- Helps both breast and the abd return to good tone environment
and is a good exercise to add on fourth day. 5. Promote breast comfort and hygiene
- Rest a moment then repeat the exercise 5 times. o Wear well-fitted bra;
- Abdominal crunches o Wash hands
- 10th – 12th day do 6. Manage pain from engorgement
- Lying flat on her back with knees bent, woman compress – warm if the mother is lactating; cold if not
folds her arms across her chest and raises herself -breast pumping
to sitting position. -analgesic as ordered
24
10. Follow up Check Ups Specific management:

- A woman should notify AP or midwife if she notices  Doctor removes sutures to drain area and
increase in lochial discharge or if lochia serosa or alba resutures
becomes rubra. Delayed postpartal hemorrhage can  Hot sitz bath or warm compress
occur in women who become extremely fatigued.
Getting adequate rest during her 1st wks. at home will B. Endometritis
do much to prevent the possibility of this complication Specific symptoms:
- 4 – 6 wks. after birth – return to AP or midwife for  Abdominal tenderness
examination.  Uterus not contracted and painful to touch
- important to ensure complete involution and repro  Dark brown, foul-smelling lochia
planning can be discussed further Specific management
 Oxytocin administration
PREVENT POSTPARTUM COMPLICATIONS  Fowler’s position to drain out lochia and prevent
1. Hemorrhage pooling of infected discharge
- Bleeding of >500 cc (NSD 500 cc normal, CS 600-800
cc) C. Thrombophlebitis – infection of the lining of a
Early postpartum hemorrhage - bleeding within 1st 24 blood vessel with formation of clots; usually an
hours; extension of endometritis
- baggy or relaxed uterus, profuse bleeding (UTERINE Specific symptoms:
ATONY)  Pain, stiffness and redness in the affected part of
Mngt: massage uterus until contracted the leg
- cold compress  Leg begins to swell below the lesion because
- modified T.berg position venous circulation has been blocked
- IV drip: OXYTOCIN  Skin is stretched to a point of shiny whiteness,
called milk leg or phlegmasia alba dolens
2. Infection  Positive Homan’s sign – pain in the calf when the
1. Sources foot is dorsiflexed
Endogenous (primary) sources – bacteria in the normal Specific management:
flora become virulent when tissues are traumatized  Bed rest with affected leg elevated
and general resistance is lowered.  Anticoagulants, e.g., Dicumarol or Heparin, to
Exogenous sources – pathogens introduced from prevent further clot formation or extension of a
external sources. (Most common is anaerobic thrombus
streptococci). Common exogenous sources:  Analgesics are given but never Aspirin because it
a. Hospital personnel inhibits prothrombin formation therefore causes
b. Excessive obstetric manipulations hemorrhage
c. Breaks in aseptic techniques – faulty
handwashing, unsterile equipments and FAMILY PLANNING METHODS
supplies 1. General Definition and Methods of Family
d. Coitus in late pregnancy Planning
e. Premature rupture of the membranes Family Planning Methods
2. General symptoms: malaise anorexia, fever, chills - Family planning involves the use of all techniques,
and headache practices, and medical devices that help a couple plan
3. General management their family. It not only helps in deciding the number
a. Complete bed rest (CBR) of children to have but also when to have and how to
b. Proper nutrition space their births.
c. Increased fluid intake
d. Analgesics Philippine Family Planning Program
e. Antipyretics and antibiotics, as ordered -improvement of family welfare
-FOCUS: women’s health, safe motherhood and child
Types of infection survival
A. Infection of the perineum
Specific symptoms: Role of Nurse: EDUCATOR and FACILITATOR
 Pain, heat and feeling of pressure in the perineum Ideal spacing: 3 years (WHO)
 Inflammation of the suture line, with 1 or 2
stitches sloughed off
 With or without elevated temperature
25
METHODS OF FAMILY PLANNING

1. NATURAL METHODS
- Based on abstinence at the time of ovulation to
prevent conception.
Advantages:
1. Safe and has no side effects
2. Inexpensive
3. Acceptable to religious affiliations that do not accept
artificial methods of contraception
4. Helpful for planning pregnancy and avoiding Billing’s Method: check the cervical mucus
pregnancy - also called as Wet Dry wet method
5. Promotes communication about family planning and - based on the changes in cervical mucus during the
contraception between couples menstrual cycle
- before ovulation, the normal vaginal discharge is
Disadvantages: either absent or it is thick and scant.
1. Involves long preparation and intensive recording - just before ovulation, mucus discharge become
before it can be used clear, abundant, slippery and stretchable due to
2. There is a need to abstain on certain days which may high estrogen level.
be inconvenient for the couple
3. Not ideal to women with irregular cycles Characteristics of Mucus During Ovulation
4. Not very reliable because of menstrual - clear, watery mucus
cycle variations that may occur anytime - SPINNBARKEIT - mucus is stretchable
- positive ferning’s test; when mucus is examined
under the microscope, it resembles a fern-like
2. ARTIFICIAL METOHDS appearance
These methods employ various products and devices
that are used to avoid pregnancy, and in some cases Basal Body Temperature
STDs. - pre-ovulatory temperature is ↓ d/t high estrogen
and low progesterone
NATURAL METHODS - ovulation - ↑ temp d/t progesterone
1. Behavioral - take BT at same time each day after at least 4-6
Abstinence – no sexual intercourse hours of sleep for 3 months before using this
Coitus Interruptus/ Withdrawal- not always method
effective d/t premature ejaculation - sustained increase in temp by 0.5-1 degree during
ovulation for 3 days
2. Calendar Method
Checkpoint question: The ovum is viable for hrs Sympthothermal Method (Billing’s +
while the sperm is viable for _ BBT): combination of Billing’s Method and Basal Body
Rhythm or Calendar Method Temperature
Ogino Kaus Method (Regular Cycle) - couple needs to record cycle days, coitus, mucus
- The couple abstain on days when the woman is changes, increase libido, abdominal bloating,
fertile mittelschmerz
- subtract 14 from the number of days of
the menstrual cycle to determine day of ovulation Lactational Amenorrhea Method (LAM) -
- abstain 5 days before and 3 days after ovulation continuous and exclusive breastfeeding; good for 6
Example: months
- used only temporarily based on exclusive
breastfeeding
- can be used when woman is: breastfeeds often
during day and night
- menstruation has not yet returned
ARTIFICIAL METHODS
BARRIER METHOD
Irregular (Remember these two #s: 18 and 11) o Chemical (jellies, creams, foams, tablets)
Spermicides: makes vagina more acidic
- subtract 18 from the shortest cycle
S/e: vaginitis, works for 2 hours only
- subtract 11 from the longest cycle
26
o Mechanical DANGER SIGNS:

Condom (Male and Female): inserted when penis is Period is late or missed
erect; placed prior to contact Abdominal pain is severe
: spermatozoa are deposited at the tip of the Increased temperature (chills and fever)
condom Noticeable vaginal discharge, foul smelling
: interrupts sex; reduces sensation Spotting, bleeding, clots, heavy period
: Contraindication: LATEX ALLERGY (Severe When to insert: after delivery or during menstruation
redness, itching, swelling) When to check: once a week for the first month
: Side effect: perineal irritation Then once every month
: prevents STIs Common complication:
Pelvic Inflammatory Disease (PID)
Diaphragm (inserted into the anterior vagina Period is either late or skipped
and cervix) Abdominal pain
Specific action: A circular rubber disc that fits over the Increase temperature/ chills
cervix and forms a barrier against the entrance of Noticeable vaginal discharge; foul smelling
sperms Spotting, bleeding
- Is initially inserted by the doctor who determines Mngt: treat with antimicrobial
the depth of the vagina Wof: Wilson’s disease (d/t copper toxicity)
- May be coated with spermicide jelly or cream for
double protection SURGERIES
- Maybe washed with soap and water after use; us Female
reusable Bilateral Tubal Ligation (BTL)
- Sperms remain viable in vagina for 6 hours, so the - best time to perform: AFTER DELIVERY
device should be kept in place during such time, Requirements: 30 and above
but should not stay for more than 24 hours - number of desired children
because stasis of semen can lead to infection - man will give consent
- Needs fitting (consult physician if you have gained
10 lbs.) Hysterectomy- removal of uterus
Cervical Cap Male

- risk for infection Sterilization: a surgical procedure intended to
- use spermicide discontinue the capacity of a person to have children.
- inserted 2 hrs prior to intercourse and removed 6 Passages of the ovum and sperm cells are occluded to
hrs after intercourse (risk for cervicitis) render the person infertile
Reasons for sterilization:
IUD (98% effective) - Genetic abnormalities
- a flexible appliance is inserted into the uterine - Medical reasons - hypertensive, renal or
cavity cardiovascular disease
- made of copper (*assess allergies) - The couple have reached their desired
- Copper-coated: 5 years ; progesterone-coated: 1 number of children
year)
- Specific action: Prevent implantation by setting Vasectomy: reversible thru microsurgery
up a non-specific cell inflammatory reaction to the - does not provide immediate sterility
device - need to ejaculate for up to 20 times to remove all
- Inserted during menstruation to ensure that the sperm
woman is not pregnant; septic abortion can result
if she is pregnant HORMONAL (99% efficient):
Side effects: inhibits OVULATION!
- Increased menstrual flow PILLS
- Spotting or uterine cramps during the first 2 1. Mini-pill (Progestin only pill): alters cervical
weeks after insertion mucus; prevents IMPLANTATION
- Increased risk of infection
- When pregnancy occurs with the IUD in place, it 2. Morning after pill: taken after unprotected
need not be removed since it stays outside the intercourse at midcycle; ESTROGEN only
membranes and, therefore, will not in any harm
the fetus. 3. Combined: available in 21- or 28-day preparations
(with FeSO4 placebo pills (7 tabs)
*taken during the first day of menstruation
*set schedule for drinking pills
27
*IF YOU MISSED A PILL: take the pill as soon as you Contraindications: Pregnancy, desire to get
remember it along with the pill scheduled on that day. pregnant within the next 2 years, undiagnosed vaginal
*IF YOU MISSED 2 PILLS: take two pills as soon as bleeding
you remember and two pills again the following day
(S/E: breakthrough bleeding); use another method of THE NEWBORN
contraception A. Essential Newborn Care
*IF YOU MISSED 3 or MORE PILLS: throw out the 1. Immediate thorough drying
rest of the pack and start a new one 2. Skin-to-skin contact
S/E: N/V, breast tenderness, weight gain,
3. Delayed Cord clamping
breakthrough bleeding
C/I: History of DVT and heavy smokers; advanced age 4. Non-separation of the newborn to the mother
(>35 y/o), breastfeeding (if pills contain estrogen),
liver disease (hepatotoxic) B. Profile of the Newborn
1. General Appearance
OCP DANGER SIGNS 2. Physiologic function
Hypertensive effects - APGAR score, Ballard’s score, Review of
Abdominal pain (severe) systems, Anthropometric measurements
Chest pain
(weight, head, chest, abdomen
Headache
circumference, length, other relevant
Eye problems (blurred vision, loss of vision)
Severe leg pain measures)
REFER IMMEDIATELY! 3. Vital signs
4. Behavioral assessment & other significant
INJECTABLE information
DEPO PROVERA 5. Newborn Screening
(Depo Medroxyprogesterone; X ESTROGEN)
: good for 3 months (dosage: 150 mg progesterone) C. Nursing care of the newborn
: DO NOT MASSAGE THE SITE 1. Establishment of respiration
: DO NOT SHAKE WHEN PREPARING 2. Maintaining patent airway
: interferes with INSULIN (not for DIABETICS) 3. tub bath, changing of diapers
4. Eye prophylaxis
IMPLANT 5. Cord care
Norplant: 6 capsules of progestin are inserted SC in 6. Vitamin K administration
the upper arm 7. Regulation of temperature
: can lasts for up to 5 years 8. Sensory stimulation (audio& tactile)
: made up of synthetic progesterone-levonorgestrel. 9. Vestibular stimulation
:it slowly releases hormones to suppress ovulation 10. Breast feeding
: makes cervical mucus thicker and rapidly transports 11. Burping
ovum through the oviducts and prevents thickening of 12. Elimination
the endometrium to prevent implantation. 13. Cuddling
: implanted using anesthesia during menses or within
7 days of menses, 6 weeks after delivery or CONCEPT OF GROWTH AND DEVELOPMENT
immediately after abortion A. Principles of Growth and Development
Advantages: long term reversible contraception
: does not interfere with coitus B. Factors Influencing Growth and
: has no estrogen related side effects Development
: can be used during breastfeeding 1. Freud (Psychosexual Theory)
: can be used by adoloescents 2. Erickson (Psychosocial Theory)
: rapid return of fertility - 3 months after removal 3. Piaget (Stages of Cognitive Development)
Disadvantages: expensive, scarring at insertion site 4. Kohlberg (Theory of Moral Development)
Side effects: weight gain
: irregular menstrual cycle, spotting, breakthrough
C. Stages of Growth and Development
bleeding, amenorrhea, prolonged periods
(Infancy to Adolescents)
: hair loss
: depression - Caring for Infants, Toddlers, Pre-
: infection at insertion site Schoolers, School-aged and Adolescents
: local raction of itching and pain at insertion site
usually resolves within one month
28
A. ESSENTIAL NEWBORN CARE- Discussed in  Increased concentration of red blood cells in

Skills Laboratory newborns, and decreased amount of
B. PROFILE OF THE NEWBORN subcutaneous fat gives them a ruddy complexion. 
Newborns may look alike, but each has their own  In the first month, this ruddy complexion slightly
physical attributes and personalities. Some newborns fades.
are fat and short while some are long and thin. There  A pale and cyanotic newborn signifies that she
are newborns who never give a fuss whenever they are may have poor central nervous system control.
changed or cuddled, but some can cry in high decibels  A gray color in newborns may indicate infection.
whenever you lift them from their cradles.  Acrocyanosis is normal in a newborn, wherein
 The weight of newborns varies according to their the hands, feet, and lips are bluish in color.
race, genetics, and nutritional factors.   Central cyanosis, however, is a cause for concern
 To determine if the newborn’s weight is as this may indicate a decrease in oxygenation. 
appropriate for its gestational age, a neonatal  Jaundice appears on the second or third day of
graph should be used in plotting the newborn’s life as a result of the breakdown of fetal red blood
weight. cells.
 Plotting the height and head circumference of the  Early feeding to speed the passage of feces
newborn also helps determine any disproportions. through the intestine and prevent reabsorption of
 The average birth weight for a mature female bilirubin from the bowel may diminish physiologic
newborn in the United States is 3.4kg or 7.5 lbs, jaundice.
and for the mature male newborn is 3.5 kg or 7.7  Pallor in newborns is a sign of anemia, and the
lbs. newborn must be watched closely for signs of
 For all races, the normal weight is 2.5 kg or 5.5 blood in the stool or vomitus. 
lbs.  Harlequin sign or when a newborn who is lying
 The newborn loses 5% to 10% of its birth weight on his or her side appears red on the dependent
during the first few days of life, then has 1 day of side and pale on the upper side does not have a
stable weight, and gains weight rapidly afterward.  clinical significance.
 The newborn must gain 2 lbs per month for the  Vernix caseosa or the white cream cheese-like
first six months of life. substance is washed away in the first bath, but
 The average birth length of mature female never rub harshly as it will only come off gradually.
newborns is 53 cm or 20.9 inches. The mature  Lanugo or the fine, downy hair that covers the
male newborn has an average birth length of 54 shoulders, arms and back of the newborn would
cm or 21.3 inches. be rubbed away by the friction of the bedding and
 A mature newborn has a head circumference of 34 clothes of the newborn.
to 35 cm.  A white, pinpoint papule called milia can be found
 Head circumference is measured with a tape in some newborns, mainly on the cheek or the
measure drawn across the center of the forehead bridge of the nose, and they disappear by 2 to 4
and around the most prominent part of the weeks of age.
posterior head.  The fontanelles or the spaces or openings where
 The chest circumference in a mature newborn is 2 the skull bones join are soft spots on the
cm less than the head circumference. newborn’s head.
 Chest circumference is measured at the level of o The anterior fontanelle is located between
the nipple using a tape measure. the two parietal bones and the two frontal
bones which gives it a diamond shape, and
1. General Appearance normally closes at 12 to 18 months of age.
o The posterior fontanelle is located at the
junction of the parietal bones and the
occipital bone and is triangular in shape, and
closes at the end of the second month.
29
 Newborns cry tearlessly until three months of  The bowel sounds can be heard after the first 15
age when the lacrimal ducts mature. minutes of life and becomes present afterward.
 Birthmarks
o Hemangiomas are vascular tumors of the A. Apgar Scoring- done in skills laboratory
skin. B. Ballard Scoring
o Nevus flammeus are muscular purple or The Ballard Maturational Assessment, Ballard
dark red lesion. Generally appear on the face Score, or Ballard Scale is a commonly used
and thighs. technique of gestational age assessment. The
o Strawberry hemangiomas—elevated assessment assigns a score to various criteria. These
areas formed by immature capillaries and
criteria are divided into physical and neurological
endothelial cells.
o Cavernous hemangiomas—these are criteria.
dilated vascular spaces. Performed between 30 minutes to 96 hours, ideally
o Mongolian spots—slate gray patches within 24 hours. However, studies have debated its
across the sacrum or buttocks and consist of validity up to 7 days.
a collection of pigment cells. For preterm babies < 26 weeks, it must be done in first
o Forceps marks—these are circular or linear 24 hours because on second day babies may suffer
contusion matching the rim of the blade from consequences of prematurity.
forceps on the infant’s cheeks.
 Permanent eye color appears on the 3 rd to 12th
Neuromuscular Maturity
month of age.
1. Posture: Muscle tone is reflected in the infant's
 The newborn’s external ear is not yet fully formed,
preferred posture at rest. As maturation
and the top part of the external ear should be on
progresses, the fetus gradually assumes
a line drawn from the inner canthus to the outer
increasing passive flexor tone at rest that precedes
canthus of the eye and back across the side of the
in a centripetal direction with lower extremities
head.
slightly ahead of upper extremities. Term newborn
 The newborn’s nose tends to look large for the (flexed posture) and preterm newborn (extended
face but the rest of the face will grow more than
posture).
the nose does.
2. Square window, assessing the flexibility of the
 The newborn’s mouth must open evenly when he wrist. Wrist flexibility and resistance to extensor
or she cries.  stretching are responsible for the resulting angle
of flexion at the wrist. The examiner strengthens
2. Physiologic function the infant's fingers and applies gentle pressure on
Adjustment to Extrauterine Life the dorsum of the hand, close to the fingers. From
 The newborn’s color on the first 15 to 30 minutes extremely preterm to post term, the resulting
of life is still acrocyanotic, and after 2 to 6 hours, angle between the palm of the infant's hand and
there are quick color changes that may occur with forearm is gradually diminished
movement or crying.  3. Arm recoil: Arm recoil examines the passive flexor
 The temperature within the first 15 to 30 minutes tone of the biceps muscle by measuring the angle
after birth falls from the intrauterine temperature of recoil following very brief extension of the upper
of 100.6⁰F or 38.1⁰C then stabilizes at 37.6⁰C extremity. With the infant lying supine, the
after 2 to 6 hours. examiner places one hand beneath the infant's
 The rapid heart rate of as much as 180 BPM on elbow for support taking the infant's hand, the
the first 15 to 30 minutes of life will have wide examiner briefly sets the elbow in flexion, then
swings in rate with activity as it slows to 120-140 momentarily extents the arm before releasing it.
BPM. The angle of recoil, to which the forearm springs
 The newborn’s respirations are irregular in the first back into flexion is noted.
few minutes of life, then slows to 30-60 breaths 4. Popliteal angle: This maneuver assesses the
per minute after 30 minutes and will become maturation of passive flexor tone of the knee
irregular again only during activity. extensor muscles by testing for resistance to
 The newborn would be alert in the first 15 to 30 extension of the lower extremity. With the neonate
minutes of life, and later on, will alternate between lying supine, the thigh is placed gently on the
the sleeping and awakening phases. abdomen of the knee fully flexed. The examiner
 Just a few minutes after birth, the newborn would gently grasps the foot at the sides with one hand
respond to stimulation vigorously but would be while supporting the side of the thigh with the
difficult to arouse while it is still on a resting period other. Care is taken not to exert pressure on the
until it becomes responsive again 2 to 6 hours hamstrings. The leg is extended until a definite
after birth. resistance to extension is appreciated. At this point
30
the angle formed at the knee by the upper and placed supine and the flexed lower extremity is
lower leg is measured. brought to rest on the cot. The examiner supports
5. Scarf sign: It is testing the passive tone of the the infant's thigh laterally alongside the body with
flexors about the shoulder girdle. With infant lying the palm of one hand. The other hand is used to
supine, the examiner adjusts the infant's head to grasp the infant's foot at the sides and to pull it
the midline and supports the infant's hand across towards the ipsilateral ear. The examiner feels for
the upper chest with one hand. The thumb of the the resistance to extension of the posterior pelvic
examiner's other hand is placed on the infant's girdle flexors and notes the location of the heel
elbow. The examiner tries to pull the elbow gently where significant resistance is appreciated.
across the chest, feeling for the resistance.
6. Heel To ear: This measures the passive flexor tone 3. Vital Signs and Anthropometric
of the posterior hip flexor muscles. The infant is Measurements
Vital Statistics
Vital signs
Vital Sign Immediately At Birth After Birth
Temperature 36.5 to 37.2 Celsius
120-140
Pulse 180 beats/minute
beats/minute ave.
30-50
Respiration 80 breaths/minute
breaths/minute
100/50 mmHg (by
Blood Pressure 80/46 mmHg
10th day)
Behavioral Assessment & Other Significant

Information
• Resting Period
– 2 to 4 hours
– VS returning to baseline
• Period of Reactivity – 1 ½ sleep and difficult to be aroused
– 30 minutes after birth
– Awake and active
• Second Period of Reactivity
– 4 to 6 hours
– VS are increased
– Mother infant bonding  breastfeeding
31
4. Newborn Screening evaluation of NBS implementation; Sustainable

Definition: financial scheme; Strengthen patient management
NBS is an essential public health strategy that enables
the early detection and management of several Policies and Laws:
congenital disorders, which if left untreated, may lead RA 9288 or the Newborn Screening act of 2004 and
to mental retardation and/or death. Early diagnosis and DOH AO no. 2014-0045 or the Guidelines on the
initiation of treatment, along with appropriate long- Implementation of the Expanded Newborn Screening
term care help ensure normal growth and development Program
of the affected individual. It has been an integral part
of routine newborn care in most developed countries. Importance of NBS:
Most babies with metabolic disorders look normal at
Program objective: birth. One will never know that the baby has the
By 2030, Filipino newborns are screened; Strengthen disorder until the onset of signs and symptoms and
quality of service and intensify monitoring and more often ill effects are already irreversible.
32
When is Newborn Screening done?

Newborn screening is ideally done on the 48th hour or When is the Newborn Screening results
at least 24 hours from birth. Some disorders are not available?
detected if the test is done earlier than 24 hours. The Newborn screening results are available within three
baby must be screened again after 2 weeks for more weeks after the NBS Lab receives and tests the
accurate results. samples sent by the institutions. Results are released
by NBS Lab to the institutions and are released to your
How is Newborn Screening done? attending birth attendants or physicians. Parents may
Newborn screening is a simple procedure. Using the seek the results from the institutions where samples
hell prick method, a few drops are taken from the are collected.
baby's heel and blotted on a special absorbent filter A negative screen mean that the result of the test is
card. The blood is dried for 4 hours and sent to the normal and the baby is not suffering from any of the
Newborn Screening Laboratory. (NBS Lab) disorders being screened. In case of a positive screen,
the NBS nurse coordinator will immediately inform the
Who will collect the sample for Newborn coordinator of the institution where the sample was
Screening? collected for recall of patients for confirmatory testing
A physician, a nurse, a midwife or medical technologist
can do the newborn screening. What should be done when a baby has a positive
newborn screening result?
Where is Newborn Screening Available? Babies with positive results should be referred at once
Newborn screening is available in practicing health to the nearest hospital or specialist for confirmatory
institutions (hospitals, lying-ins, Rural Health Units and test and further management. Should there be no
Health Centers). If babies are delivered at home, specialist in the area, the NBS secretariat office will
babies may be brought to the nearest institution assist its attending physician.
offering newborn screening
Disorder Effect Effect if SCREENED and treated
Screened SCREENED
CH (Congenital Severe Mental Retardation Normal
Hypothyroidism)
CAH (Congenital Adrenal Death Alive and Normal
Hyperplasia)
GAL (Galactosemia) Death or Cataracts Alive and Normal
PKU (Phenylketonuria) Severe Mental Retardation Normal
G6PD Deficiency Severe Anemia, Kernicterus Normal
1. Congenital Hypothyroidism (CH) phenylalanine. Excessive accumulation of

CH results from lack or absence of thyroid hormone, phenylalanine in the body causes brain damage
which is essential to growth of the brain and the body.
If the disorder is not detected and hormone 5. Glucose-6-Phosphate Dehydrogenase
replacement is not initiated within (4) weeks, the Deficiency (G6PD Deficiency)
baby's physical growth will be stunted and she/he may G6PD deficiency is a condition where the body lacks
suffer from mental retardation. the enzyme called G6PD. Babies with this deficiency
may have hemolytic anemia resulting from exposure to
2. Congenital Adrenal Hyperplasia (CAH) certain drugs, foods and chemicals.
CAH is an endocrine disorder that causes severe salt
lose, dehydration and abnormally high levels of male 6. Maple Syrup Urine Disease
sex hormones in both boys and girls. If not detected Is an autosomal recessive metabolic disorder affecting
and treated early, babies may die within 7-14 days. branched-chain amino acids. It is one type of organic
academia. The condition gets its name from the
3. Galactosemia (GAL) distinctive sweet odor of affected infant’s urine,
GAL is a condition in which the body is unable to particularly prior to diagnosis and during times of acute
process galactose, the sugar present in milk. illness.
Accumulation of excessive galactose in the body can
cause many problems, including liver damage, brain C. NURSING CARE OF NEWBORN
damage and cataracts 1. Establishment of Respiration and
Maintaining Patent Airway
4. Phenylketonuria (PKU)  2nd stage of labor- initial airway
PKU is a metabolic disorder in which the body cannot  initiation of airway is a crucial adjustment
properly use one of the building blocks of protein called
33
 most neonatal deaths with in 24 h caused by  Process of Heat Loss

inability to initiate airway 1. Evaporation------- loss of heat through
 lung function begins after birth only conversion of a liquid to vapor.
Example: heat is loss during tepid sponge bath
How to initiate Airway
A. Remove secretions 2. Conduction------- transfer of heat to a cooler
B. Catheter Suctioning solid object in contact with the baby
1.) place head to side to facilitate drainage - heat loss through direct contact
2.) suction mouth 1st before nose
-neonates are nasal breathers
3.) period of time
- 5-10 sec suctioning, gentle and quick
- prolonged and deep suctioning can
lead to hypoxia, laryngospasm, bradycardia
due to stimulation of vagal nerve
4.) evaluate for patency
- cover nostril and baby struggles there’s a 3. Convection------- flow of heat from the
need for additional suctioning newborn’s body surface through air currents
C. If not effective, requires effective Example: Use of electric fans
laryngoscopy to open airway. After deep suctioning
an endotracheal tube can be inserted and oxygen can
be administered by an (+) pressure bag and mask with
100% oxygen at 40-60b/m.
Nsg alert:
1. No smoking
2. Always humidify to prevent drying of mucosa
3. Over dosage of oxygen can lead to scarring of retina
leading to blindness (retro 4. Radiation- transfer of body heat to a cooler solid
lentafibrolasia or retinopathy of prematurity) object without
4. When meconium stained (greenish) never
administer oxygen with pressure (O2 pressure will
push meconium inside)
2. Bathing and Changing of Diapers, Eye Prophylaxis,

Cord Care and Vit K administration- discussed in
skills laboratory
Effects of Hypothermia (Cold stress)
3. Regulation of Temperature 1. Hypoglycemia- 45-55 mg/dl normal (40-
borderline) due to utilization of glucose
- GOAL : maintain temperature of not less than 2. Metabolic acidosis- catabolism of brown fats
97.7% F (36.5 C) (best insulator of newborns body) will form
- Maintenance of temperature is crucial in preterm ketones (found in chest/back)
and SGA (small for gestational age) - more prone 3. High risk for kernicterus- bilirubin in brain leading
to stress and hypothermia to cerebral palsy
4. Additional stress to cardiovascular system
 Factors Leading to Development of
HYPOTHERMIA Prevention of Hypothermia:
1. Preterms are born Poikilothermic- cold 1. Dry and wrap baby. Put the baby in a bassinette
blooded covered with warm blanket
 Babies easily adapt to temp of 2. Use radiant warmer if necessary
environment due to immaturity of thermo 3. Initiate skin-to-skin contact- kangaroo care (skin
regulating system of body to skin contact)
(Hypothalamus)
2. Inadequate subcutaneous tissue fats 4. Sensory Stimulation (audio& tactile)
3. Baby is not capable of shivering *Earliest Children require sensory stimulation of an appropriate
sign of hypothermia- increase in RR nature and duration, at the right time. Failing to
4. Babies are born wet provide children with adequate sensory stimulation
puts them at a high risk of developmental and cognitive
34
delays. This is known to have been recorded in young development. Just like adults, it also helps them get
babies who grew up in orphanages, as well as in more relaxed and sleep better. Massaging stimulates
preterm babies. the development of their main systems. Those
include the nervous system, circulatory system,
Sensory stimulation during a critical period soon after respiratory system, elimination system and immune
birth is essential for establishing networks in the brain system. It also helps with pain relief.
that “map” sensations and enable the development of
normal behaviors 7. Lay him on his back
Newborns have no concept of what their arms and
These sensory activities will help to ensure a healthy legs are. By laying him down on his back he will have
development both mentally and physically. the opportunity to explore his hands and feet. This
helps with eye hand and eye foot coordination. You
1. Tummy time can encourage his interest by playing games with his
This is an important activity for your baby. It helps arms and feet.
to build coordination and strengthens your baby’s For example:
neck, shoulders, arms and trunk. These muscles Playing ‘this little piggy’ and counting his toes.
help with the motor skills such as rolling over, For hands you can sing a finger song such as ‘Tommy
crawling, pulling self-up and sitting up. Thumb’ and massage each finger as you sing.
Basically, any game or song that includes moving his
2. Face to face time arms and legs will suffice.
Research has identified that infants have shown
preference for looking at human faces. They enjoy 8. Movement
looking at open eyes and smiling faces. So, take that Give your newborn opportunity to be moved in
time to look at your baby, smile at your baby. Make different directions. This can be done in many
funny faces and noises. Be creative and follow your different ways. You can rock or lift your baby (up,
little one’s cues to what they enjoy. down, side to side, round and round). You can:
Move your baby fast and slow. Make sure you stop
3. Cuddle time every minute or so to let his body register the
There are many benefits to holding and cuddling movements and to make sure your baby is not over
with your baby. It helps to boost healthy stimulated.
psychological and physical development. Babies who You can carry your baby in a sling or a baby carrier
get frequent cuddling tend to sleep better, manage (ensure you use appropriate head support). Movement
stress more easily and have better autonomic helps with the development of their vestibular system,
functions such as heart rate and temperature. which is responsible for the awareness of our body in
space.
4. Singing to your newborn
Everything goes here. Whether these include 9. Bicycle ride
nursery rhymes or songs that you make up on the This activity involves placing your newborn on his
go. You can include them while you are cuddling, back and moving your baby’s legs in a bicycle
walking, changing their diaper or giving them a bath. motion. It helps to ease any gas from the tummy
Singing can be used to sooth, entertain and create and tone their muscles to prepare for crawling and
that special bond. It is also a great start to their walking.
language development.
10. Going for a walk outside
5. Talking to your newborn This is a great activity that has many benefits for
This lays down the foundations for language you and your baby. Both of you will get the much-
development. You can narrate your cooking process in needed Vitamin D. You get exercise. Your baby will
the kitchen, or get an opportunity to stimulate their other senses by
Describe all that is around you when you take them for seeing, hearing and feeling the wind on their face.
a walk. Remember: Each baby develops at their own pace.
Feel free to also use the high pitch voice which If your child is not ready or not interested in these
newborns are drawn to. Just make sure you don’t months’ activities, just try them again in a few
mispronounce words to avoid any speech difficulties weeks.
in the future.
5. Breast Feeding
6. Massage  Implications of Physiology of Breastmilk
This is such an amazing activity that has a wide production
range of benefits. The latest research shows that
infant massage helps with the parent-baby bond
35
 Regardless of the mother’s physical condition,  Soap or alcohol should never be used on the
method of delivery, or breast size/condition, breasts as they tend to dry and crack the nipples
milk will be produced. and cause sore nipples.
 Lactation does not occur during pregnancy  Wash hands before and after every feeding.
because estrogen and progesterone are  Insert clean OS squares or piece of cloth in the
present and therefore inhibit prolactin brassiere to absorb moisture when there is
production. considerable breast discharge.
 Lactation – suppressing agents are to be 1. Method – as suggested by the La Leche
given immediately after placental delivery to League
be effective.  Side-lying position with a pillow under the
 Oral contraceptives are contraindicated in mother’s head while holding the bulk of breast
lactating mother because they contain tissues away from the infant’s nose.
estrogen and progesterone, thereby  Stimulate the baby to open his mouth to grasp
decreasing milk supply. the nipples by means of the rooting reflex
 Afterpains are felt more by breastfeeding a.) Rooting reflex- by touching the
women because of oxytocin production; they side of lips/cheeks then baby will turn to
also have less lochia and experience more stimulus.
rapid involution. b.) Sucking – when you touch middle
 In an emergency delivery; of lips then baby will suck
o Determine the EDC, whether the - Disappears by 6 months
woman in labor is a primi or a multi, - When not stimulated
and the stage of labor. sucking will stop.
o If no sterile equipment is available to c.) Swallowing- when food touches
cut the cord, wrap the baby and posterior of tongue then it will be
placenta together; never cut the automatically swallowed NEVER DISAPPEAR
cord unless sterile equipment is
are available. d.) Extrusion/ Protrusion reflex
o If the uterus fails to contract after -when food touches
delivery, put the infant to the breast; anterior portion of tongue thenit will
the sucking of the infant produces be automatically extruded or
oxytocin which causes uterine protruded.
contraction Purpose: to prevent from poisoning
Disappear by 4 months & baby can already spit out by
 Advantages of Breastfeeding 4 months.
1. Economical: >good for 6 mon. from freezer/  Infant should grasp not only the nipple but also
at room. temp. don’t heat the areola for effective sucking motion.
2. Always available Effectiveness is ensured when the:
3. Promotes Bonding (PROPER LATCHING)
4. Breastfed babies have higher IQ than bottle baby’s mouth covers the areola
fed babies. Lower lip is turned outward
5. It facilitates rapid involution mother feels after pains as the baby sucks
6. Decrease incidence of breast cancer. other nipple flows with milk while baby is feeding
7. Contents of BREAST MILK: on other breast
a. Antibodies- IgA  To prevent nipples from becoming sore and
b. Lactobacillius bifidus- interferes w/ cracked, infant should be introduced to the breast
attack of pathogenic bacteria in GIT gradually. The baby should be fed for only 5
c. Macrophages minutes at each breast during each feeding on the
d. Lactoferrin - iron bindig protein first day, increasing the time at each breast by 1
e. Lyzozymes - breastmilk enzyme that minute per day until the infant is nursing for 10
destroys bacteria by lyzing or minutes at each breast, making a total feeding
disolving cell membrane time of twenty minutes per feeding.
f. Interferons - it inhibits viral growth  For continuous milk production, at each feeding,
g. Immunoglobulins the infant should be placed first on the breast he
fed last in the previous feeding. This ensures that
 Health Teachings: each breast will be completely emptied at every
1. Hygiene other feeding. If breasts are completely emptied,
 Wash breasts daily at bath or shower time. they completely refill; if only half-emptied will also
half-refill and after some time, will become
insufficient.
36
Note: A newborn placed under phototherapy lights as a treatment for jaundice has bright green stools because of
increased bilirubin excretion.
Newborns with bile duct obstruction have clay-colored (gray) stools, because bile pigments are not entering the
intestinal tract
Blood-flecked stools usually indicate an anal fissure

 To break away from the closed suction at the
breast after feeding, insert a clean little finger in Nutrition – lactating mothers should take 3000
the corner of the infant’s mouth to release the calories daily and should have larger amounts of
suction, then pull the chin down. This also helps proteins (96 Gms per day), calcium, iron Vitamins A, B
prevent sore nipples. and C. Non-breastfeeding women can have the same
 Feed as often as the baby is hungry, especially requirements as in pregnancy.
during the first few days, because he is receiving Contraindications
colostrums which is not very filling; however, it Drugs – oral contraceptives, atropine, anticoagulants,
contains gamma globulin (antibodies), the only antimetabolites, cathartics, tetracyclines. (Insulin,
group of substances that can never be replicated epinephrine, most antibiotics, antidiarrheals and
by any artificial formula. histamines are generally not contraindicated.
 Advise the mother to learn how to relax during Therefore, diabetics and those with asthma can
feedings because tension prevents good let-down. breastfeed.)
Certain disease conditions, specifically
Associated Problems tuberculosis, because of the close contact between
Engorgement – feeling of tension in the breasts mother and baby during feeding. (However, mothers
during the third postpartum day sometimes may use masks to prevent droplet spread) TB germs,
accompanied by an increase in temperature (milk however, are not transmitted thru breast milk.
fever). The breasts become full, feel tense and hot,
with throbbing pain. It lasts for about 24 hours and is 6. Establishing Waste Elimination
due to increased lymphatic and venous circulation. A. Types of Stools
Management: 1. Meconium - physiologic stool
 Advise use of firm-fitting brassiere for good Characteristics - blackish green, sticky, tar
support. It will not only decrease the discomfort like, odorless (Sterile intestine) (no bacteria)
from breast engorgement but will also prevent will pass w/in 24 – 48 hrs.
contamination of the nipples and areolae. **Failure to pass meconium after 24 hours-
 Cold compress is applied if the mother does not GIT obstruction
intend to breastfeed; warm compress is applied if Suspect presence of: Hirschsprungs disease
she will breastfeed. Imperforate anus
 Breast pump should not be used and breast Meconium ileus – due to Cystic Fibrosis
massage should not done if the mother is not
going to breastfeed, since either will stimulate milk 2. Transitional Stool - (4-14 days)
production. - green loose & shiny, like diarrhea to the
Sore nipples – not contraindications to breastfeeding. untrained eye (primipara mother)
Management: - by 4th day of life, breastfed babies pass three
 Do not use plastic liners that are found in some or four light yellow stools per day
nursing bras because they prevent air from - described as sweet-smelling due to lactic
circulating around the breasts. acid, which reduces the number of
 Use nipple shield. putrefactive organisms in the stool.
Mastitis – inflammation of the breasts 3. Bottlefed Stool - pale yellow, formed hard with
Symptoms typical offensive odor, seldom passed, 2–3 x/day
 Localized pain, swelling and redness in breast
tissues 4. Supplementary - with food added -brown &
 Lumps in the breasts odorous
 Milk becomes scantly
Management
 Antibiotics as ordered
 Ice compress
 Proper breast support
 Discontinue breastfeeding in affected breast
37
CONCEPT OF GROWTH AND DEVELOPMENT life; in latter part of life, atrophy predominates
A. PRINCIPLES OF GROWTH AND growth
DEVELOPMENT *Piaget- “structures are far from being static given
from the start”
- maturing organism undergoes continued
and progressive changes
*Bower- cyclic process but not continuous;
competencies occurs in development (repetitions
and disappearance)
*Psychologic growth-continuous and additive
process
Goal of Developmental Changes

GOAL: to enable people to adapt to the
environment in which they live in
- Self-realization/actualization is important to
achieve this goal
- It is never static
- “urge”-> to do what one is fitted to do, to
become the person, both physically and
psychologically, that one wants to be
Developmental Psychology - Depends on innate abilities and trainings
 Branch of psychology that studies intra - People with good personal social adjustments
individual changes and inter individual must have opportunities to express their
changes within these intra individual changes. interests and desires -> lack of opportunities
 “Not only description but also explication of can lead to frustrations and negative attitudes
age-related changes in behavior in terms of toward people and life
antecedented-consequent relationships”-La
Bouvie Studies of Developmental Change
- Studies on childhood and adolescent are more
Major objectives: extensive than later years
1. To find out what are the common and characteristic  Prevailing traditional beliefs
age changes in appearance, - Postadolescent beliefs are less numerous;
behavior, interest, and goals from one middle age-> physiological rather than
developmental period to another psychoilogical
2. To find out when changes occur - Old age -> small percentage
3. To find out what causes them - It is now recognized that changes in any
4. To find out how they influence behaviour developmental study are worthy of study
5. To find out whether they can or cannot be predicted
- Nature vs. nurture (genetic factors vs.
6. To find out whether they are universal or individual
environment and experience
Developmental Changes
Attitudes toward Developmental Changes
- Many people are vaguely aware unless
Development
occurring markedly or abruptly affect the
- Progressive series of changes that occur as a
pattern
result of maturation and experience
- Fast pace or slow pace; still requires
Growth readjustments
- Increase in size of a structure. Human growth - Adolescents->spurt of growth; senescence-
is orderly and predictable, but not even;it >failing health
follows a cyclical pattern. - Some remember the past than the present;
Growth(evolution) and atrophy(involution) children wants to be teens; retirement from
- Two essentially antagonistic processes early years
- Both begin in conception and end in death
- In early years growth predominates, even
atrophic changes occur as early as embryonic
38
Factors Influencing Attitudes Toward - “ontogenetic functions” – specific to the

Developmental Changes individuals –requires training, without it,
1. Appearance- for improvement are welcome development would not take place
(favorable); detractions are resisted and
camouflaged 3 facts on development, maturation and
2. Behavior- disconcerting (unfavorable) or learning:
otherwise, favorable 1. Because human beings are capable of learning,
3. Cultural stereotypes- mass media, variations are possible ->individual differences
stereotypes associated with different ages, 2. Maturation sets limits beyond which
judgement development cannot progress, even with the most
favorable learning methods and the strongest
4. Cultural values- every culture has certain
motivation on the part of the learner
values; middle-aged ->productive
3. There is a definite timetable for learning-
5. Role changes- affected by age; directly
>readiness to learn; determines the moment
related
learning can and should take place
6. Personal experiences- profound effect on
individual C. Development follows a definite and
predictable pattern
Significant Facts about Development - Orderly patterns of bodily aspects
A. Early foundations are critical
- “Cephalocaudal” and “proximodistal”
- Attitudes, habits, and patterns of behavior - There is no record for that individuals have
established during the early years determines
their own pattern, but difference in rate
success in adjustment in life
- Should lead to good personal and social occurs
adjustments *Importance: possible to predict what people will
- Preschool years-> among the most do at a given age and to plan their education and
important; foundations are laid built for training to fit into this pattern
lifetime
*Erikson- babyhood-> trust vs. mistrust D. Individuals are different
remain throughout lifetime - “Every person is indeed biologically and
- early patterns tend to persist, but not
genetically different from every other”
changeable. There are 3 reasons which
change is likely to occur: - Differences increases as age advances; adults
1. When the individual receives help are more complex and different from children
and guidance in making the change - No two people can be expected to react in the
2. When significant people treat the same manner to the same environmental
individual in new and different ways stimuli
3. When there is strong motivation - Because of this, one can never predict with
on the part of the individual to make accuracy how people will react to a situation
the change
- Differences are significant because they are
*Knowing the early foundations can predict
what a child’s future development responsible for personality make up
B. Roles of maturation and learning in E. Each phase of Development has

development characteristic behavior
- Play important roles in development - Patterns are marked by periods of
*Maturation-unfolding of the inherent traits equilibrium->adapt easily->good personal
- Provides the raw materials for learning and and social adjustments
determines the more general patterns and - Disequilibrium ->difficulty adapting->poor
sequences of behavior personal and social adjustments
- “Phylogenetic functions”- common to the - Some stages of growing up are marked by
human race difficult behavior
- Development comes from maturation - “problem behavior”->individual’s behavior is
*Learning- development that comes from typical for a particular age group and leads to
exercise and effort on the individual’s part poor adjustment
39
- Many of these behavior will gradually wane to do when they reach their next stage of
and disappear, that would be replaced by as development.
difficult as the behaviors they have outgrown
- Never assume that difficult behavior will Hazards of Developmental Task
Because developmental tasks play such an
disappear->may be a warning of possible
important role in setting guidelines for normal
future development, anything that interferes with their
- At every age, there are equilibrium and mastery maybe regarded as a potential hazard.
disequilibrium ->physical, environmental, 1. inappropriate expectations
carry-overs 2. bypassing of a stage of development as
a result of failure to master the tasks for
F. Each phase of development has hazards that stage of development
- each period in the life span has
Two serious consequences of failure to master
developmental hazards-these involves
developmental tasks
adjustment problems 1. unfavorable social judgment
- persons who are in charge of taking care 2. foundations for the mastery of later
people should be aware of the hazards developmental tasks are inadequate
associated ->such awareness helps to
prevent or alleviate the hazards J. Traditional Beliefs about People of all
Ages
G. Development is aided by stimulation - These beliefs about people; their physical and
psychological characteristics affect the
- Most development is from maturation and
judgment of others as well as their self –
experience; much can be done to aid so that evaluations
it will reach its full potential
- Directly encouraging to use an ability- General Principles of Growth And Development
>effective in developing 1. Growth and development are continuous
processes from conception until death.
H. Development is affected by cultural - G/D proceeds or keeps going on at all times
changes since a child is growing new body cells and
learning new skills
- Changes in standard affected development
Ex: an infant 2x his birth wt at 6 months
pattern
3x his birth wt at 12 months
- Sex roles, traditional vs egalitarian roles 4x his birth wt at 24 months
an infant 2x his birth length at 4 yrs
I. Social expectations for every stage of 3x his birth length at 13 yrs
development
- Every cultural group expects a certain age 2. Growth and development proceed in an orderly
acquire and master skills and certain patterns sequence.
of behavior - G/D proceeds in a predictable manner
Ex: A child sits before be creeps
*Developmental task- a task which arises at or
Creeps before he can stand upright
about a certain period in the life of the individual, Stands before he can walk
successful achievement which leads to happiness Walks before he can run
and to success with later tasks, or otherwise
-physical maturation, cultural pressures, personal 3. Development are directional:
values and aspirations  Cephalocaudal – development proceeds from
head downward toward the feet; head to
Purposes of Developmental Task tail/lower extremities.
1. they are guidelines that enable individuals to Ex: Newborn: can lift only his head off the
know what society expects of them at given bed in when prone position
stages; 2 mos: infant can lift head & chest off the bed
2. motivate individuals to do what the social 4 mos : can lift head, chest & part of abdomen
group expects them to do at certain ages 5 mos 1: can roll or turn over
during their lives; 9 mos : can control legs – crawl
3. developmental tasks show individual what lies 1 Yr: can stand and walk
ahead of them and what they will be expected
40
 Proximo-distal – development proceeds from  Preschool: 3 - 6 years

the center of the body outward to the  School age: 6- 12 years
extremities.  Adolescence: 12-18 years
Ex: NB makes little use of arms or hands
3-4 mos: can support upper body
wt using his forearms & can scoop B. FACTORS INFLUENCING GROWTH AND
objects (grasp reflex) DEVELOPMENT
10 mos: can coordinate thumb & (Theories of Growth and Development)
index finger to pick up fine/small A. Psychosexual Stages of Development by Freud
objects (pincer reflex) According to Freud, a child is dominated by the id or
 Simple to complex – child masters simple the pleasure principle. Thus, a child always yearns to
operations before complex functions get whatever he/she wants but unaware of the
Ex: 12 months: can walk possible result of the act. So a child is preoccupied with
3 yrs pedal a trike the erogenous zone a body part which is responsible
4 years ride a bicycle for producing pleasure through physical stimulation.
Sigmund Freud divided personality development into
4. All body systems do not develop at the same rate. five stages: oral, anal, phallic, latent, and genital. What
- Certain body tissues mature more rapidly than makes these stages controversial is that each stage is,
others. Also known as asynchronous growth. according to Freud, associated with sexual pleasure.
- Ex: neurologic tissues grow during the 1st year of The psychosexual theory of personality development is
life; genital tissues grow during puberty basically shaped and driven by the libido or sexual
energy. This sexual energy would greatly affect the
5. Discontinuity of growth rate – growth spurts and person’s personality in the later part of the
growth lags/slow down are common; there are 2 development.
periods of very rapid growth: infancy & Each stage has several challenges that a child must
adolescence period; slow growth rate: toddler successfully deal with. If those challenges are resolved,
it will result in healthy personality formation.
6. Play is central to the life of a child. - it is universal However, if challenges at any stage of the development
language of a child. are not resolved, a problem may arise. The unresolved
issues may manifest in the persons behavior. A person
7. A great deal of skill and behavior is learned by becomes fixated at a certain behavior that is usually
practice. unhealthy.
- Infants practice over and over taking his 1st Fixation is an indication that a person has stuck in the
step before he can accomplish walking previous stage of psychosexual development. For
instance, a person who was not able to resolve the
without falling.
issues during the oral stage, he/she become fixated
8. Each child is unique. - the differences from child
with certain behaviors. The most common one is oral
to child are due to: heredity, racial
stimulation in the form of smoking or eating.
characteristics, sex, environment
Stages or Divisions of Childhood:
 Infancy: Birth - 1 year  Phases
 Toddler: 1 – 3 years
Phase Age Site of Activities Task
Gratificati
on
Oral Phase 0 – 18 Mouth  Biting  Provide oral stimulation even if baby
mos.  Crying is place NPO (use pacifier)
 Never discourage thumb sucking
 Sucking
(enjoyment and
release
of tension)
41
Anal Phase19 mos. – Anus  Elimination  Help the child achieve bowel and
(stage where OC3 yrs.  Retention/ bladder control even if the child is
are developed) Defecation of Feces hospitalized
 Principle of holding on and letting go
 Mother wins or child wins
 Child Wins
 Child turns to be hardheaded,

antisocial, stubborn, unreliable,
irresponsible
 Mother Wins
o Letting go
o Child turns to be kind,
obedient, perfectionist
o Meticulous, OCs,
reliable,responsible
Phallic Phase 4 – 6 yrs. Genital  May show  Accept the child fondling his own
exhibitionism genetalia as normal area of
 Have or increase exploration
knowledge of 2  Divert attention from masturbation
sexes  Answer the child’s question
 directly
 Human sexuality
Latent Phase 7 – 12 yrs. School aged  Period of  Help the child achieve (+)
suppression experiences so that he’ll be ready to
 No obvious face the conflicts of adolescents
development, slower
growth
 Child’s energy or
Libido is diverted
into more concrete
type of thinking
Genital Phase 12 – 18 yrs Genitalia  Achieve sexual  Give opportunity to relate to opposite sex
maturity and learn
to establish
satisfactory
relationship with
the opposite
sex
B. Psychosocial Development One of the main elements of Erikson's psychosocial

by Erikson stage theory is the development of ego identity.
Erik Erikson's theory of psychosocial development is one Ego identity is the conscious sense of self that we
of the best-known theories of personality in psychology. develop through social interaction. According to
Much like Sigmund Freud, Erikson believed that personality Erikson, our ego identity is constantly changing due
develops in a series of stages. Unlike Freud's theory of to new experiences and information we acquire in our
psychosexual stages, Erikson's theory describes the daily interactions with others.
impact of social experience across the whole lifespan.
42
When psychologists talk about identity, they psychosocial development takes place during
are referring to all of the beliefs, ideals, and values that early childhood and is focused on children
help shape and guide a person's behavior. The formation developing a greater sense of personal control.
of identity is something that begins in childhood and  Like Freud, Erikson believed that toilet training
becomes particularly important during adolescence, was a vital part of this process. However,
but it is a process that continues throughout life. Our Erikson's reasoning was quite different then
personal identity gives each of us an integrated and that of Freud's. Erikson believe that learning
cohesive sense of self that endures and continues to to control one's bodily functions leads to a
grow as we age. feeling of control and a sense of
independence.
In addition to ego identity, Erikson also  Other important events include gaining more
believed that a sense of competence motivates control over food choices, toy preferences,
behaviors and actions. Each stage in Erikson's theory and clothing selection.
is concerned with becoming competent in an area of  Children who successfully complete this stage
life. If the stage is handled well, the person will feel a feel secure and confident, while those who do
sense of mastery, which is sometimes referred to as not are left with a sense of inadequacy and self-
ego strength or ego quality. If the stage is doubt.
managed poorly, the person will emerge with a sense  Erikson believed that achieving a balance
of inadequacy. between autonomy and shame and doubt
would lead to will, which is the belief that
In each stage, Erikson believed people children can act with intention, within reason
experience a conflict that serves as a turning point and limits.
in development. In Erikson's view, these conflicts are
centered on either developing a psychological quality Psychosocial Stage 3 - Initiative vs. Guilt
or failing to develop that quality. During these times,  During the preschool years, children
the potential for personal growth is high, but so is the begin to assert their power and control
potential for failure. over the world through directing play and
other social interactions.
 Children who are successful at this stage feel
Psychosocial Stage 1 - Trust vs. Mistrust capable and able to lead others. Those who
fail to acquire these skills are left with a sense
 The first stage of Erikson's theory of of guilt, self-doubt, and lack of initiative.
psychosocial development occurs between
 When an ideal balance of individual
birth and one year of age and is the most
initiative and a willingness to work with
fundamental stage in life.
others is achieved, the ego quality known
 Because an infant is utterly as purpose emerges.
dependent, the development of
trust is based on the
Psychosocial Stage 4 - Industry vs. Inferiority
dependability and quality of the
child's caregivers.  This stage covers the early school years from
 If a child successfully develops trust, he or she will approximately age 5 to 11.
feel safe and secure in theworld.  Through social interactions,
Caregivers who are inconsistent, emotionally children begin to develop a
unavailable, or rejecting contribute to sense of pride in their
feelings of mistrust in the children they care accomplishments and abilities.
for. Failure to develop trust will result in fear  Children who are encouraged and
and a belief that the world is inconsistent and commended by parents and teachers
unpredictable. develop a feeling of competence and belief in
 Of course, no child is going to develop a sense their skills. Those who receive little or no
of 100 percent trust or 100 percent doubt. encouragement from parents, teachers, or
Erikson believed that successful development peers will doubt their abilities to besuccessful.
was all about striking a balance between the • Successfully finding a balance at this stage of
two opposing sides. When this happens, psychosocial development leads to the
children acquire hope, which Erikson strength known as competence or a belief our
described as openness to experience own abilities to handle the tasks set before us.
tempered by some wariness that danger may Psychosocial Stage 5 - Identity vs. Confusion
be present.
Psychosocial Stage 2 - Autonomy vs. Shame and  During adolescence, children explore their
Doubt independence and develop a sense of self.
 The second stage of Erikson's theory of  Those who receive proper encouragement
43
and reinforcement through personal will experience many regrets. The individual will
exploration will emerge from this stage with a be left with feelings of bitterness and despair.
strong sense of self and a feeling of  Those who feel proud of their
independence and control. Those who remain accomplishments will feel a sense of
unsure of their beliefs and desires will feel integrity. Successfully completing this phase
insecure and confused about themselves and means looking back with few regrets and a
the future. general feeling of satisfaction. These
 Completing this stage successfully leads to individuals will attain wisdom, even when
fidelity, which Erikson described as an ability confronting death.
to live by society's standards and expectations.
C. Cognitive Stages of Development by Piaget
Psychosocial Stage 6 - Intimacy vs. Isolation  Cognitive development refers to how a
 This stage covers the period of early person perceives, thinks, and gains
adulthood when people are exploring understanding of his or her world through
personal relationships. the interaction of genetic and learned
 Erikson believed it was vital that people factors. Among the areas of cognitive
develop close, committed relationships development are information processing,
with other people. Those who are intelligence, reasoning, language
successful at this step will form development, and memory.
relationships that are committed and
secure. Sensorimotor
years)
(0-2 Development proceeds from reflex activity to representation and sensorimotor solut
to problems
 Remember that each step builds on skills

learned in previous steps. Erikson believed Pre-operational
years)
(2-7 Problems solved through representation; language development; (2 -4
years); thoughts and language both egocentric; cannot solve conservation
that a strong sense of personal identity was problems.
important for developing intimate relationships.

Concrete Operation (7- Reversibility attained; can solve conservation problems; Logical operation develop
Studies have demonstrated that those with 11 years) and applied to concrete problems; cannot solve complex verbal problems.
a poor sense of self tend to have less

committed relationships and are more likely to Formal Operation (11 Logically solves all types of problems; thinks scientifically; solves complex proble
suffer emotional isolation, loneliness, and years-adulthood) cognitive structures mature.
depression.
 Successful resolution of this stage results in the
virtue known as love. It is marked by the ability Sensorimotor stage (infancy): In this period,
to form lasting, meaningful relationships with which has six sub-stages, intelligence is demonstrated
other people. through motor activity without the use of symbols.
Knowledge of the world is limited, but developing,
Psychosocial Stage 7 - Generativity vs. because it is based on physical interactions and
Stagnation experiences. Children acquire object permanence at
about seven months of age (memory). Physical
 During adulthood, we continue to build our lives,
development (mobility) allows the child to begin
focusing on our career and family. developing new intellectual abilities. Some symbolic
 Those who are successful during this phase (language) abilities are developed at the end of this
will feel that they are contributing to the stage.
world by being active in their home and
community. Those who fail to attain this Pre-operational stage (toddlerhood and early
skill will feel unproductive and uninvolved in childhood): In this period, which has two sub
the world. stages, intelligence is demonstrated through the use
 Care is the virtue achieved when this stage is of symbols, language use matures, and memory and
handled successfully. Being proud of your imagination are developed, but thinking is done in a
accomplishments, watching your children non-logical, non-reversible manner. Egocentric
grow into adults, and developing a sense thinking predominates.
of unity with your life partner are important
accomplishments of this stage Concrete operational stage (elementary and
early adolescence): In this stage, characterized
Psychosocial Stage 8 - Integrity vs. Despair by seven types of conservation (number, length,
 This phase occurs during old age and is focused liquid, mass, weight, area, and volume),
intelligence is demonstrated through logical and
on reflecting back on life.
systematic manipulation of symbols related to
 Those who are unsuccessful during this stage concrete objects. Operational thinking develops
will feel that their life has been wasted and (mental actions that are reversible). Egocentric
44
thought diminishes. Head lag when pulled to sitting position

No longer clinches fist tightly
Formal operational stage (adolescence and Follows object past midline
adulthood): In this stage, intelligence is Recognizes parents
demonstrated through the logical use of symbols
related to abstract concepts. Early in the period there 3 months
is a return to egocentric thought. Only 35 percent of Holds head and chest up when in prone
high school graduates in industrialized countries Holds hands open at rest
obtain formal operations; many people do not think Hand regard, follows object past midline
formally during adulthood. Grasp and tonic neck reflexes are fading
Reaches for familiar people or object
C. Stages of Growth and Development (Infancy to Anticipates feeding
Adolescents)
MILESTONES 4 months
Head control complete
Infancy Turns front to back; needs space to turn
 Solitary play Laughs aloud; Babbling sound
o Consider when choosing a play Babinski Reflex disappears
 Safety
 Age appropriateness 5 months
Turn both ways (roll over)
 Hygiene Teething rings, handles rattle well
 Fear: Stranger Anxiety Moro reflex disappears (5 – 6 months)
o Begins: 6 – 7 months Enjoys looking around environment
o Peaks: 8 months
o Diminishes: 9 months 6 months
Reaches out in the anticipation of being
Neonate picked- up
 Complete head lag Sits with support
 Largely reflex visual fixation for human face Puts feet in mouth in supine position
 Hands fisted with thumbs in Eruption of first temporary teeth ( Lower 2
central incisors)
 Cries without tears because lacrimal glands
Vowel sounds “ah, eh”
are not fully developed
Uses palmar grasp; handless bottle well
Recognizes strangers
1 month
Dance reflex disappears
Looks at mobile; follows midline
7 months
Transfer objects from hand to hand (6 – 7
Alert to sound, regards face
months)
Likes objects that are good sized for
2 months transferring
Holds head up when in prone
Social smile, cries with tears, cooing sound
Closure of posterior fontanel (2-3 months)
8 months
Sits without support Peek – a – boo, pat a cake, since they can
Peak of stranger anxiety clap
Plantar reflex disappear (6-8 months)
11 months
9 months Cruising, stand with assistance
Creeps or crawls; need space for creeping Walking while holding to his crib’s handle
Neat pincer grasp reflex, probes with One word other than mama and dada
forefinger
Finger feeds, combine 2 syllables “mama & 12 months
dada” Stands alone
Walk with assistance
10 months Drink from cup, cooperates in dressing
Pulls self to stand Says two words other than mama and dada
Understand the word no Pots & pans, pull toys and nursery rhymes
Respond to name Imitates actions, comes when called
45
Follows one – step command and gesture 4. Appetite decreases.

Uses mature pincer graps, throws objects 5. Able to feed self.
6. Negativism may interfere with eating.
Toddler (12 months to 3 years) 7. Initial dental examination at 3 years.
A. Physical tasks: this is a period of slow growth
1. Weight: gain of approximately 11 lb (5 kg) during E. Play
this time; birth weight quadrupled by 2 1/2 years 1. Predominantly- “parallel play” period.
2. Height: grows 20.3 cm (8 inches); 2. Provide toys appropriate for increased locomotive
3. Head circumference: 19½ - 20 inches (49 - 50 cm) skills: push toys, rocking horse, riding toys or tricycles;
by 2 years; anterior fontanel closes by 18 months swings and slide.
4. Pulse 110; respirations 26; blood pressure 99/64 3. Give toys to provide outlet for aggressive feelings:
5. Primary dentition (20 teeth) completed by 2 1/2 work bench, toy hammer and nails, drums, pots, pans.
years 4. Provide toys to help develop fine motor skills,
6. Develops sphincter control necessary for bowel and problem-solving abilities: puzzles, blocks; finger paints,
bladder control crayons.
B. Psychosocial tasks G. Fears: separation anxiety

1. Increases independence; better able to tolerate 1. Learning to tolerate and master brief periods of
separation from primary caregiver. separation is important developmental task.
2. Less likely to fear strangers. 2. Increasing understanding of object permanence
3. Able to help with dressing/undressing at 18 months; helps toddler overcome this fear.
dresses self at 24 months. 3. Potential patterns of response to separation
4. Has sustained attention span. a. Protest: screams and cries when mother leaves;
5. May have temper tantrums during this period; attempts to call her back.
should decrease by 2 1/2 years. b. Despair: whimpers, clutches transitional object, curls
6. Vocabulary increases from about 10 - 20 words to up in bed, decreased activity, rocking.
over 900 words by 3 years. c. Denial: resumes normal activity but does not form
7. Has beginning awareness of ownership (my, mine) psychosocial relationships; when mother returns, child
at 18 months; shows proper use of pronouns (I, me, ignores her
you) by 3 years.
8. Moves from hoarding and possessiveness at 18 Preschooler (3 to 5 years)
months to sharing with peers by 3 years. A. Physical tasks
9. Toilet training usually completed by 3 years. 1. Slower growth rate continues
a. 18 months: bowel control a. Weight: increases 4 - 6 lb (1.8 - 2.7 kg) a year
b. 2 - 3 years: daytime bladder control b. Height: increases 2 1/2 inches (5-6.25 cm) a
c. 3 - 4 years: nighttime bladder control year
c. Birth length doubled by 4 years
C. Cognitive tasks 2. Vital signs decrease slightly
1. Follows simple directions by 2 years. a. Pulse: 90-100
2. Begins to use short sentences at 18 months to 2 b. Respirations: 24-25/minute
years. c. Blood pressure: systolic 85-100 mm Hg
3. Can remember and repeat 3 numbers by 3 years. diastolic 60-90 mm Hg
4. Knows own name by 12 months; refers to self, gives 3. Permanent teeth may appear late in preschool
first name by 24 months; gives full name by 3 years. period; first permanent teeth are molars, behind last
5. Able to identify geometric forms by 18 months. temporary teeth.
6. Achieves object permanence; is aware that objects 4. Gross motor development
exist even if not in view. a. Walks up stairs using alternate feet by 3 years.
7. Uses “magical” thinking; believes own feelings affect b. Walks down stairs using alternate feet by 4
events (e.g., anger causes rain). years.
8. Uses ritualistic behavior; repeats skills to master c. Rides tricycle by 3 years.
them and to decrease anxiety. d. Stands on 1 foot by 3 years.
9. May develop dependency on “transitional object” 4. Gross motor development
such as blanket or stuffed animal. e. Hops on 1 foot by 4 years.
f. Skips and hops on alternate feet by 5 years.
D. Nutrition g. Balances on 1 foot with eyes closed by 5 years.
1. Caloric requirement is approximately 100 h. Throws and catches ball by 5 years.
calories/kg/day. i. Jumps off 1 step by 3 years.
2. Increased need for calcium, iron, and phosphorus. j. Jumps rope by 5 years.
3. Needs 16 - 24 oz milk/day.
46
5. Fine motor development books, puzzles; paints, crayons, clay, simple sewing
a. Hand dominance is established by 5 years. sets.
b. Builds a tower of blocks by 3 years. 5. Television, when supervised, can provide a quiet
c. Ties shoes by 5 years. activity; some programs have educational content.
d. Ability to draw changes over this time
1) copies circles, may add facial features by 3 G. Fears
years. 1. Greatest number of imagined and real fears of
2) copies a square, traces a diamond by 4 childhood during this period.
years 2. Fears concerning body integrity are common.
a. Magical and animistic thinking allows
B. Psychosocial tasks children to develop many illogical fears
1. Becomes independent (fear of inanimate objects, the dark, ghosts).
a. Feeds self completely.
b. Dresses self. School-age (6 to 12 years)
c. Takes increased responsibility for actions. A. Physical tasks
2. Aggressiveness and impatience peak at 4 years then 1. Slow growth continues.
abate. a. Height: 2 inches (5 cm) per year
3. Gender-specific behavior is evident by 5 years. b. Weight: doubles over this period
4. Egocentricity changes to awareness of others; rules c. At age 9, both sexes same size; age 12,
become important; understands sharing girls bigger than boys
2. Dentition
C. Cognitive development a. Loses first primary teeth at about 6 years.
1. Focuses on one idea at a time; cannot look at entire b. By 12 years, has all permanent teeth
perspective. except final molars.
2. Awareness of racial and sexual differences begins. 3. Bone growth faster than muscle and ligament
a. Prejudice may develop based on values of development; very limber but susceptible to bone
parents. fractures during this time.
b. Manifests sexual curiosity. 4. Vision is completely mature; hand-eye coordination
c. Sexual education begins. develops completely.
d. Beginning body awareness. 5. Gross motor skills: predominantly involving large
3. Has beginning concept of causality. muscles; children are very energetic, develop greater
4. Understanding of time develops during this period. strength, coordination, and stamina.
a. Learns sequence of daily events. 6. Develops smoothness and speed in fine motor
b. Is able to understand meaning of control.
sometime-oriented words (day of week,
month, etc.) by 5 years. B. Psychosocial tasks
5. Has 2000-word vocabulary by 5 years. 1. School occupies half of waking hours; has cognitive
6. Can name 4 or more colors by 5 years. and social impact.
7. Is very inquisitive (why? why? why?) a. Readiness includes emotional (attention
span), physical (hearing and vision), and
D. Nutrition intellectual components.
1. Caloric requirement is approximately 90 b. Teacher may be parent substitute,
calories/kg/day. causing parents to lose some authority.
2. May demonstrate strong taste preferences. 2. Morality develops
3. More likely to taste new foods if child can assist in a. Before age 9 moral realism predominates:
the preparation. strict superego, rule dominance; things are
black or white, right or wrong.
F. Play b. After age 9 autonomous morality
1. Predominantly associative play develops: recognizes differing points of
2. Enjoys imitative and dramatic play. view, sees “gray” areas.
a. Imitates same-sex role functions in play. 3. Peer relationships
b. Enjoys dressing up, dollhouses, trucks, a. Child makes first real friends during this
cars, telephones, doctor and nurse kits. period.
3. Provide toys to help develop gross motor skills: b. Is able to understand concepts of
tricycles, wagons, outdoor gym; sandbox, wading pool. cooperation and compromise (assist in
4. Provide toys to encourage fine motor skills, self- acquiring attitudes and values); learns fair
expression, and cognitive development: construction play vs competition.
sets, blocks, carpentry tools; flash cards, illustrated c. Help child develop self-concept.
d. Provide feeling of belonging.
47
4. Enjoys family activities. b. Boys: growth spurt starts around age 13;
5. Has some ability to evaluate own strengths and height increases 4 inches/year; slows in late
weaknesses. teens.
6. Has increased self-direction. c. Boys double weight between 12 and 18, related
7. Is aware of own body; compares self to others; to increased muscle mass.
modesty develops. d. Body shape changes
e. Apocrine glands cause increased body odor.
C. Cognitive development f. Increased production of sebum and plugging of
1. Period of industry sebaceous ducts causes acne.
a. Is interested in exploration and 4. Sexual development: girls
adventure. a. Development of secondary sex characteristics
b. Likes to accomplish or produce. and sexual functioning under hormonal
c. Develops confidence. control
2. Concept of time and space develops. b. Breast development is first sign of puberty.
a. Understands causality. 1) bud stage: areola around nipple is
b. Masters concept of conservation: protuberant.
permanence of mass and volume; concept 2) breast development is complete around
of reversibility. the time of first menses.
c. Develops classification skills: understands 5. Sexual development: boys
relational terms; may collect things. a. Development of secondary sex
d. Masters arithmetic and reading. characteristics, sex organs and function
under hormonal control.
D. Nutrition b. Enlargement of testes is first sign of
1. Caloric needs diminish in relation to body size: 85 sexual maturation; occurs at approximately
kcal/kg. age 13, about 1 year before growth spurt.
2. “Junk” food may become a problem; excess sugar, c. Scrotum and penis increase in size until
starches, fat. age 18.
3. Obesity is a risk in this age group. d. Reaches reproductive maturity about age
4. Nutrition education should be integrated into school 17, with viable sperm.
program. e. Nocturnal emission: a physiologic reflex
to ejaculate buildup of semen; natural and
E. Play normal; occurs during sleep (child should
1. Rules and ritual dominate play; individuality not not be made to feel guilty; needs to
tolerated by peers; knowing rules provide sense of understand that this is not enuresis).
belonging; “cooperative play.” f. Masturbation increases (also a normal way
2. Team play: games or sports to release semen).
a. Help learn value of individual skills and g. Pubic hair continues to grow and spread
team accomplishments. until mid 20s.
b. Help learn nature of competition. h. Facial hair; appears first on upper lip.
3. Quiet games and activities: board games, i. Voice changes due to growth of laryngeal,
collections, books, television, painting cartilage.
4. Athletic activities: swimming, hiking, bicycling, j. Gynecomastia: slight hypertrophy of
skating breasts due to estrogen production; will pass
within months but causes embarrassment.
G. Fears:
more realistic fears than younger children; include B. Psychosocial tasks
death, disease or bodily injury, punishment; school 1. Early adolescence: ages 12-14 years
phobia may develop, resulting in psychosomatic illness. a. Starts with puberty.
b. Physical body changes result in an altered
Adolescent (12 to 19 years) self-concept.
A. Physical tasks c. Tends to compare own body to others.
1) boys become leaner with broader chest. d. Early and late developers have anxiety
2) girls have fat deposited in thighs, hips, and breasts; regarding fear of rejection.
pelvis broadens. e. Fantasy life, daydreams, crushes are all
a. Girls: height increases approximately 3 normal, help in role play of varying social
inches/year; slows at menarche; stops around situations.
age 16. f. Is prone to mood swings.
g. Needs limits and consistent discipline.
2. Middle adolescence: ages 15-16 years
48
a. Is separate from parents (except

financially).
b. Can identify own values.
c. Can define self (self-concept, strengths
and weaknesses).
d. Partakes in peer group; conforms to
values/fads.
e. Has increased heterosexual interest;
communicates with opposite sex; may form
“love” relationship.
3. Late adolescence: ages, 17-19 years
a. Achieves greater independence.
b. Chooses a vocation.
c. Participates in society.
d. Finds an identity.
e. Finds a mate.
f. Develops own morality.
g. Completes physical and emotional
maturity.
C. Cognitive development
1. Develops abstract thinking abilities.
2. Is often unrealistic.
3. Is capable of scientific reasoning and formal logic.
4. Enjoys intellectual abilities.
5. Is able to view problems comprehensively.
D. Nutrition
1. Nutritional requirements peak during years of
maximum growth: age 10-12 in girls, 2 years later in
boys
2. Appetite increases.
3. Inadequate diet can retard growth and delay sexual
maturation.
4. Food intake needs to be balanced with energy
expenditure.
5. Increased needs include calcium for skeletal growth;
iron for increased muscle mass and blood cell
development; zinc for development of skeletal and
muscle tissue and sexual maturation.
F. Activities:
group activities predominate (sports are important);
activities involving opposite sex by middle adolescence.
G. Fears
1. Threats to body image: acne, obesity
2. Injury or death
3. The unknown
Child’s Response to Death

1. Toddlers - may insist on seeing a significant other
long after that person’s death.
2. Preschoolers - See death as temporary; a type of
sleep or separation.
3. School-age – See death as a period of immobility.
Feel death is punishment.
4. Adolescents - Have an accurate understanding of
death.
49
50
51

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NCM 107 – CARE OF MOTHER, CHILD, ADOLESCENT (WELL CLIENTS)

CONCEPT OF PROCREATION In male: strong rhythmic muscular contraction of the

- Chromosomal abnormality in a previous child 7. Done to determine chromosomal abnormalities but

Risk: place) and round ligaments (from sides of the uterus

1. False pelvis – superior half formed by the Female Reproductive System

Did you know? PHASES OF THE MENSTRUAL CYCLE (28-day

 Graafian follicle produces increasing amount of Management:

II. OVARIAN CYCLE

2. LUTEAL PHASE (DAYS 15-28) FETAL DEVELOPMENT

SYSTEMIC CHANGES d) There is increased level of circulating fibrogen, that

C. Psychoprophylaxis – prevention of pain

PHASES OF UTERINE CONTRACTIONS CRANIAL BONES (1 FOSE, 2 PaTe)

Signs of fetal distress

SIGNS OF LABOR C. Uterine Changes

3. TRANSITION PHASE o Danger of serious intrauterine

 During this period, the uterus undergoes 2. Integumentary System

o Atony of bladder wall is caused by elevated estrogen levels. The sudden

epithelial cells, erythrocytes, leukocytes, and 5.4. Perineum

hormonal changes, fatigue or feeling of inadequacy in 4. Fourth degree - + mucous membrane of

o Perineal area is immersed in 4-6 inches of 7. Diet

10. Follow up Check Ups Specific management:

METHODS OF FAMILY PLANNING

o Mechanical DANGER SIGNS:

Cervical Cap Male

A. ESSENTIAL NEWBORN CARE- Discussed in  Increased concentration of red blood cells in

Temperature 36.5 to 37.2 Celsius

Behavioral Assessment & Other Significant

4. Newborn Screening evaluation of NBS implementation; Sustainable

When is Newborn Screening done?

1. Congenital Hypothyroidism (CH) phenylalanine. Excessive accumulation of

 most neonatal deaths with in 24 h caused by  Process of Heat Loss

2. Bathing and Changing of Diapers, Eye Prophylaxis,

Blood-flecked stools usually indicate an anal fissure

Goal of Developmental Changes

Factors Influencing Attitudes Toward - “ontogenetic functions” – specific to the

B. Roles of maturation and learning in E. Each phase of Development has

 Proximo-distal – development proceeds from  Preschool: 3 - 6 years

 Child turns to be hardheaded,

B. Psychosocial Development One of the main elements of Erikson's psychosocial

 Remember that each step builds on skills

that a strong sense of personal identity was problems.

important for developing intimate relationships.

a poor sense of self tend to have less

thought diminishes. Head lag when pulled to sitting position

Follows one – step command and gesture 4. Appetite decreases.

B. Psychosocial tasks G. Fears: separation anxiety

a. Is separate from parents (except

Child’s Response to Death

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