Maternal NCMMMM

Table of Contents
UNIT I.............................................................................................................................................................................. 6
A. Foundation of Maternal and Child Health Nursing Practices/Biophysical Aspects of
Human Reproduction ......................................................................................................................................... 6
1. The philosophy of Maternal and Child Health Nursing includes .................................................. 6
2. Goals ............................................................................................................................................................. 7
3. What is the childbearing-childrearing continuum? ..................................................................... 7
4. The 2 Pillars of the 2020 National Health Goals ............................................................................................... 7
6. The Global Health Goals of 2020 ....................................................................................................................... 7
7. Four phases of health care .................................................................................................................... 8
B. Concepts, Theories, Principles and Standards of Care ................................................................ 8
1. Common Measures to Ensure Family Centered Maternal and Child Health Care Principle
................................................................................................................................................................................... 8
2. Nursing Interventions .............................................................................................................................. 8
3. Nursing theorists .................................................................................................................................... 9
4. Standards of Care ...................................................................................................................................... 9
5. The Nursing Process ................................................................................................................................. 9
6. Evidence-Based Practice ........................................................................................................................ 10
7. Nursing research ....................................................................................................................................... 10
C. Anatomy and Physiology .......................................................................................................................... 10
1. Female Reproductive System ............................................................................................................. 10
2. Male Reproductive System ................................................................................................................. 11
3. Process of Spermatogenesis................................................................................................................. 11
D. Sexuality ......................................................................................................................................................... 12
1. Several Theories Exist Regarding the Development of Gender Identity arises from
primarily a Biologic or a Psychosocial focus. ..................................................................................... 12
2. Four discrete stages in sexual response are ................................................................................ 12
3. Types of Sexual Orientation ................................................................................................................ 13
Other Types of Sexual Expression ......................................................................................................... 13
Learning Activity ........................................................................................................................................... 14
UNIT II ....................................................................................................................................................................... 15
A. The Menstrual Cycle ................................................................................................................................... 15
2. Four body structures are involved in physiology of Menstrual Cycle ................................. 15
2. Indications of Ovulation ........................................................................................................................ 16
3. Description: Composed of four phases ........................................................................................... 16
B. Responsible Parenthood............................................................................................................................ 16
1. Family planning ........................................................................................................................................ 17
2. Reproductive Life Planning .................................................................................................................. 17
3. The concept of family planning includes these elements: ...................................................... 17
4. Purposes of Family Planning ............................................................................................................... 17
5. The ultimate goal of family planning is directed towards: ..................................................... 17
6. Advantages of family planning to the mother:............................................................................ 17
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NCM 107: CARE FOR MOTHER, CHILD ADOLESCENT (WELL CLIENTS)
BY: LUZVIMINDA D. SAMIN, PhD., R.N., EPPIE DC BUGARIN, PhD.
“UNAUTHORIZED REPRODUCTION IS PUNISHABLE BY LAW” BY: NUEVA ECIJA UNIVERSITY OF SCIENCE AND TECHNOLOGY
7. Contraception............................................................................................................................................ 18
8. Kinds of Contraceptives ........................................................................................................................ 18
9. Benefits of Oral Contraceptives are: ............................................................................................... 21
10. Side Effects ............................................................................................................................................. 21
11. Absolute Contraindications to OC’s ............................................................................................... 21
12. Possible Contraindications to OC’s ................................................................................................. 21
UNIT III ..................................................................................................................................................................... 26
A. Pregnancy-Antepartum ............................................................................................................................. 26
1. Classification of Pregnancy .................................................................................................................. 26
2. Terminologies ........................................................................................................................................... 26
3. Duration of pregnancy........................................................................................................................... 27
4. Periods of Pregnancy ............................................................................................................................. 27
5. Conditions for Fertilization ................................................................................................................... 27
B. Process of Reproduction ........................................................................................................................... 27
1. Related theories ........................................................................................................................................ 27
2. Fertilization: A Sperm and an Egg Form a Zygote..................................................................... 27
3. The Zygote Becomes an Embryo: Development Prior to and During Implantation ..... 28
4. In Eight Weeks, the Embryo Develops ........................................................................................... 28
5. Stages of Fetal Development ............................................................................................................. 28
6. Special structure in fetal development ........................................................................................... 28
7. Maternal Changes and Fetal Development..................................................................................................... 29
C. Signs and Symptoms of Pregnancy ..................................................................................................... 31
1. Manifestations : ............................................................................................................................................... 31
2. Nursing Care .............................................................................................................................................. 31
E. Alternative Methods of Birth.................................................................................................................... 36
1. Laborer method ....................................................................................................................................... 36
2. Hydrotherapy and Water Birth ........................................................................................................... 36
3. Physiological and Psychological Changes of Pregnancy ........................................................... 36
5. Developmental Task of Pregnancy .................................................................................................. 37
6. Activities During First Prenatal visit ................................................................................................. 37
7. Components of initial visit ................................................................................................................... 37
8. Leopold’s Maneuver ................................................................................................................................ 43
9. Internal Examination or vaginal examination ............................................................................... 44
10. Laboratory Test ..................................................................................................................................... 44
11. Components of Subsequent Visits ................................................................................................. 45
12. Fetal Diagnostic Test /Procedure .................................................................................................... 45
13. Schedule of clinic visits ...................................................................................................................... 50
14. Danger Signs of Pregnancy............................................................................................................... 51
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UNIT 1V ..................................................................................................................................................................... 52
A. Pregnancy Intrapartum Care .................................................................................................................. 52
1. Intrapartum period ................................................................................................................................. 52
2. Theories of labor onset ......................................................................................................................... 52
3. Signs of Impending Labor .................................................................................................................... 53
4. Variables Affecting Labor (4 P’s of labor) ...................................................................................... 53
5. 4 Types of Pelvic Shapes ...................................................................................................................... 53
6. Pelvic Divisions .......................................................................................................................................... 54
7. Affected by the following Factors in Determining the Adequacy of the Pelvic size: ..... 54
Passenger ........................................................................................................................................................ 55
The bones of the skull meet at suture lines: ..................................................................................... 55
8. Three Phases of Labor Contraction .................................................................................................... 57
9. Characteristics of Contractions .......................................................................................................... 57
10. Comparison of True and False Labor ........................................................................................... 57
11. Stages During Labor and Delivery ................................................................................................. 57
3 phases of Stage 1 ..................................................................................................................................... 58
12. Nursing Care During the First Stage of Labor ........................................................................... 58
13. Mechanism of Labor ............................................................................................................................. 59
14. Nursing Care During 2nd Stage ...................................................................................................... 60
1. Preparing place of birth ........................................................................................................................ 60
15. Two Types of Episiotomy ................................................................................................................... 61
16. Advantage of Mediolateral Episiotom............................................................................................ 61
If tearing occurs beyond the incision, it will be away from the ectum. .................................. 61
17. Advantage of median episiotomy ................................................................................................... 61
18. Signs of Placental Separation .......................................................................................................... 62
19. 2 types of placental delivery ............................................................................................................ 62
20. Local anesthesia .................................................................................................................................... 62
21. Regional blocks ...................................................................................................................................... 62
Types: ............................................................................................................................................................... 63
22. Watch for possible complications: ................................................................................................. 63
23. Postpartum PE: ...................................................................................................................................... 64
Learning Activity .......................................................................................................................................... 64
UNIT V .......................................................................................................................................................................... 65
A. Post-Partum ................................................................................................................................................... 65
1. Postpartum Biophysical Changes .......................................................................................................... 65
2. Postpartum Nursing Care ..................................................................................................................... 67
3.Postpartum Warnings Signs and Symptoms to Report to the Physicial.............................. 67
UNIT -V1 ................................................................................................................................................................... 68
1. Postpartum Psychosocial Adaptation ................................................................................................... 68
2. Normal Puerperium Changes .............................................................................................................. 68
Lochia ................................................................................................................................................................ 68
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4. Postpartum Teachings ........................................................................................................................... 70
UNIT –VII .................................................................................................................................................................. 72
A. Problem/Disorders in Mothers including Gynecologic Disorders............................................... 72
1. High Risk Maternal Conditions:.......................................................................................................... 72
2. Nursing interventions for high risk pregnancy ............................................................................ 72
3. Pregnancy Related Conditions ............................................................................................................ 72
B. Metabolic, Cardiac, Hematologic, Aberrations in pregnancy .................................................... 73
2. Heart Disease............................................................................................................................................ 75
3. Anemias of Pregnancy ........................................................................................................................... 76
C. Cellular Aberrations of the Reproductive Organs ........................................................................... 79
1. Cervical Cancer ................................................................................................................................................ 79
2. Cancer of the Uterus or Endometrial Cancer; Uterine Cancer)............................................. 80
3. Fallopian Tube Cancer ........................................................................................................................... 81
4. Reproductive cancers in Men are: .................................................................................................... 83
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Introduction
Maternal and child health (MCH) care is the health service provided to mothers (women
in their childbearing age) and children. The targets for MCH are all women in their reproductive
age groups from 15 - 49 years of age. Maternal mortality is an adverse outcome of many
pregnancies. Miscarriage, induced abortion, and other factors are causes for over 40 percent
of the pregnancies in developing countries to result in complications, illnesses, or permanent
disability for the mother or child. About 80 percent of maternal deaths are directed by
obstetric Maternal and Child Health Care 2 deaths. The result "from obstetric complications of
the pregnant state (pregnancy, labor, and puerperium), from intervention, omissions,
incorrect treatment, or from a chain of events resulting from any of the above.
The slowing down of the rate of decline in maternal and child mortality in the
Philippines places the country at risk of missing its Millennium Development Goal targets of
reducing maternal and child mortality. To ensure the rapid reduction of maternal and child
mortality, the Department of Health (DOH) issued Administrative Order 2008-0029 entitled:
Implementing Health Reforms for the Rapid Reduction of Maternal and Neonatal
Mortality. This Manual of Operations (MOP) for the MNCHN strategy is intended to guide
Local Government Units (LGUs) in designing approaches to deliver MNCHN services, especially
to populations that are most at risk from maternal and child deaths. In recognition of the
differences in local conditions and constraints, the LGU design the implementation of the
MNCHN strategy. The strategy aims to achieve the following intermediate results: 1. Every
pregnancy is wanted, planned, and supported; 2. Every pregnancy is adequately managed
throughout its course; 3. Every delivery is facility-based and managed by skilled birth
attendants/experienced health professionals; and 4. Every mother and newborn pair secures
proper post-partum and newborn care with smooth transitions to the women’s health care
package for the mother and child survival package for the newborn. This Manual of Operations
(MOP) is an updated version of the MOP
There is now also abundant evidence that family planning is one of the most important
means of improving the health of mothers and children. Maternal-child health and family
planning seem to fit naturally together. For many years, the importance of family planning
for health as well as for socio-economic development was largely ignored. The intensive effort
has been required in implementing family planning services successfully to catch up with other
development activities. Efforts are continuing to improve access to and utilization of health,
family welfare, and nutrition services with a particular focus on under-served and under-
privileged segments of the population. Technological improvements and increased access to
health care have resulted in a steep fall in the mortality rate.
Nurses and other health care providers play an important role and must be
knowledgeable in giving health education to all women in childbearing age and updated on
the DOH programs.
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UNIT I
Learning Objectives
At the end of the unit, I can:
1. explain the Concepts, Theories, Principles, and Standards of care.
2. can use the Nursing process to provide nursing care for maternal and child clients.
3. can describe the Anatomy and Physiology of the female reproductive organ associated
with conception and pregnancy.
4. can understand the type of sexual expression
Pre-activity: Case Scenarios
Case 1
Instructions: For no.1-Question enumerate them and for
no.2-Question; Write in matrix form.
1. What are the purposes of Standards of care in nursing? (10pts)
2. What is the difference between Standard of Nursing Practice and Standard of Care?
(15pts)
Case2-Health promotion
Scenario:
A nurse is giving nutrition counseling to a patient who is 18weeks pregnant. The nurse
tells her that the ideal pregnancy weight gain is around 35pounds. The patient says,” Do
not weigh the baby when he/she is just 6-7pounds? What is the nurse's best response?
1. ” That’s true, but let me explain where the additional weight is distributed.”
2. ” Please don’t worry about that now. We want you to concentrate on eating well”.
3. ” It may sound like a lot of weight, but it is essential for your baby’s health.”
4. ” Are you concerned about your baby image?
Case 3-Phases of Health Care

Instruction: Question no.1 Discuss in 150 words but not less than 100 (15pts.)
1: Why everyone should be concerned about Global Health Issues?
2. Enumerate global health goals and explain why is it important (briefly explanation each
goal) (15pts.)
Case 4 Scenario
Question: Cristy tell the nurse, she is worried about her breast, she might be sub fertile. To
increase her self- esteem to meet her learning needs, how could you assure her from the
given fact? Choose the answer below:
1. Adrenarche, the development of the breast, typically occurs before the first
menstrual period.
2. Breast development or menarche is not fully complete until about age 25.
3. The time for the development of breast varies a great deal and is termed thelarche
4. Menarche, the term for breast development, typically occurs between 12years of
age.
A. Foundation of Maternal and Child Health Nursing Practices/Biophysical Aspects

of Human Reproduction
Essential maternity information int the overall continuous of nursing care to show how to
provide safe care in the clinical setting.
1. The philosophy of Maternal and Child Health Nursing includes
1 Maternal and child health nursing is family-centered.

2 Maternal and child health nursing is community-centered.
3 Maternal and child health nursing is research-oriented.
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Both nursing theory and evidence-based practice provide afoundation for nursing care
4 The Maternal and child health nurse serves as an advocate.
5 Maternal and child health nursing includes a high degree of independent nursing functions.
6 Maternal and child health nursing is a challenging role for a nurse and is a significant
factor in promoting high-level wellness in families.
2. Goals
1. The Primary purpose of maternal and child health nursing is the promotion and
maintenance of optimal family health to ensure cycles of optimal childbearing and
childrearing. The range of practice includes:
A. Pre conceptual health care
1.Care of women during three trimesters of pregnancy and the puerperium.
2. Care of children during the perinatal period (6 weeks before conception to 6 weeks after
birth)
3. Custody of children from birth through adolescence
4. Care in settings as varied as the birthing room, the pediatric intensive care unit, and the
home in all environments and types of care, keeping the family at the center of
care delivery is an essential goal.
3. What is the childbearing-childrearing continuum?
The continuum for maternal, newborn and child health usually refers to the continuity
of individual care. It is the population level or public-health framework based on integrated
service delivery throughout the life cycle and promote health for mothers, babies and children.
1. The provision of preconceptual health care- care receive before pregnancy- can be
expensive, not covered until pregnant, having fertility issues, pay for fertility
2. Provision of nursing care of women throughout pregnancy, birth, and postpartum.
3. Provision of nursing care to families in all settings.
4. The 2 Pillars of the 2020 National Health Goals are:
1. Increase quality and years of healthy life

2. Eliminate health discrepancies
5. The New Objectives Recommend as Part of Healthy 2020
The new objectives of healthy 2020 that all pre licensure programs in nursing include core
content on:
1. Counseling for health promotion and disease prevention
2. Cultural diversity
3.Evaluation of health sciences literature
4. Environmental health
5.Public health nursing
6. Global health
6. The Global Health Goals of 2020
Global health goal is to improve public health, straighten our national security through global
disease detection, response prevention and control strategies. Overview, why is global health
important? Understanding global health emerging issues in global health.
1. End poverty
2. Achieve universal primary education
3. Promote gender equality and empower women
4. Reduce child mortality
5. Improve maternal health
6. Combat HIV/AIDS, malaria and other diseases
7. Ensure environmental sustainability
8. Develop a global partnership for development
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7. Four phases of health care are:
1. Health promotion
Educating parents and children to follow health practices through teaching and role
modeling
Ex. Teaching women the importance of rubella immunization before pregnancy;
teaching adolescents the importance of safer sex practices
2. Health Maintenance
Intervening to maintain health when risk of illness is present
Ex. encouraging women to be partners in prenatal care; teaching parents the
importance of safe-guarding their home by childproofing against poisoning
3. Health Restoration
Using conscietious assessment to be certain that symptoms of illness are identified
and interventions are begun to return client to wellness most rapidly
ex. Caring for a woman during a complication of pregnancy such as gestational
diabetes or a child during an acute illness such as pneumonia
4. Health Rehabilitation
Helping prevent complications from illness; helping a client with residual effects
achieve an optimal state of wellness and independence; helping a client to accept
inevitable death
Ex. encouraging a woman with gestational trophoblastic disease (abnormal
placenta growth) to continue therapy or a child with a renal transplant to continue
to take necessary medications.
B. Concepts, Theories, Principles and Standards of Care
1. Common Measures to Ensure Family Centered Maternal and Child Health Care
Principle
A nursing theory is asset of concept definition, relationship and assumptions or propositions
derived from nursing models or from other disciplines and project a purposive, systematic
view of phenomena by designing specific inter-relationships among concepts for the purpose
of describing explaining predicting and for prescribing
1. The family is the basic unit of society.
2. Families represent racial, ethnic, cultural, and socioeconomic diversity
3. Children grow both individually and as part of a family.
2. Nursing Interventions
The actual treatment and action thatcare perforemnd to help patient to reach the goals
that are set for them. Nurses uses him or her knowledge, experience and critical thingking
skills to descide which intervention will help the patient the most
1. Consider the family as a whole as well as its individual members.

2. Encourage families to reach out to their community so that family members are not
isolated from their community or from each other.
3. Encourage family bonding through rooming-in in both maternal and child health
hospital settings.
4. Participate in early hospital discharge programs to reunite families as soon as
possible.
5. Encourage family and sibling visits in the hospital to promote family contacts
6. Assess families for strengths as well as specific needs or challenges
7. Respect diversity in families as a unique quality of that family.
8. Encourage families to give care to a newborn or ill child.
Include developmental stimulation in nursing care.
9. Share or initiate information on health planning with family member so that care is
family oriented.
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3. Nursing theorists
This term given to the body of knowledge used to support nursing practice, and is the
framework to organize and explain phenomena in nursing at a more concrete and specific
level.
1. Offer helpful ways to view clients so that nursing activities can best meet client
needs—for example, by seeing a pregnant woman not simply as a physical form but
as a dynamic force with important psychosocial needs.
2. Another issue most nursing theorist address is how nurses should be viewed or what
the goals of nursing care should be.
3. The previous goal of nursing care could have been stated as “Providing care and
comfort to injured and ill people.”
4. Most nurses today are equipped to fill these expanded roles to do preventive care,
health promotion as a major nursing goal, teaching, counseling, supporting, and
advocacy are also common roles.
4. Standards of Care
To promote consistency and ensure quality nursing care and outcomes in these areas,
specialty organizations have developed guidelines for care in their specific areas of nursing
practice.
Standard I: Quality of Care The nurse systematically evaluates the quality and effectiveness
of nursing practice.
Standard II: Performance Appraisal The nurse evaluates his/her own nursing practice in
relation to professional practice standards and relevant statutes and regulations.
Standard III: Education The nurse acquires and maintains current knowledge in nursing
practice.
Standard IV: Collegiality The nurse contributes to the professional development of peers,
colleagues, and others.
Standard V: Ethics The nurse’s decisions and actions on behalf of patients are determined in
an ethical manner.
Standard VI: Collaboration The nurse collaborates with the patient, significant others, and
health care providers in providing patient care.
Standard VII: Research The nurse uses research findings in practice.
Standard VIII: Resource Utilization The nurse considers factors related to safety,
effectiveness, and cost in planning and delivering patient care.
Standard IX: Practice Environment The nurse contributes to the environment of care delivery
within the practice settings.
Standard X: Accountability The nurse is professionally and legally accountable for his/her
practice. The professional registered nurse may delegate to and supervise qualified personnel
who provide patient care.
5. The Nursing Process
Using an organized series of steps, to ensure quality and consistency of care (Carpenito,
2007).
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The nursing process is a form of problem solving based on the scientific method, serves as
the basis for assessing, making a nursing diagnosis, planning, organizing, and evaluating
care.
The nursing process is applicable to all health care settings, from the prenatal clinic to the
pediatric intensive care unit.
6. Evidence-Based Practice
Is the conscientious, explicit, and judicious use of current best evidence in making decisions
about the care of patients and can be a combination of research and clinical expertise.
The worth of evidence is ranked according to:
Level I: Evidence obtained from at least one properly designed randomized controlled trial.
Level II: Evidence obtained from well-designed controlled trials without randomization, well-
designed cohort or case-control analytic studies, or multiple time series with or without an
intervention.
Level III: Opinions of respected authorities, based on clinical experience, descriptive studies,
or reports of expert committees
7. Nursing research
The controlled investigation of problems that have implications for nursing practice, provides
evidence and justification for implementing activities for outcome achievement
A classic example of how the results of nursing research can influence nursing practice is the
research carried out by Rubin (1963) on nurses assumed that a woman who did not
immediately hold and cuddle her infant at birth was a “cold” or unfeeling mother. After
observing a multitude of new mothers, Rubin concluded that attachment is not a spontaneous
procedure; rather, it more commonly begins with only fingertip touching
C. Anatomy and Physiology

To distinguish between anatomy and physiology and identify several branches of each,
describe the structure of the body regions and directions in the body
1. Female Reproductive System
A. External Genitalia
1. Vulva
2. Mons Pubis (Mons Veneris)
3. Labia Majora (large lips)
4. Labia Minora (nymphaea)
5. Clitoris
6. Fourchette
7. Vestibule
8. Urinary meatus
9. Skene’s (Paraurethral gland)
10. Bartholin’s (Paravaginal)
11. vaginal orifice
12. hymen
13. perineum
B. Internal Genitalia
1. vagina:
2. Uterus:
3. Ovaries
4. Fallopian tube
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2. Male Reproductive System
A. External
1. Penis:
2. Scrotum
B. Internal structures
1. Testes
2. Epididymis:
3. Vas deferens
4. Seminal
5. Ejaculatory Duct
6. Prostate Gland
7. Bulbourethral Gland
8. Urethra
3. Process of Spermatogenesis
(*sperm maturation begins at 13 years old*)

Testes – produce sperm cell and responsible for the production of the male hormone;
testosterone.
Leydig’s cells – produce sperm cell
Sertoli cells – nourished the sperm cells; “nurse cells”
Stimulates APG (Anterior pituitary gland) = secrete FSH & LH = stimulates

seminiferous tubules to produce spermatozoa
Epididymis – maturation of the sperm cell occurs. ( 12- 24 days)
Vas deferens – passageway of the matures sperm.
Seminal vesicle – produce sugar fluid known as fructose to increase motility.
Ejaculatory duct – passageway
Prostate gland – secretes fluid that lubricates and nourished sperm cell.
Cowper’s gland – bulbourethral gland - Secretes alkaline fluid that helps

counteract the acid secretion of the urethra and ensure the safe passage of
the spermatozoa.
Urethra – a hollow tube leading from the base of the bladder continues to the
outside through the shaft and glands of the penis. 8 inches long
OUT
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D. Sexuality
It is a multidimensional phenomenon that includes feelings, attitudes, and actions. It has both
biologic and cultural components. It encompasses and gives direction to a person’s physical,
emotional, social, and intellectual responses throughout life.
Biologic gender is the term used to denote a person’s chromosomal sex: male (XY) or female
(XX).
Gender identity or sexual identity is the inner sense a person has of being male or female,
which may be the same as or different from biologic gender.
Gender role is the male or female behavior a person exhibits, which, again, may or may not
be the same as biologic gender or gender identity.
1. Several Theories Exist Regarding the Development of Gender Identity arises

from primarily a Biologic or a Psychosocial focus.
a) The amount of testosterone secreted in utero (a process termed sex typing) may affect
how gender develops.
b) Role models portray their gender roles may also influence how a child envisions himself
or herself.
c) Gender role is also culturally influenced.
2. Four discrete stages in sexual response are
1. excitement,
2. plateau,
3. orgasm,
4. resolution.
Excitement It occurs with physical and psychological stimulation (i.e., sight, sound,
emotion, or thought) This leads to arterial dilation and venous constriction in the genital
area leading to vasocongestion and increasing muscular tension.
1. In women, this vasocongestion causes the clitoris to increase in size and mucoid fluid
to appear on vaginal walls as lubrication.
2. The vagina widens in diameter and increases in length. c. The nipples become erect.
3. In men, penile erection occurs, as well as scrotal thickening and elevation of the testes.
4. In both sexes, there is an increase in heart and respiratory rates and blood pressure.
Plateau: stage is reached just before orgasm.
1. In woman, the clitoris is drawn forward and retracts under the clitoral prepuce; the
lower part of the vagina becomes extremely congested (formation of the orgasmic
platform), and there is increased nipple elevation.
2. In men, the vasocongestion leads to distention of the penis. heart rate increases to
100 to 175 beats per minute and respiratory rate to approximately 40 respirations per
minute.
Orgasm :
It occurs when stimulation proceeds through the plateau stage to a point at which the body
suddenly discharge accumulated sexual tension.
Resolution:
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It is a 30-minute period during which the external and internal genital organs return to an
unaroused state
3. Types of Sexual Orientation
A person’s sexual orientation is their emotional and erotic attraction toward another individual
and is generally defined but the sex of the person that an individual is sexually and emotionally
attracted (Brohan, 1996)., includes heterosexual, lesbian, gay and bisexual orientation.
Heterosexuality is a person who finds sexual fulfillment with a member of the opposite
gender.
Homosexuality is a person who finds sexual fulfillment with a member of his or her own sex.
Many homosexual men prefer to use the term “gay.” “Lesbian” refers to a homosexual woman.
Bisexuality if they achieve sexual satisfaction from both homosexual and heterosexual
relationships. Like men who have sex with men, bisexual men may be at greater risk for HIV
and STIs than are others.
Trans-sexuality or transgender person is an individual who, although of one biologic gender,

feels as if he or she is of the opposite gender. Such people may have sex change operations
so that they appear cosmetically as the gender they feel that they are.
Other Types of Sexual Expression
There are people who are heterosexual are romantically and physically attracted to members
of the opposite sex. Heterosexual males are attracted to females, and hetero sexual females
are attracted to males.
Sexual Abstinence (celibacy) is separation from sexual activity). It is the avowed state of
certain religious orders. It is also a way of life for many adults and one that is becoming
fashionable among a growing number of young adults.
Masturbation is self-stimulation for erotic pleasure.
Erotic Stimulation is the use of visual materials such as magazines or photographs for
sexual arousal.
Fetishism is sexual arousal resulting from the use of certain objects or situations. Leather,
rubber, shoes, and feet are frequently perceived to have erotic qualities.
Transvestism is an individual who dresses in the clothes of the opposite sex. Transvestites
can be heterosexual, homosexual, or bisexual.
Voyeurism is obtaining sexual arousal by looking at another person’s body. Almost all
children and adolescents pass through a stage when voyeurism is appealing.
Sadomasochism involves inflicting pain (sadism) or receiving pain (masochism) to achieve

sexual satisfaction.
Other Types of Sexual Expression
Exhibitionism: is revealing one’s genitals in public.
Bestiality: is sexual relations with animals.
Pedophiles: are individuals who are interested in sexual encounters with children. Known
pedophiles are registered as sex offenders.
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Learning Activity
Nursing role in the Reproductive and Sexual health.
Case#1Scenario
1.Samantha and Joshua de Guzman, a young adult couple, planned to have a baby soon as
they married. However, it took Samantha 1year before she conceived. Now,12 weeks
pregnant, she comes to your clinic for a parental visit. In tears she states.” My husband is not
interested in me anymore. We have not had sex since I became pregnant.” Joshua states,” I
am afraid I’ll hurt the baby.”
Instruction: Explain your answer in 5-7 sentences in each question.
1. How to educate children, women, and their partners, about anatomy, physiology
and sexuality to better prepare them for childbearing and child rearing?
2. How would you counsel Samantha and Joshua de Guzman?
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UNIT II
Learning Objectives
At the end of the unit, Iam able to

1. describe the menstrual cycle;
2. know the four major developmental tasks associated with the psychological adaptation to
pregnancy;
3. know the advantages of family planning;
4. know what both men and womn need for effective family planning; and
5.understand what family planning means.
A. The Menstrual Cycle

For menstrual cycle to be complete, all four structures must contribute their part Therefore,
inactivity of any parts results in an incomplete or ineffective cycle.
1. Definition of Terms
To explain the meaning, rationale as used in the study, social constructionism to introduce
the standard definition of terms also refers to a detailed explanation of the technical terms
and measurements used during data collection.
Menstruation is a periodic discharge of blood, mucus and epithelia cell from the
uterus.
Menstrual cycle is a beginning of menstruation to the beginning of the next
menstruation.
Menarche is the first menstruation in women
Dysmenorrhea is a severe pain during menstruation
Metrorrhagia is the complete bleeding at completely irregular interval
Menorrhagia is the excessive bleeding during menstruation
Amenorrhea a is the bsence of menstruation leading to pregnancy
Menopause is the end of menstruation/ Cessation of menstruation
2. Four body structures are involved in physiology of Menstrual Cycle
Here is what we have learned from the 4 major organs in the human body in a single
structure but it is made up of billions of smaller structures of four major kinds.
1. Hypothalamus: produces GnRH or Gonadotropin Releasing Hormone to stimulate the
anterior Pituitary gland.
2. Anterior Pituitary Gland: secretes Gonadotropins (FSH and LH); stimulates the ovary
(estrogen and progesterone)- if estrogen/progesterone increase in blood vessels, this gives
positive feedback to the hypothalamus to decrease all hormones
3. Ovaries -After an upsurge of LH, the graafian follicle raptures and the ovum is set free
from the ovary, called ovulation and swept into an open end of a fallopian tube, the FSH has
done its work and now decreases its amount. it occurs approximately on the 14th day before
the onset of the next menstrual cycle. Because ovulation happens at the midpoint of a 28-
day cycle. (16-20 weeks)
If conception does not occur, the unfertilized ovum atrophies after 4 days and the corpus
luteum remain for only 8-10 days and regresses. stimulation from the hormones produced by
the ovaries causes specific monthly effects on the uterus and uterine changes occur during
the menstrual cycle.
th
Example: if the cycle is only 20 days long 20-14=6 day of ovulation not the 10 or middle
day
4. Uterus: If conception occurs, the fertilized ovum implants on the endometrium of the
uterus, the corpus luteum remains throughout
If conception does not occur, the unfertilized ovum atrophies after 4 days and the corpus
luteum remain for only 8-10 days and regresses. stimulation from the hormones produced by
the ovaries causes specific monthly effects on the uterus. From ovulation to the beginning of
P a g e 15 | 84
the next menstrual cycle is usually 14 days. In other words, ovulation occurs 14 days before
the next menstrual cycle. Sperms lives approximately 3 days and eggs live about 24 hours.
A couple must avoid unprotected intercourse for several days before the anticipated ovulation
and for 3 days after ovulation in order to prevent pregnancy. Episodic uterine bleeding in
response to cyclic hormonal changes. Purpose is to bring an ovum to maturity and renew a
uterine tissue bed, if fertilization occurs
Menstrual flow is composed of:

Human ovary undergoing evolution. The menstrual cycle describes the female human
reproductive cycle. This is cycle endocrine regulated change in female anatomy and
physiology that occur over 28 days, 4 weeks, a lunar month, during reproductive life between
puberty an menopause.
1. Blood from ruptured capillaries
2. Mucin from the glands
3. Fragments of the endometrial tissue
4. The microscopic, atrophied, unfertilized ovum.
The mean age for menarche is 12.87 years or 1-3 years after breast budding. Pregnancy can
occur from the very first menstrual cycle, most women have ovulatory. The menstrual phase
varies in length for most women. Average period: 5 days. Average cycle 28 days. Normal
Blood Loss: 50 cc. Menses is actually the end of an arbitrary defined menstrual cycle.
2. Indications of Ovulation
There is slight drop in temperature one day prior to ovulation with a one-half to one
degree rise in temperature at ovulation that remains elevated for 12-14 days. Cervical mucus
is abundant, watery, clear and more alkaline. Cervical os dilates slightly, softens and rises in
the vagina. Presence of Spinnbarkeit (egg-white stretchiness of cervical mucus) and Ferning
under microscope
3. Description: Composed of four phases
It is the process in which the nucleus of eukaryotic cell divides, during this process
sister chromatids separate from each other and more to opposite roles of the cell. This
happens in 4 phases called Prophase Metaphase and Telophase.
1. Menstrual Phase -Days 1-5 cycle. Shedding of the endometrium occurs as uterine
bleeding, approximately 50 to 60 ml (<2 ounces).
2. Proliferative (Follicular) Phase -Day 5 of ovulation. Endometrium is restored under

primary hormone influence of estrogen. In this preovulatory phase, FSH is secreted
by the anterior pituitary. Preovulatory surge of LH affects one follicle and ovulation
occurs.
3. Secretory Phase -Ovulation to approximately 3 days before menstrual cycle.

Estrogen Levels off and progesterone lvel increase
4. Ischemic Phase -If fertilization did not occur, the corpus luteum degenerates and
estrogen and progesterone levels drop off causing the endometrium to become “blood
starved” leading to menstruation.
B. Responsible Parenthood
A responsible person is a man or woman who is able and willing to give the proper response
to the demands of a given situation.
with specific reference to marriage and family life.
The responsible spouse is one who gives the proper responses to the needs of his/ her
spouse, as well as his own, and of their life together.
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Responsible parents give proper responses to the needs of their children.
1. Family planning
refers more specifically to the voluntary and positive action of a couple to plan and
decide the number of children they want to have and when to have them.
2. Reproductive Life Planning
Includes all decisions an individual or couple make about having children:

1. If and when to have children
2. How many children to have
3. How children are spaced
3. The concept of family planning includes these elements:
a. Responsibility of parents to themselves and to each other

b. Responsibility to their present and future children
c. Responsibility to their community and country
4. Purposes of Family Planning
1. improvement of health
2. promotion of human right to determine reproductive performance
3. relation of demographic change to economic development
5. The ultimate goal of family planning is directed towards:
a. Birth spacing, to allow the mothers time to rest and regain their health before
the next pregnancy
b. Birth limitation, when the desired number of children is reached
c. Helping those who do not have children to have children
6. Advantages of family planning to the mother:
It provides many benefits to mothers, children father and family enables her to regain
her health after delivery, gives enough time, opportunity to love, provide attention to her
husband, children gives more time for her family and personal advancement.
1. Enables the mother to regain her health after the delivery

2. b. Gives mother enough time and opportunity to love and provide attention to
her husband and children
3. Provides mother who has chronic illness enough time for treatment and
recovery without further exposure to the physiologic burden of pregnancy
4. Prevents high risk pregnancy
5. Gives mother more time to herself, family and community
To the children
The practice of family planning will make them healthier, happier, feel wanted and
satisfied, secure
To the fathers:
1. Lightens his burden and responsibility in supporting his family
2. Enables him to give his children a good home, good education and better
future
3. Enables him to give his family a happy and contented life
4. Gives him time for his personal advancement
5. Provides a father who has chronic illness enough time for treatment and
recovery from his illness
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To the family:
1. Gives the family members more opportunity to enjoy each other’s company
with love and affection
2. Enables the family to save some amount for improvement of standard of
living, and for emergencies
To the community
1. Improves the economic and social status of the community
2. Better job opportunities
3. Health status will improve
4. Extra resources in the community (less congestion, less pollution, potable water
supply, etc)
5. Members will have more time to socialize with each other; to participate in socio-
civic activities.
7. Contraception
Is any device used to prevent fertilization of an egg leading to pregnancy? In the United
States, 40 million women use some form of contraception, 65% of women of childbearing
age.
The Considerations are:

1. Personal values
2. Ability to use method correctly
3. How method will affect sexual enjoyment
4. Financial factors
5. Status of couple’s relationship
6. Prior experiences
7. Future plans
8. Contraindications
8. Kinds of Contraceptives
In the current way of contraceptive methods there is no method that is explicitly intended to
prevent pregnancy among women who have been exposed to unprotected sex.
1. Natural methods
a. rhythm method or calendar method
b. basal body temperature
c. billings method or cervical mucus method
d. coitus interruptus or withdrawal
e. lactation Amenorrhea method
2. Hormonal methods
a. oral contraceptives
b. injected or implanted steroidal contraceptive
3. Barrier methods
A. Chemical barriers
a. spermicides
b. gels
c. vaginal suppositories
d. sponges
B. Mechanical barriers
a. condoms
b. cervical cap
c. diaphragm
4. Intrauterine device (IUD)
5. Permanent methods
P a g e 18 | 84
a. tubal ligation
b. Vasectomy
2. Natural Family Planning Method

Refers to a non-chemical or foreign material into the body. Failure rate of
approximately 25%.
1. Fertility Awareness Methods
2. Calendar (rhythm) method
3. Basal body temperature
4. Cervical mucus (Billings) method
5. Symptothermal method
6. Ovulation awareness
7. Lactation amenorrhea method
1. Calendar/ Rhythm (Natural Family Planning)

Teaching – fertile period may be determined by a drop in the basal body
temperature before and a slight rise after ovulation and/ or by a change in
cervical mucus from thick, cloudy and sticky during nonfertile period to more
abundant, clear, thin, stretchy and slippery as ovulation occurs. Entails keeping
a day-by-day record of your cycle for 6 consecutive months noting the onset of
bleeding as day 1 and the last day before your next menstrual bleeding as the
final day of your cycle. This 6 month record will show you your longest and
shortest cycles- from which you can calculate your FERTILE days. The first day
of menstrual bleeding (day 1 of your period) counts as the first day of the cycle.
Approximately 14 days (or 12 to 16 days) before the start of the next period,
an egg will be released by one of the ovaries. While the egg from the woman
lives for only around 24 hours, sperm from the man can survive for up to 3 days,
possibly longer. First unsafe day: subtract 18 from the number of days in
Last unsafe day: subtract 11 from the number of days in your longest cycle.
Ex: shortest: 26 – 18 = day 8
longest: 31 – 11 = day 20
UNSAFE PERIOD!! Days 8 -20, avoid coitus or use a contraceptive during this
period.
2. Coitus Interruptus
Is a periodic abstinence from intercourse during fertile period; based on the regularity of
ovulation; variable effectiveness,. The oldest method. Couple proceeds with coitus until the
moment of ejaculation, then the man withdraws and spermatozoa are emitted outside the
vagina. Offers little protection because ejaculation may occur before withdrawal is complete
and despite the care used, spermatozoa may be deposited in the vagina.
3. Basal Body Temperature

Involves taking the temperature every morning BEFORE the woman gets out of bed and
recording it. The temperature drops slightly 24 hours before ovulation, then rises to about
half a degree higher than normal and remains thus for up to three days: UNSAFE period!
Not a very efficient method unless combines with calendar and mucus methods. there are
factors that affect BBT :Sore throat, cold, flu, fever, toothache, vomiting, diarrhea, Anxiety,
medications, travel, sleep disturbance, alcoholic beverages.
4. Cervical Mucus Billings Method

Involves becoming aware of the normal changes in the cervical secretions that occur
throughout your cycle by inserting the forefinger into the vagina first thing in the morning. A
few days after menstrual bleeding, there is little secretion, vagina is dry and gradually,
secretion increases and becomes thicker, cloudy white and sticky. As ovulation approaches,
this secretion or mucus becomes copious, clear, thin, less viscous, more liquid, slippery or
stringy; as soon as this change begins and for 3 full days later: UNSAFE PERIOD
How to check
1 Begin checking the mucus:
a. when the menstrual bleeding ends or becomes light enough for you to be
able to see mucus
b. if there is no prior sexual intercourse
c. if a woman is not sexually stimulated
P a g e 19 | 84
2. Checking sensation of wetness or dryness:
While standing. Inspect underwear regularly for the presence of mucus, wipe
with the middle or index finger and the thumb test for the consistency,
slipperiness, stretchiness of the mucus. Observe also it’s color.
Cervical Changes
1 Spinnbarkeit test
Cervical mucus is thin, watery and can be stretched into long strands means
there is high level of estrogen and ovulation is about to occur.
2. Ferning or arborization of cervical mucu
At the height of estrogen stimulation just before ovulation
Ferning is due to crystallization of sodium chloride on mucus fibers
Client Instructions:
During fertile period – mucus is abundant, slippery, watery, thin and stretchable.
It has a ferning pattern when viewed under the microscope. As soon as you notice
changes in your mucus, consider yourself fertile. Avoid sexual intercourse.
During infertile period – mucus is thick, scant, yellowish or absent. Sexual
intercourse is allowed.
5. Sympto - thermal method

Combines BBT and cervical mucus methods. The woman takes her temperature daily,
watching for the rise in temperature that marks ovulation. She also analyzes her cervical
mucus daily.
Abstain from intercourse until 3 days after the rise in temperature or the fourth day after the
peak of mucus change.
6. Lactation amenorrhea method

As long as a woman is breastfeeding an infant, there is some natural suppression of
ovulation.Not dependable- woman may be fertile even if she has not had a period since
childbirth. After 6 months, she should use another method of contraception. The effectivity of
this method is greatly dependent on the frequency & duration of sucking. When the baby
sucks the breast & nipple, the nerves in the mothers’ breast send messages to the brain. The
greater the frequency & duration of sucking the more pronounced the suppression of ovulation
due to constant secretion of prolactin. Thus, when a woman breastfeeds her baby she is
unlikely to ovulate. The LAM is considered to be 98 % effective when all the following
conditions are present if she is fully breastfeeding, amenorrheic and within 6 months’
postpartum period.
2. Hormonal Methods
1. Oral Contraceptives
Composed of varying amounts of estrogen combined with small amount of
progesterone. 99% effective. Estrogen suppresses FSH and LH, thereby
suppressing ovulation. Progesterone decreases the permeability of cervical
mucus
Effects on the cervical mucus

Tracking your cervical mucus for either fertility or contraceptive is inexperience
and doesn’t have ant side effects. Some women choose to use the cervical mucus
method for of fertilization and protects the cervical mucus known as multifactorially
determined filtering system.
1. The pill makes the cervical mucus thick, scanty & cellular so that sperms
have difficulty in penetrating it & reaching the uterus.
2. Prevention of implantation due to the effect of progestin on the
endometrium.
Effects on the sperm

Capacitation, the activation of enzymes that permit the sperm to penetrate the
ovum, maybe inhibited. This makes the sperm unable to penetrate and fertilize
the ovum.
P a g e 20 | 84
Types of Oral Contraceptives
6. Monophasic
Fixed doses of estrogen and progesterone; 21-28 day cycle.The preparation may
come w/ 21 tablets thus with a seven day pill free interval/ seven iron/ vitamin
tablets substituted for that interval. Safe & effective method of birth control and
are close to100% (98%), effective but the actual rate is lower because of poor
compliance in women.
7. Biphasic
There is constant amount of estrogen with increased progesterone
8. Triphasic
Varying levels of estrogen and progesterone
Note: if pill is missed, take it as soon as remembered and take the next dose at the
usual time, if 2 pills are missed, take2 pills for 2 days and use alternate method of
contraception for next 7 days. If more than 2 pills or more are missed in the 3rd week,
quit pills for that cycle and use alternate method.
9. Benefits of Oral Contraceptives are:
Decreased incidences of:

Dysmenorrhea
Premenstrual dysphoric syndrome
Iron deficiency anemia
Acute PID with tubal scarring
Endometrial and ovarian cancer and ovarian cysts
Fibrocystic breast disease
10. Side Effects
Over the past 30 years oral contraceptive have become one of the most intensively studied
drugs in history. Consumer information about the medication. Oral contraceptives include
side effects, during interaction recommended dosages and storage information. Read more
about the prescription drug orally.
Nausea, weight gain, headache, breast tenderness, breakthrough bleeding, monilial vaginal
infections, mild hypertension, Depression
11. Absolute Contraindications to OC’s
When considering the use of birth control pills, absolute and relative contra indication include;
thrombophlebitis disorders, cerebro or coronary disease.
Breastfeeding, family history of CVA or CAD, history of thromboembolic disease, history of

liver disease, Undiagnosed vaginal bleed
12. Possible Contraindications to OC’s
Contra indications to use include cerebrovascular disease and coronary artery disease,
a history of deep vein thrombosis, pulmonary embolism or congestive heart failure, untreated
HPN diabetes with vascular complications, estrogen dependent neoplasia, breast cancer,
undiagnosed vaginal bleeding.
Age 40+
Breast or reproductive tract malignancy
Diabetes Mellitus
Elevated cholesterol or triglycerides
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High blood pressure
Migraine or other vascular type headaches
Obesity
Pregnancy
Seizure disorders
Sickle cell or other hemoglobinopathies
Smoking
Use of drug with interaction effect
Other Contraceptives:
Contraception defined as the intentional prevention of conception through the use of

various devices, sexual practices, chemicals, drugs or surgical procedures. Thus, any or act
to prevent a woman from becoming pregnant can be considered as contraceptive.
Continuous or extended regimen pills
Mini-pills
Estrogen-progesterone patch
Vaginal rings
1. Estrogen-progesterone patch
Highly effective, weekly hormonal birth control patch that’s worn on the skin.
Combination of estrogen and progestin. It is absorbed on the skin and then
transferred into the bloodstream. Can be worn on the upper outer arm,
buttocks, upper torso or abdomen. Worn for 1 week, replaced on the same day
of the week for 3 consecutive weeks. No patch-4th week.
2. Emergency Postcoital Contraceptives

The “Morning-after pills”. High level of estrogen. Must be initiated within 72
hours of unprotected intercourse.
How to take the pill:

Take 1 pill every day, always start your pill on the day one of your
menstruation. Those taking a 21day pill have a 7day pill free period then start
taking the ist pill om the next pack. For the 28-day pill start the next day after
all 28 pills have been taken. There is no pill free.
3. Subcutaneous implants (eg, Norplant)

6 nonbiodegradable Silastic implants with synthetic progesterone embedded
under the skin on the inside of the upper arm.
Slowly release the hormone over the next 5 years.
Suppress ovulation, stimulating thick cervical mucus and changing the
endometrium so implantation is difficult.
4. Intramuscular injections
Administered every12weeks, and contain Medroxy progesterone (depo
provera). 100% effective.
Advantages
1. Highly effective (99.6%)
2. Safe, convenient, easy to use
3. Can be used by breast feeding mothers
4. Does not interfere w/ intercourse. Easily administered by non – physician
5. Does not contain estrogen, so that the heart & blood- clotting effects do
not occur.
6. Rapidly effective
Disadvantages
1. Menstrual irregularities maybe experienced
2. weight gain in some women due to increase in appetite
P a g e 22 | 84
3. Mechanical barrier
1. Intrauterine Devices
A T-shaped plastic device with copper. With progesterone.
Must be fitted by physician, nurse practitioner or midwife. Insertion is
performed in ambulatory setting after pelvic examination and pap smear.
Device is contained within uterus with a string protrudes into vagina.
Effective for 5-7 years (mirena typ.e) or 8 years (Copper T380).
Mechanism of Action
1. Inactivating the sperm due to the action of the copper.
2. interfering w/ the transport of sperm in the genital tract due to the
production of prostaglandin & enzymes.
3. Seeding the ovum’s transport through the fallopian tubes.
Effectiveness: 98-99%.
Precautions: The IUD should not be given to women w/ pregnancy, active
recent/ recurrent pelvic infections.
Advantages
1. Very low pregnancy rate, thus it is very effective.

2. Easy to remove if couple wants another child. Once IUD remove, wife
become pregnant immediately
3. Inexpensive: it can be used for 8 years
4. Only requires yearly check up to make sure the IUD is still in place.
5. Creates no mess.
Disadvantages
st
1. Client may feel slight pain during the 1 few days after an IUD
insertion
2. The IUD maybe expelled
3. Clients may not protect from STDs
Side Effects:
Spotting or uterine cramping, Increased risk for PID
heavier menstrual flow, dysmenorrhea and ectopic pregnancy
Other Barrier Methods
Spermicidal products
Diaphragms
Cervical caps
Condoms
1. Spermicidal Agent
Goal: to kill the sperm before the sperm enters the cervix
Nonoxynol-9 made up of Gel, creams, films, foams, suppositories. It is 82 % effective.
Advantages
Safe to use, protection against STDs
Disadvantages
Need to use for every act of coitus, messy & sometimes irritating, temporary skin
irritations to the vulva/ penis caused by sensitivity.
Precautions
Hypersensitivity to the spermicidal foam, jelly, cream/ tablets
P a g e 23 | 84
a. Diaphragm
Mechanically blocks sperm from entering the cervix. Soft latex dome supported
by a metal rim. Can be inserted 2 hours before intercourse; removed at least
6 hours after coitus or within 24 hours. size must fit the individual, washable,
may be used for 2-3 years.
b. Cervical cap
similar to diaphragm but smaller thimble-shaped rubber cap held onto the
cervix by suction.
c. Male condom
Is widely used method both in developing & developed countries. Mechanical
barriers covering the penis had been used for protection against pregnancy.
Mechanism of action
Condom is a rubber sheath worn over an erect penis during sexual intercourse.
It acts as barrier that blocks the man’s sperm from entering the vagina in order
to prevent pregnancy
Effectiveness
85-87%
Advantages:
No serious side effects.no prescription. Encourage male participation in
contraception
Disadvantages:
1. Decrease sensation
2. New condom should be used for each act of coitus
3. Sexual activity is interrupted
Precaution
1. Couples who are allergic to rubber
2. Men who cannot maintain erection while using condom
Instruction
1. Put the condom on the erect penis
2. Condom can tear, so be careful with them
3. Leave ½ inch of empty space at the tip of the condom
4. Wait until the vagina is well lubricated, because a condom can tear if the
vagina is dry
5. If extra lubrication is needed, use water, ky jelly, gel, cream
6. After ejaculation while the penis is still erect, hold on to the rim of the
condom & withdraw the penis immediately.
7. Check condom for tears, then throw it away.
3. Surgical Methods
Methods involving surgery are generally more effective than the non-surgical
method. The most common surgical procedure for male is vasectomy and for female
is tubal ligation.
1. Tubal Ligation
28%of all women in US. fallopian tubes are cut, tied/ cauterized to block
passage of ova and sperm. Laparoscopy is the procedure to perform tubal
sterilization.
Advantages
Surgical contraception advantages sometimes this method does not provide
permanent birth control. (i.e. tubal ligation failure), this is very effective and permanent
method of contraception it does not affect sex drive. There is no effect on your normal
hormonal rhythms or periods.
1. Very effective & safe
2. No long-term side effect
P a g e 24 | 84
3. Does not interrupt sexual activity
4. Permanent method
Disadvantages
1. Discomfort during & shortly after the procedure

2. Discomfort of serious bleeding, injury to internal organs/ infection soon after
the procedure.
3. Irreversible
2. Vasectomy
Almost 11% of all men in US. Incisions are made in the sides of scrotum; vas
deferens is cut and tied, then plugged or cauterized. iT blocks the passage of
sperm. The sperm is viable for 6 months post op. It is reversible 95%.
Advantages
Sterilization is the most effective, and one of the most widely used
contraceptive methods available worldwide. It is often the best contraceptive
choice when desired family size has been achieved. Both tubal ligation and
vasectomy.
1. Very effective (99.5-99.9%) safe procedure
2. No long term side effect
3. Does not interfere w/ sexual activity
Disadvantage
The client feel some discomfort during & shortly after the
procedure.
Complications
There is scrotal swelling, discoloration, discomfort & pain, hematomas, wound
infection.
Learning Activity
Instruction: write in not less than 100 words.

1. Question: You discuss Phases of menstrual cycle (10pts.)
Instruction: write in not less than 50 words but not more than 80 words.
2. Question: You discuss the difference between menarche and menopause.(10pts.)
Instruction: Enumerate the indication, condition and process.

3. Question :You explain the following.(20pts.)
1. Indications of ovulation
2. Conditions for fertilization
3. Implantation
4. Fetal development
Instruction: Enumerate and explain the methods /procedures, give example of each kind
(30pts.)
4. Question: You enumerate and describe kinds of contraceptive procedures and give
example of each kind (30pts.
Instruction: Discuss in not less than 60Words and not more than 70 words.
5. Question: What if Gregoria Cruz decides to have tubal ligation (damping of fallopian
tubes after the birth of her baby. You notice the first time she voids following surgery that
her urine looks blood tinged. Would you assume the urine was contaminated by vaginal
secretions so its appearance is innocent? Or would you report this as an potential serious
finding her surgery was on her reproductive not her urinary system?
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UNIT III
Learning Objectives
At the end of the unit, I am able to:
1. Define key terminologies associated with antepartum.

2. Recommend interventions to manage the discomforts of pregnancy.
4. Interpret diagnostic tests for antepartum clients.
5. analyze nutritional requirements for antepartal clients.
A. Pregnancy-Antepartum
Refers to the medical and nursing care given to the pregnant woman between conception
and the onset of labor. Consideration is given to the physical, emotional, and social needs
of the woman, the unborn child, her partner, and other family members.
1. Classification of Pregnancy
2. Terminologies
Gestation: is a newborn born after 40 weeks of gestation. The process of carrying or being
carried in the womb between conception and birth
Viability: is the ability of a fetus to survive outside of the womb at the end of 20 weeks
Gravida: is the number of times pregnant, regardless of duration and outcome, including the
present pregnancy.
Nulligravida: is a Woman who has not and never has been pregnant
Primigravida: is a woman pregnant for the first time.
Multigravida: is a pregnant for second or subsequent time.
Para: is the number of pregnancies that lasted more than 20 weeks, regardless of outcome.
Nullipara: is a woman who has not given birth to a baby beyond 20 weeks gestation.
Primipara: is a woman who has given birth to one baby more than 20 weeks
gestation.
Multipara : is a woman who has had two or more births at more than 20 weeks
gestation.
TPAL: Para is subdivided to reflect births that went to Term, Premature births, Abortions,
and Living children.
Preterm: is a newborn born before 37 weeks of gestation.
Term: is a newborn born after 37 weeks to 40 weeks of gestation.
Post Term: is a newborn born after 40 weeks of
LMP: Last Menstrual Period
EDC: refers to the Expected Date of Delivery
AOG : is the Age of Gestation
CIL: refers to the Cephalic in Labor
P a g e 26 | 84
3. Duration of pregnancy
The duration of pregnancy is 266-280 days, 38-42 weeks, 9 calendar months, 10 lunar
months (28 days).
EDC: Nagelle’s rule by adding 7 days to the first day of LMP and counting back 3 months.
Because some women experience implantation bleeding or spotting, they do not know they
are pregnant.
4. Periods of Pregnancy
Childbirth usually occurs about 38 weeks after conception, approximately 40 weeks from the
start o the last menstrual period. Pregnancy is divided into 3 trimester that roughly
approximately specific developmental stage.
First trimester: period of organogenesis; teratogens are highly damaging.
Second trimester: most comfortable period for the mother, fetal growth continues.
Third trimester: rapid deposition of fats, thus period of most rapid growth, with rapid iron and
calcium deposition
5. Conditions for Fertilization
Postcoital test demonstrates live, motile, normal sperm present in cervical mucus. Fallopian
tubes patent. Endometrial biopsy indicates adequate progesterone and secretory
endometrium. Semen is supportive to pregnancy at least 2 ml semen and contain at least
20million sperm/ml; >60 % normal and > 50 % motile (moving forward).
B. Process of Reproduction
Reproduction is the creation of a living being from the maternal of previous living
being. It is a process common to all living entities.
Procreation
The production of offspring; in general humans copulate purely for the purpose of
procreation
1. Related theories
There are two main theories:
Creation - God created the world an all that's in it, including humans, and they reproduce
through sexual intercourse;
Evolution - Darwin's theory that humans evolved over the years through natural occurrences
and from the growth and development of monkeys and other creatures.
2. Fertilization: A Sperm and an Egg Form a Zygote
During sexual intercourse, some sperm ejaculated from the male penis swim up
through the female vagina and uterus toward an oocyte (egg cell) floating in one of the uterine
tubes. The sperm and the egg are gametes. They each contain half the genetic information
necessary for reproduction. When a sperm cell penetrates and fertilizes an egg, that genetic
information combines. The 23 chromosomes from the sperm pair with 23 chromosomes in
the egg, forming a 46-chromosome cell called a zygote. The zygote starts to divide and
multiply. As it travels toward the uterus it divides to become a blastocyst, which will burrow
into the uterine wall.
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3. The Zygote Becomes an Embryo: Development Prior to and During Implantation
Fertilization takes place in ampula (outer 1/3) portion of the Fallopian tube.A fertilized
egg, or zygote, takes about five days to reach the uterus from the uterine tube. As it moves,
the zygote divides and develops into a blastocyst, with an inner mass of cells and a protective
outer ring. The blastocyst attaches to the wall of the uterus and gradually implants itself into
the uterine lining. During implantation, its cells differentiate further. At day 15 after
conception, the cells that will form the embryo become an embryonic disc. Other cells begin
to form support structures. The yolk sac, on one side of the disc, will become part of the
digestive tract. On the other side, the amnion fills with fluid and will surround the embryo as
it develops. Other cell groups initiate the placenta and umbilical cord, which will bring in
nutrients and eliminate waste.
4. In Eight Weeks, the Embryo Develops; Fifteen days after conception marks the
beginning of the embryonic period. The embryo contains a flat embryonic disc that now
differentiates into three layers: The endoderm, Mesoderm and the Ectoderm. All organs of
the human body derive from these three tissues. They begin to curve and fold and to form an
oblong body. By week 4, the embryo has a distinct head and tail and a beating heart.
Over the next six weeks, limbs, eyes, brain regions, and vertebrae form. Primitive
versions of all body systems appear. By the end of week 10, the embryo is a fetus.
(Note: Pregnancy is often measured in terms of gestational age—age of the fetus starting
with the first day of a woman’s last menstrual period—and embryonic or fetal age—actual age
of the growing fetus. We are referring to the gestational age of the fetus.)
5. Stages of Fetal Development
”Fetal growth and development are typically divided into three periods: pre-embryonic
(first 2 weeks, beginning with fertilization), embryonic (weeks 3 through 8), and fetal (from
week 8 through birth)” (Pillitteri, 2010).
Ovum - From ovulation to fertilization
Zygote - (12-14 days after Fertilization)-from the time the ovum is fertilized until
it is implanted in the uterus.
Embryo - from implantation to 5–8 weeks. During this period, embryo is most
vulnerable to teratogens: viruses, drugs, radiation or infection can cause major
congenital anomalies.
Fetus - 5-8 weeks until term (38-41 weeks).
Conceptus –The developing embryo or fetus and placental structures

throughout pregnancy.
Age of viability the earliest age at which fetuses could survive if they were born
at that time, generally accepted as 24 weeks, or fetuses. During intra uterine life
the fetus derives O2 and excrete carbon dioxide, not from o2 exchange in the
lungs but from the placenta. Fetal circulation differs from extra-uterine circulation
in several aspects:
6. Special structure in fetal development
“The placenta, which will serve as the fetal lungs, kidneys, and digestive tract in utero,
begins growth in early pregnancy in coordination with embryo growth”(Pillitteri, 2010).
Placenta- where the gas exchange takes place during fetal life
Umbilical arteries- carry unoxygenated blood from the fetus to the placenta
Umbilical vein- brings oxygenated blood coming from the placenta to the
fetus.
P a g e 28 | 84
Foramen ovale- connects the left and the right atrium. It pushes blood
from the right atrium to the left atrium so that blood can be supplied to
brain, kidney and heart.
Ductus venosus- carry oxygenated blood from umbilical vein to inferior

venacava, by passing fetal liver. (vein to vein)
Ductus arteriosus- carry unoxygenated blood from pulmonary artery to aorta,

by passing (artery to artery)
7. Fetal Circulation
The oxygenated blood enters the umbilical vein from the placenta. (direction of blood
is toward the fetal heart).
Enters ductusvenosus that connects the umbilical vein to the inferior venacava, w/c allows
oxygenated blood to be supplied directly to the fetal liver.
It passes through inferior venacava, enters the right atrium (heart), enters the foramen ovale
(opening bet. rt. atrium and left atrium.
Goes to the left atrium, passes through the left ventricle, flows to ascending aorta to supply
nourishment to the brain and upper extremities.
It enters superior venacava (return to the heart), goes to the right atrium. enters the right
ventricle, enters pulmonary artery with some blood going to the lungs to supply oxygen and
nourishment.
It flows to ductus arteriosus (channel bet. aorta and main pulmonary artery. It closes during
normal respiration. Allows blood to bypass the fetal lung.
It enters descending aorta (some blood going to the lower extremities) and enters hypogastric
arteries that return the blood to the placenta (unoxygenated blood because it is away from
the fetal heart) and goes back to the placenta.
7. Maternal Changes and Fetal Development
“ The following discussion of fetal developmental milestones is based on gestational

weeks, because it is helpful when talking to expectant parents to be able to correlate fetal
development with the way they measure pregnancy—from the first day of the last
menstrual period.” (Pillitteri, 2010)
The maternal changes during 8 weeks AOG are; nausea persists up to 12

weeks; uterus changes from pear to globular shape; hegar’s sign: softening of the isthmus
of cervix; goodell’s sign: softening of the cervix; leukorrhea increases; ambivalence about
pregnancy may occur,;no noticeable weight gain,; chadwick’ssign appears (bluing of vagina)
appears as early as4 weeks’ gestation.
The fetal development during 8 weeks AOG are; rapid development; heart begins to
pump blood; limb buds are well developed, facial features discernible; major divisions of brain
discernible; ears develop from skin folds; tiny muscles are formed beneath this skin embryo;
weighs 2 grams.
The nursing interventions during 8 the weeks AOG are; to teach prevention of nausea;
eat dry crackers before getting out of bed in the morning; eat small, frequent meals and avoid
fatty foods; increase fluid intake to 3l/day; teach safety: avoid hot tubs, saunas, and steam
rooms throughout pregnancy (hypotension may cause fainting); prepare for pregnancy;
discuss attitudes toward pregnancy; discuss value of early pregnancy classes that focus on
what to expect during pregnancy; provide information about childbirth preparation classes;
include father/family in preparation for childbirth (Expectant fathers experience many of the
same feeling/conflicts experienced by the expectant mother).
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The maternal changes during 28 weeks AOG are; fundus halfway between umbilicus and
xiphoid process; thoracic breathing replaces abdominal breathing; fetal outline palpable;
woman becomes tired of pregnancy and eager for delivery; heartburn may begin;
hemorrhoids may develop.
The fetal development during 28 weeks AOG are; fetus can breathe, shallow, regulate
temperature; surfactant forms in lungs; fetus is 2/3 birth size; baby can hear; eyelids open;
period of greatest fetal; weight gain begins; fetus weighs 1100 gms (21/2 lbs).
The nursing interventions during the 28 weeks AOG are; treatment for hemorrhoids:;
sitz bath; gentle reinsertion of hemorrhoids with lubricated fingertip; suppositories as
ordered; topical anesthetic agents; stool softeners as ordered; teach comfort measures;
elevate legs when sitting; assume side-lying position when resting; teach measures to avoid
heartburn; eat small frequent meals; avoid fatty foods; avoid lying down after meals; maalox
or mylanta may be helpful; avoid sodium bicarbonate; prepare for delivery and parenthood;
discuss mother’s/father’s/family expectations of labor and delivery; Discuss
mother’s/father’s/family expectations of caring for infant.
The maternal changes during 32 weeks AOG are; Fundus reaches xiphoid process;
Breast full and tender; Urinary frequency returns; Swollen ankles may occur; Sleeping
problems may develop; Dyspnea may develop.
The fetal development during 32weeks aog are; brown fat develop beneath skin to
insulate baby following birth; fetus is 15-17 inches in length; begins storing iron, calcium and
phosphorous; fetus weighs 1800-2200 gms (4-5 lbs).
The nursing interventions during 32 weeks AOG are; teach measures to decrease
edema; elevate legs 1-2x/day for approximately 1 hour; use naturally-occurring diuretics,
ex., watermelon or2 tbsp. lemon juice/cup of water; teach comfort measures; wear well-
fitting supportive bra. ;maintain proper posture; use semi-fowler’s position at night for
dyspnea; prepare for childbirth; review signs of labor; discuss plans for other children; discuss
plans for transportation to hospital; assess father’s (family member’s) role during childbirth.
The Maternal Changes during 38 weeks AOG

Intro
Lightening occurs.
Placenta weighs approximately 20 oz.
Mother eager for birth, may have burst of energy.
Backaches increase.
Urinary frequency increases.
Braxton Hick’s contractions intensify (cervix and lower uterine segment prepare
for labor.
The fetal development during 38 weeks AOG are; fetus occupies entire uterus;
activity is restricted; maternal antibodies are transferred to fetus (provides immunity
for approximately 6 months, until infant’s own immune system can take over); fetus
weighs 3200 gms and more (7 lbs).
The nursing interventions during 38 weeks AOG are; teach safety measures; wear low-heeled
shoes or flats; avoid heavy lifting; sleep on side to relieve bladder pressure; urinate
frequently; prepare for delivery; continue pelvic tilt exercises; pack a suitcase for delivery;
fundus reaches xiphoid process; breast full and tender; urinary frequency returns; swollen
ankles may occur; sleeping problems may develop; dyspnea may develop.
P a g e 30 | 84
C. Signs and Symptoms of Pregnancy
1. Manifestations :
“The medical diagnosis of pregnancy serves to date when the birth will occur and also
helps predict the existence of a high-risk status. If a pregnancy was planned, the diagnosis
produces a feeling of intense fulfillment and achievement. If it was not planned or not desired,
it can result in an equally extreme crisis state” (Pillitteri, 2010).
1. Presumptive
Includes amenorrhea, breast changes-more erect, areolas darken and increase
in diameter. Colostrum is formed, montgomery gland become bigger. Skin
changes: presence of choasma/melasmsa (due to hyperpigmentation in the
face and armpit, linea negra and striae gravidarum . there is morning sickness,
frequency of urination and dizziness-can be the first sign of pregnancy
2. Probable
Enlargement of the abdomen-umbilicus push out. Chadwick’s sign-deep
purle/violet discoloration of the vagina due to increased vascularity. Goodell’s
sign-cervix becomes more vascular and edematous. Hegar’s sign-softening of
the lower uterine segment. Braxton Hick’s contraction, Ballotment- (bounching
back of the uterus). Changes in the level of HCG, Quickening-(1st uterine
contraction during pregnancy), and
Positive pregnancy test.
3. Positive
Fetal Heart Tone can be heard, Fetal movement felt by the examiner and
outlining of the fetal body through sonography evidence/US/pelvimetry
2. Nursing Care
”Planning nursing care in connection with the physiologic and psychological changes
of pregnancy should involve a plan to review these types of concerns with a woman as well
as a plan to ask about the individual responses she is experiencing” (Pillitteri, 2010).
1. Ankle edema is probably caused by reduced blood circulation due to uterine

pressure and gen fluid retention.
Management
Sitting with your feet elevated. Resting in left side lying position.
Avoid standing for long periods of time, and avoid using restrictive garments on
the lower half of your body.
2. Backache to maintain balance may lead to backache (lumbar lordosis) or the “pride
of pregnancy.”
Management
Apply local heat, Avoid long periods of standing. Advise to squat rather than bent
to pick up objects. Wear low-heeled shoes. Maintain correct posture. Firm
mattress is used, Tailor sitting, pelvic rocking and shoulder circling exercises to
strengthen back. Acetaminophen (Tylenol) in usual adult dose may help.
3. Breast tenderness
Wear a supportive bra with a wide shoulder strap, decrease the amount of
caffeine and carbonated beverages ingested.
4. Constipation
As the weight of the growing uterus presses against the bowel it slows down the
peristalsis and due to increase progesterone level w/c inhibits gastric motility
P a g e 31 | 84
Management:
Increase fiber in your diet. Drink additional fluids. Have a regular time for bowel
movements. Exercise and use stool softener as prescribed. Enema is
contraindicated
5. Difficulty sleeping
Management
Drink a warm, caffeine-free drink before bed, and practice relaxation techniques.
4. Fatigue
Is due to increased metabolic rate
Management
Schedule rest periods daily. Have a regular bedtime routine. Use extra pillow for
comfort.
7. Faintness-
Management
Move slowly. Avoid crowds. Remain in a cool environment, and always lie on your
left side when at rest.
8. Headache
Is due to expanding blood volume which put pressure on cerebral arteries.
Management
Avoid eye strain. Visit your eye doctor. Rest with a cool cloth on your forehead.
Report immediately on persistent headaches to your primary care provider.
9. Heartburn -is due to increase progesterone that slows gastric

motility
Management
Eat small, frequent meals each day. Avoid overeating, as welas spicy, fatty
and fried foods
10. Hemorrhoids varicosities of rectal veins due to gravid uterus

Management
Avoid constipation and straining with a bowel movement. Practice regular bowel
movement. Knee chest position for 10 t0 15 min to relieve pressure. Replacing
hemorrhoids with gentle finger can be helpful, and take a sitz bath. Use of stool
softener as prescribed.
11. Leg cramps

Is due to increased calcium levels and decrease phosphorous level and
interference with circulation due to increase pressure due to gravid uterus
Management
Avoid pointing your toes. Lie on her back straighten your leg and dorsiflex your
ankle. Lowering milk intake and supplementing this with calcium lactate. Do
not massage
12. Nausea
Due to increase HCG resulting to increase gastric acid
Management
Eat 6 small meals / day rather than three. Eat a piece of dry toast or some
crackers before getting out of bed. Avoid foods or situations that worsen the
nausea If it persists, report this problem to your primary care provider. Drink
fluids separately rather than with your meals. Avoid fried, greasy, gas-producing,
or spicy foods, and foods with strong odors.
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13. Nasal stuffiness
Management
Use cool air vaporizer or humidifier
Increase fluid intake
Place moist towel on the sinuses, and
Massage the sinuses.
14. Ptyalism
Is due to hyperacidity that increases salivation
Management
Use mouthwash as needed. Chew gum or suck on hard candy.
.
15. Round ligament pain/ Abdominal discomfort
Management
Avoid twisting motions. Rise to a standing position slowly and use your hands to
support the abdomen. Bend forward to relieve discomfort.
16. Shortness of breath
Management
Use proper posture. Use pillows behind the head and shoulders at night. Adequate
rest period
17. Urinary Frequency

Management
Ist trimester – increase urination due to increase blood supply to the kidney
nd
2 trimester – decrease urination
rd
3 trimester- increase urination due to increase pressure
Void as necessary, at least every 2 hours. Increase fluid intake.
Avoid caffeine. Practice Kegel exercises (contracting and relaxing perineal
muscles)to decrease urinary incontinence.
18. Vaginal discharge/ Leukorrhea

Due to increase progesterone
Management
Wear cotton underwear. Bathe daily. Avoid tight pantyhose.Use of perineal pad
19. Varicose veins

Due to pressure on the veins returning blood from the lower extremities. This
causing blood to pool
Management
Walk regularly. Rest with feet elevated for 15- 20 minutes.
Avoid long periods of standing. Don’t cross your legs when sitting. Avoid knee-
high stockings. Wear support hosiery. Take vitamin C or fresh fruits.
D. Birth Setting and Alternative Methods of Delivery
1. Hospital Birth
Is a mother-friendly based on, through its practices, if the hospital expects that birth is a
normal, natural, and healthy process and a woman has the opportunity to:
a. Experience a healthy and joyous birth experience, regardless of her age or
circumstances:
b. Give birth as she wishes in an environment in which she feels nurtured and
secure. Have access to the full range of options for pregnancy, birth, and
nurturing her baby
c. Receive accurate and up-to-date information about the benefits and risks
of all procedures, drugs, and tests suggested for use during pregnancy,
birth, and the postpartum period, with the rights to informed consent and
informed refusal
d. Receive support for making informed choices about what is best for her and
her baby based on her individual values and beliefs.
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2. Characteristics of a Mother-Friendly Hospital :
1. Offers a birthing mother:
a. Unrestricted access to the birth companions of her choice, including
fathers, partners, children, family members, and friends
b. Unrestricted access to continuous emotional and physical support from
a skilled woman—for example, a doula or labor-support professional
c. Access to professional midwifery care.
2. Provides accurate descriptive and statistical information to the public about its
practices and procedures for birth care, including measures of interventions and
outcomes.
3. Provides culturally competent care—that is, care that is sensitive and

responsive to the specific beliefs, values, and customs of the mother’s
ethnicity and religion.
4. Provides a birthing woman with the freedom to walk, move about, and assume
the positions of her choice during labor and birth (unless restriction is
specifically required to correct a complication), and discourages the use of the
lithotomy position.
5. Has clearly defined policies and procedures for:

a. a.Collaborating and consulting throughout the perinatal period with other
maternity services.
b. Linking the mother and baby to appropriate community resources,
including prenatal and post-discharge follow-up and breastfeeding
support
c. Does not routinely employ practices and procedures that are unsupported
by scientific evidence such as routine perineal shaving
6. Educates staff in nondrug methods of pain relief and does required to not
promote the use of analgesic or anesthetic drugs not specifically correct a
complication.
7. Encourages all mothers and families, including those with sick or premature
newborns or infants with congenital problems, to touch, hold, breastfeed, and
care for their babies to the extent compatible with their conditions.
8. Discourages nonreligious circumcision of the newborn.
9. Promotes successful breastfeeding by:

a. Having a written breastfeeding policy that is routinely communicated to
all health care staff
b. Educating all health care staff in skills necessary to implement this policy
c. Informing all pregnant women about the benefits and management of
breastfeeding
d. Helping mothers initiate breastfeeding within a halfhour of birth
e. Showing mothers how to breastfeed and how to maintain lactation even
if they should be separated from their infants
f. Giving newborn infants no food or drink other than breast milk unless
medically indicated
g. Practicing rooming in to allow mothers and infants to remain together
24 hours a day
h. Encouraging breastfeeding on demand
i. Giving no pacifiers to breastfeeding infants
j. Fostering the establishment of breastfeeding support groups and
referring others to them on discharge from hospitals or clinics
Advantages
a. A woman is encouraged to be prepared to control the discomfort of labor
through nonmedication measures such as controlled breathing although
anesthesia such as an epidural is readily available.
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b. A woman is encouraged to be knowledgeable about the labor process
and make decisions about procedures performed.
c. A woman is encouraged to consider breastfeeding to aid uterine
contraction and infant bonding after birth.
d. Labor, birth, and immediate postpartal care can all be scheduled in a
single room.
e. A woman is attended by skilled professionals during labor and birth and
the postpartal period.
f. Emergency care and extended high-risk care are immediately available.
Disadvantages
a. Separation of the family for at least one night
b. Mother may not feel as much in control of the childbirth experience
as she may wish.
c. Care may be fragmented, particularly if a woman’s physician is not
present during the entire labor and birth, or if labor nurses change
shifts in the middle of labor.
3. Alternative Birthing Centers (ABCs)

Are wellness-oriented childbirth facilities designed to remove childbirth from the acute care
hospital setting while still providing enough medical resources for emergency care should a
complication of labor or birth arise.
a. The birth attendants tend to be nurse-midwives.

b. Women who deliver in ABCs are screened for complications before
being admitted.
c. Like hospitals, ABCs have LDRP rooms where a woman and her support
person can invite friends and siblings to participate in the birth.
d. A minimum of analgesia and anesthesia is provided, and she can choose
a birth position.
e. She can bring her own music or distraction objects, and the partner can
perform such tasks as cutting the umbilical cord if he or she chooses.
f. Women remain in an ABC from 4 to 24 hours after birth
Advantages
a. A woman is encouraged to be prepared to control the discomfort of labor
through nonmedication measures such as controlled breathing.
b. A woman is encouraged to be knowledgeable about the labor process
and to help care providers with decision making.
c. A woman is encouraged to breastfeed to aid uterine contraction and
infant bonding after birth.
d. Family integrity can be maintained because family members may
accompany a woman to the birthing center.
e. A woman is attended by skilled professionals during labor and birth.
f. Emergency care is immediately available. Extended high-risk care is
easily arranged.
Disadvantages
a. Extended high-risk care is not immediately available.
b. A woman may be fatigued after birth because of brief health care setting
stay.
c. She must independently monitor her postpartal status because of brief
health care setting stay.
Free birthing
Refers to women giving birth without any health care provider supervision also
refer to it as unassisted birth or couples birth.
a. A woman learns pregnancy care from reading articles on the Internet and
then arranges to have her child at home.
b. Education can enhance the chances of a positive childbirth experience.
c. Client attends the chosen preparation for childbirth class before the 38th
week of pregnancy.
P a g e 35 | 84
E. Alternative Methods of Birth
Are methods of childbirth delivery that avoids invasive modern medicine in favor of more
natural and homely settings.
1. Laborer method
it is kept pleasantly warm, not chilled. Soft music is played, or at least harsh noises are kept
to a minimum.The infant is handled gently; the cord is cut late; and the infant is placed
immediately after birth into a warm-water bath.
2. Hydrotherapy and Water Birth
Reclining or sitting in warm water during labor can be soothing. The baby is born underwater
and then immediately brought to the surface for a first breath. A potential difficulty is
contamination of the bath water with feces expelled with pushing efforts during the second
stage of labor could lead to uterine infection in the mother or aspiration of contaminated
bath water by a newborn, which could lead to pneumonia.
Advantage of Home Birth

a. Knowledgeable about the birth process and be an active participant in
independently reducing the discomfort of labor.
b. Has the greatest freedom for expressing her individuality.
c. There is no separation of the family at birth
d. A skilled professional can attend the birth.
Disadvantages
a. Adequate equipment other than first-line emergency equipment is
unavailable.
b. An abrupt change of goals is necessary if hospitalization is required.
c. A woman and support person may become exhausted because of the
responsibility placed on them.
d. Interference with the “taking-in phase” may occur postpartally because a
woman must “take hold.”
e. A woman must independently monitor her postpartal status.
3. Physiological and Psychological Changes of Pregnancy
“Physiologic changes of pregnancy occur gradually but eventually affect all of a

woman’s organ systems. They are changes that are necessary to allow a woman to be
able to provide oxygen and nutrients for her growing fetus as well as extra nutrients for
her own increased metabolism during the pregnancy. Psychological changes of pregnancy
occur in response not only to the physiologic alterations that are happening but also to
the increased responsibility associated with welcoming a new and completely dependent
person into a family” (Pillitteri, 2010).
4. Maternal Adaptations to Pregnancy
1. First Trimester
a. Ambivalence, fear, fantasies and anxiety
b. Pregnant woman places main focus on self
2. Second Trimester
a. Tranquil period
b. Acceptance of the reality of pregnancy
c. Increased interest in fetus
3. Third Trimester
a. Anticipates labor and delivery; assumes mothering role
b. Fantasies and dreams about labor common
c. Nestling behaviors
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5. Developmental Task of Pregnancy
“ Physiologic changes that occur during pregnancy can be categorized as local

(confined to the reproductive organs) or systemic (affecting the entire body). Both symptoms
(subjective findings) and signs (objective findings) of the physiologic changes of pregnancy
are used to diagnose and mark the progress of pregnancy” (Pillitteri, 2010).
“Iam Pregnant”
▪ acceptance of the biological fact of pregnancy
“I am Going To Have a Baby ”
▪ acceptance of the fetus as a distinct individual and a person to care for
“I am Going To Be A Mother”
• prepare realistically for the birth and parenting of the child.
6. Activities During First Prenatal visit
“Screening includes an extensive health history, a complete physical

examination, including a pelvic examination, and blood and urine specimens for
laboratory work. Manual pelvic measurements can be taken to determine pelvic
adequacy” (Pillitteri, 2010)
1. Obtain History
2. Medical history
3. Obstetric history
4. History of current pregnancy
5. Determine gravity and parity
6. Physical exam including pelvic exam
7. Calculate EDC and AOG.
8. Vital Signs
7. Components of initial visit
“ If on subsequent visits a symptom is mentioned, establishing a baseline health

picture at the initial pregnancy allows you to be able to verify that it is truly a new
symptom and a woman is not just becoming more aware of it” (Pillitteri, 2010).
1. History taking (chief concern for coming to the health care facility)
A. Personal data
“Information about a woman’s current nutrition, elimination, sleep, recreation,
and interpersonal interactions can be elicited best by asking a woman to describe a
typical day of her life. If any of this information is not reported spontaneously as she
describes her day, ask for additional details” (Pillitteri, 2010).
1. Age
a. Below 15 years are at risk for anemia, CPD, congenital deformity
b. Above 35 are at risk for HPN, DM, Placenta Previa and Abruptions
placenta, C/S, Ectopic pregnancy, Fetal growth retardation,
Macrosomia, Down syndrome,
2. Weight
a. Below 95 lb.is at risk for prematurity, Low birth weight infant,
Stillbirth and Congenital defects.
b. Obese woman prone to develop DM, HPN and thrombophlebitis.
P a g e 37 | 84
3. Height
Women less than 5 feet tall are at risk for CPD
4. Occupation
Handling toxic substances and highly stressful work places woman at
risk.
5. Civil Status
B. Menstrual History
Includes: menarche, length and regularity of menses, interval bet periods,
amount of flow by asking the number of pads used every menstrual period,
dysmenorrhea and other discomforts and actions taken.
C. Breast Health
Includes breast surgery, breast disorders breastfeeding of previous infants.
D. Contraceptives Used
a. IUD in placed to be removed
b. Contraceptive pills should be stopped
E. Medical History
Include childhood diseases, drug allergies, past surgery existing medical
conditions, immunizations, alcohol intake, cigarette smoking and use of drugs
F. Obstetrical History
a. History of past pregnancies include number, outcome, complications, labor
time, method of delivery, Puerperium, and complication of puerperium.
b. GTPALM
G Gravida (number of pregnancy)
T Number of full term infants born after 37 weeks
P Number of preterm infants born before 37 weeks
A Number of spontaneous or induced abortions
L Number of living children
M Multiple birth (twins)
c. Schedule future visit/prenatal check-up:

a. Low risk clients
1. Every month until 28 weeks.
2. Every 2 weeks from 28 weeks until 36 weeks.
3. Every week from 36 weeks until delivery.
b. High risk clients schedule is determined by client’s needs; visits are

scheduled as needed.
c. Obtained laboratory data:

1. Hgb, pregnant valuees10-14 f/dl.
2. Hct, pregnant values 32-42 %.
3. WBC and differential.
4. Hgb electrophoresis (sickle cell).
5. Pap Smear and cytology
6. Antibody Screens: HIV, HBsAg, Toxoplasmosis,Rubella (> 1:8=immunity),
SY/VDRL, Cytomegalovirus.
7. PPD.
8. Rh and BT.
9. Urinalysis.
G. History of Present Pregnancy
Expected date of delivery
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1. Inquire for last menstrual period (LMP) and compute for expected date of
delivery/ confinement (EDD/ EDC).
a. Naegele’s rule To get the EDD, the formula is the first day of the last
menstrual period then, subtract 3 months, add 7 days to the first day of LMP, and
add one year.
Ex: LMP -Sept. 16, 2018
3 months - June 16
Add 7 days -June 23
Add 1 year - June 23, 2019
EDC -June 23, 2019
09 16 2018
03 +7 +1 year
06 23 2019 = EDC
Note: pregnant women may deliver two weeks after or 2 weeks before the EDC. If
the woman cannot remember her LMP, ask her when she first felt quickening.
a. To get the EDC for primigravida, add 22 weeks to the date of quickening
15 weeks
22weeks
b. To get EDC for multigravida, add 24 weeks to the date of quickening
16 weeks
24 weeks
2. Determination of the age of gestation/ duration of pregnancy
A. The clinical parameters that can be used to measure the duration of
pregnancy are the following:
1. Last menstrual period this involves calculating the span of time from the
last menstrual period up to the present.
a. Problems encountered with the use of the LMP are the following:
1. Failure to record LMP
2. Menstrual cycle maybe irregular and variables.
3.Pregnancy may follow immediately without menstruation in between
gestation
LMP : January 10, 2017
Present date: July 09, 2017
Age of Gestation:180 days /7 days = 27weeks & 1day
Jan 21 days
Feb 28
March 31
April 30
May 31
June 30
July 09
---------------
180 days
4. Implantation bleeding maybe mistaken as menstruation.
5. Ovulation that occurs after cessation of ovulation inhibition
method of contraception may be delayed.
2. Basal body temperature record
if an isolated coitus can be dated or BBT record is available, the precise
onset of pregnancy can be dated.
3. Quickening is noted at 20 weeks in primis and at 16 weeks in multis.
3. Assessment of Fundic height
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The fundic height is measured to estimate AOG(Age of gestation),EDC, and
fetal growth. and is measured from top of symphysis pubis to the top of the
fundus with the bladder empty.
Greater fundic height indicates:
1.Multiple pregnancy
2.Miscalculated due date
3.Poly hydramnios
4.Hydatidiform mole
Lesser fundic height indicates:
1. fetal growth retardation
2. Fetal death
3. Error in estimating AOG
4. Oligohydramnios
a. Mcdonalds Rule
To determine the age of gestation in months by measuring the distance from
the fundus to the symphysis pubis(in centimeters) is measured (FH) in the
second trimester when the uterus can be palpated above the symphysis
pubis with the :
1. women lying on her back,
2. bladder empty,
3. and legs slightly flexed.
From 22 weeks to term, it is roughly equal to the age of gestation in

weeks.
Formula:
1. Fundic Height (cm) x 8/7 = AOG duration of pregnancy in weeks .
Ex. 20 cm. x8 /7 =22. 85
2. Fundic height (cm) x 2/7 = AOG duration of pregnancy in lunar
months .
Ex. 20 cm. x2/7 =5.71
b. Bartolomews Rule
is used to calculate AOG by the relative position of the uterus in the
abdominal cavity and is determined by palpation and by relating to the
different landmarks in the abdomen:
1. Above the level of symphysis bet. 12 – 14 weeks
2. At the umbilicus or 20 cm – about 20 wks.
3. Rises about 1 cm/week until 36, after which it varies.
3. Treatment of disease
4. TT immunization =
Tetanus toxoid is a cornerstone intervention to prevent tetanus neonatorum
and is administered IM
a. TT1 as early as possible during pregnancy or anytime during pregnancy=
b. TT2 one month after TT1=3 years protection from tetanus and
neonatal tetanus
c. TT3 six months after TT2 =5 years protection
d. TT4 one year after TT3 or next pregnancy = 10 years protection
e. TT5 one year after TT4 or next pregnancy= lifetime protection
Note: If the woman received DPT in infancy and 2 or 3 doses of DPT during
pregnancy, this should be considered as TT1 and TT2. The succeeding doses
will be TT3 and so forth.
5. Iron supplementation
“Iron is needed to build this high level of hemoglobin. In addition, after week 20 of
pregnancy, a fetus begins to store iron in the liver to last through the first 3 months of
life, when intake will consist mainly of milk, typically low in iron” (Pillitteri, 2010)
1. From 5 months to 2 months post-partum
2. 100- 120 mg simple iron salts for 210 days
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6. Health education
“In early pregnancy, be certain that you establish a trusting relationship with a
woman so she will see you as a person who is capable of counseling her and helping
her solve problems, and in whom she is willing to confide as she is about to undergo
what could be a stressful 9 month time period” (Pillitteri, 2010).
A. Normal signs and symptoms of pregnancy
1. Amenorrhea
2. Breast changes - more erect, areolas darken and increase in
diameter, colostrum is formed, montgomery gland become bigge
3. Skin changes: Chloasma/melasma (due to hyperpigmentation in the
face and armpit, linea negra and striae gravidarum
4. Nausea and vomiting -morning sickness
5. Frequency of urination
6. Dizziness-can be the first sign of pregnancy
B. Minor discomforts, prevention and management
C. Danger signs and symptoms
D. Nutrition and diet
E. Rest, exercise and relaxation
F. Avoidance of drugs, alcohol, cigarettes, and too much caffeine
G. Clothing
H. Sexual relations
I. Employment
J. Travel
K. Preparation for baby’s birth, labor, delivery and puerperium
7. Laboratory examination
8. Oral dental examination
9. Referral when necessary
10. Physical Examination

Should be performed systematically, one technique is by cephalocaudal method
A. Maternal assessment
1. Vital Signs
a. Blood Pressure no significant changes occur during pregnancy.
In the second trimester, it may drop slightly but return to normal in the third trimester. Blood
pressure is highest when the woman is sitting, intermediate in supine pos. and lowest in left
lateral position. Supine hypotensive syndrome when pregnant woman lies on her back,
the gravid uterus compresses the blood vessels that drains blood from the lower extremities
and this results in decrease amount of blood going back to the heart, which consequently
decreases cardiac output, resulting in less blood supply to the brain that leads to dizziness
and hypotension.
b. Pulse rate
Pulse rate increases by about 10 beats per minute due to increased cardiac workload
c. Respiratory Rate
Increases in depth, no significant change in rate, shortness of breath and dyspnea late in
pregnancy is common.
d. Temperature
Slight elevation early in pregnancy due to the thermogenic effect of progesterone. It drops to
normal after 16 weeks.
P a g e 41 | 84
2. Head and Scalp
a. Normal findings are: Hair tends to grow faster during pregnancy. Oily hair is
also not uncommon.
b. Abnormal findings are: excess hair dryness indicates poor nutrition
3. Eyes
a. Abnormal findings are:
b. Pale conjunctiva indicates anemia
c. and edema of the eyelids accompanied by visual disturbances are signs of
HPN.
4. Nose
a. Normal nasal congestion occur as a result of estrogen stimulation
5. Ears
a. Nasal stuffiness results in blockage of eustachian tube which may affect a
pregnant woman’s hearing
6. Mouth and Teeth
a. It is normal to find swollen gums (epulis) due to estrogen stimulation.

Abnormal findings are:
a. Cracked corners of the mouth maybe caused by vitamin deficiency which
pregnant woman are prone to develop.
b. Dental caries should be treated during pregnancy as they may become site
of infection.
c. Major dental operations such as tooth extraction should be postponed until
the post partum period.
7. Neck
a. Slight thyroid enlargement is brought about by increased basal metabolic
rate.
8. Breast
Normal findings :
a. includes enlargement of the breast with wider and darker areola, prominent
veins and montgomery tubercles.
b. Colostrum, a thin watery fluid, can be expressed from the nipple as early
as the first trimester.
Abnormal findings such as:
a. breast masses, nodules and bloody nipple discharge are
abnormal findings and should be reported to the physician right away.
9. Skin
Normal findings are:
a. linea negra, mask of pregnancy, spider nevi, palmar erythema are
common findings.
b.
Abnormal findings are:
a. pallor, rashes, and skin lesions.
10. Back
Exaggerated lumbar curve late in pregnancy occurs as a result of the shifting of
the pregnant woman’s center of gravity.
11. Rectum
a. Hemorrhoids
b. May be present especially in the last months of pregnancy.
12. Extremities
a. Ankle swelling is a normal finding in the second half of pregnancy.
b. Leg edema especially in the late afternoon is common to pregnant women.
c. Wadding gait is due to relaxation of pelvic joint.
d. Edema of upper extremities, face and hands are danger signs.
13. Abdominal Examinations
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8. Leopold’s Maneuver
Preferably performed after 24 weeks gestation when fetal outline can already be palpated.
Common and systematic way to determine the position of a fetus inside the woman's uterus.
And are important because they help determine the position and presentation of the fetus.
Actual position can only be determined by ultrasound performed by a competent technician
or professional. Named after the gynecologist Christian Gerhard Leopold.
Purposes
1. To determine the number of fetuses
2. To identify the presentation, position, degree of descent, and attitude of the
fetus
3. To identify the point of maximum intensity of the fetal heart tone in relation
to the woman’s abdomen
Factors affecting the performance of Leopolds Maneuver

Intro
a. Difficult to perform in obese women.
b. Women with hydramios.
c. Women with full bladder
Preparation
“Leopold’s maneuvers are a systematic method of observation and palpation to determine fetal
presentation and position” (Pillitteri, 2010).
1. Cardiac rule- instruct woman to empty her bladder first.
2. Place woman in dorsal recumbent position, supine with knees flexed to relax abdominal
muscles. Place a small pillow under the head for comfort.
3. Drape properly to maintain privacy.
4. Explain procedure to gain patient’s cooperation.
5. Warm hands first by rubbing them together before placing them over the woman’s
abdomen. Cold hands may stimulate uterine contractions.
6. Use the palm for palpation not fingers
7.
Steps in Performing Leopolds Maneuver
1. First maneuver; Fundal grip

What lies at the fundus?
Purpose:
To determine fetal part lying in the fundus
Procedure:
Using both hands , feel for the fetal part lying in the fundus.
Findings:
If the nurse- midwife feels the head which is round, smooth, with transverse groove of the
neck, the fetus is in breech presentation.
If the nurse-midwife feels the buttocks which is soft and angular, it is in vertex
presentation.
2. Second Maneuver; Umbilical Grip

Where is the fetal back?
Purpose :
To identify location of fetal back
To determine position
Procedure: One hand is used to steady the uterus on one side of the abdomen while the other
hand moves slightly on a circular motion from top to the lower segment of the uterus to feel for
fetal back and small fetal parts. Use gentle but deep pressure.
Findings
Small fetal parts feel nodular with numerous angular nodulations. Fetal back feels smooth, hard,
like a resistant PLANE.
3. Third maneuver/ Pawlik’s Grip

What is in the inlet?
P a g e 43 | 84
Purpose:
To determine engagement of presenting part.
Procedure:
Using thumb and finger, grasp the lower portion of the abdomen above the symphysis
pubis, press in slightly and make gentle movements from side to side.
Findings:
The presenting part is engaged if it is not movable.
It is not yet engaged if it is still movable.
4. Fourth maneuver/ pelvic grip

What is the attitude?
Purpose
To determine degree of flexion of fetal head
To determine attitude or habitus
Procedure
Facing foot part of the woman, palpate fetal head pressing downward about 2 inches above
the inguinal ligament.
Use both hands.
Findings
If descended deeply, only a small portion of the fetal head will be palpated.
If cephalic prominence or brow of the baby is on the same side of the small fetal parts, the
head is flexed. If cephalic prominence is on the same side of the fetal back, the head is
extended.
9. Internal Examination or vaginal examination
The doctor does the internal examination by gently putting two fingers of their gloved hand into the
vagina and feeling all around it. While they are doing this, they may put their other hand flat on the lower
abdomen (tummy area) and press down. You will have a nurse with you during your examination.
Purpose:
During the first clinic visit, the physician performs IE to
confirm pregnancy and gestation.
After 34 weeks, the physician performs IE to:
assess a consistency of cervix, length and dilatation,
fetal presenting part, bony architecture of the pelvis,
anomalies of the vagina and perineum, including rectocele, cystocele, and lesions.
10. Laboratory Test
“Risk assessment should be updated at each pregnancy visit, as the failure to identify
risk potential in pregnancy leads to increased perinatal mortality” (Pillitteri, 2010).
1. Urinalysis
Collect urinary specimen by midstream or clean catch technique
a. Benedicts test to detect glycosuria
b. Heat and acetic acid test to detect proteinuria
c. Urinalysis in the first trimester is also performed to detect
asymptomatic bacteremia. Bacteremia can lead to abortion early in
pregnancy and can cause premature labor late in pregnancy.
2. Blood Test
a. Hematocrit and Hemoglobin count
is done at initial clinic visit and repeated at 28-32 weeks to detect
anemia
Normal hemoglobin level is between 12-16 mg/dl
Normal hematocrit count is between 37-47 %
b. Determination of blood type and Rh factor
o Rh factor determination early in pregnancy is important for detection
and prompt treatment of Rh incompatibility which occurs when the
mother is Rh negative and the fetus is Rh positive
P a g e 44 | 84
11. Components of Subsequent Visits
A. Maternal assessment
1. Blood pressure
2. Weighing
Total weight gain: 20-30 lbs.
Distribution:
1. 2-4 lbs. in the first trimester.
2. 11-14 lbs. in the second trimester
3. 8-11 lbs. in the third trimester (i.e. 0.5 lb weekly)
3. Edema check
Normally on lower extremities. If found on hands, legs, and feet, it maybe an
indication of pre eclampsia
4. Fundic height measurements:

to estimate fetal growth rate. Routinely measured from 22- 34 weeks and
correlates with gestational age in normal pregnancy
5. Nutrition and appetite, discomforts of pregnancy, signs and symptoms of

pregnancy, danger signals.
6. Other problems and concerns of the woman

Urinalysis and culture, if with (+) urinalysis, CBC = presence of anemia
B. Fetal assessment
“All newborns seem to move through periods of irregular adjustment in the first
6 hours of life, before their body systems stabilize” (Pillitteri, 2010).
1. Abdominal palpation after 24 weeks to determine fetal lie, position and
presentation. (Leopold’s maneuver)
(Mark Caswell, 2011)2. Fetal heart rate after it has been initially auscultated.
a. Doppler ultrasound transducer audible at 10-12 weeks’ gestation and 10-
20 weeks’ gestation with a fetoscope
b. Normal is 120- 160. auscultation is recommended at every pre-natal visit
c.
3. Fetal movements after 20 weeks.
12. Fetal Diagnostic Test /Procedure
“Most general practitioners no longer offer lead maternity care, however, may still be involved
with the initial confirmation of pregnancy and first laboratory tests and general care during
pregnancy. The following article provides guidance on appropriate testing in early pregnancy,
throughout pregnancy and information about common changes to testing reference ranges
during pregnancy” (Mark Caswell, 2011).
1. Ultrasonography
High frequency sound waves beamed on the pregnant abdomen; echoes are
returned to a machine, which records the objects’ location and size used in
first trimester to determine: number of fetus, presence of cardiac
movement/rhythm, uterine abnormalities and assessment of gestational
age.Used in 2nd and third trimester to determine: fetal viability/AOG,
size/date discrepancies, amniotic fluid volume, placental location/maturity,
uterine anomalies/abnormalities.
Procedure
1. Instruct woman to drink 3-4 glasses of water prior to exam and not to
urinate. No known complication.
P a g e 45 | 84
2. Position woman with pillows under neck and knees to keep pressure off
bladder, late in the third trimester, place wedge under right hip to
displace uterus to the left.
3. Position display so woman can watch if she wishes.
4. Have bedpan immediately available.
2. Chorionic Villi Sampling (CVS)

Removal of small piece of villi between 8-12weeksAOG under ultrasound
guidance. Determines genetic dx early in the first trimester
Complication: spontaneous abortion (5%) and controversy about fetal
abnormalities.
Nursing Care: CVS
1. Informed consent needed
2. Place woman in lithotomy position. Warn of slight sharp pain upon
catheter insertion.
3. Result should not be given over phone.
3. Amniocentesis
Removal of amniotic fluid sample from uterus as early as 14-16 weeks AOG.
Used to determine: fetal genetic dx, maturity and well-being. Performed when
uterus rises out of symphysis at 13 weeks and amniotic fluid has formed.
Complications: Spontaneous abortion, fetal injury and infection.
Nursing Care:
1. Bladder must be full in early pregnancy to help push uterus up in the
abdomen. In late pregnancy, bladder must be empty to avoid
puncturing the bladder.
2. Obtain baseline VS and FHT
3. Place client in supine position with hands across chest.
4. If ordered, shave area and scrub with betadine.
5. Draw maternal blood sample for comparison with post maternal
blood sample to determine bleeding.
6. Provide emotional support, explain procedure.
7. Label samples.
8. After care: wash abdomen and assist woman to empty bladder.
9. Monitor FHT for 1 hr. and assess for uterine irritability.
10. Instruct woman to report any contraction, change in fetal
movement, or fluid leaking from vagina.
(Griffin, 2005-2020)
4. Baseline Variability: normal irregularity of cardiac rhythm
a. Short-term variability (STV): change in FHT from one beat to the next:
Fetal scalp electrode is necessary to evaluate STV. If STV is present, the
fetus is not experiencing cerebral hypoxia, therefore it is a reassuring
sign.
b. Long-term variability (LTV): average 6-10 changes/min. ex., FHT may
average 140 BPM, but changes from 137 to 149 during that minute.
1. Accelerations
a. Caused by sympathetic fetal response.
b. Occur in response to fetal movement.
c. Indicative of a reactive, healthy status
2. Early Decelerations:
Uniform Shape
a. Benign pattern caused by parasympathetic response (head
compression).
b. Heart rate slowly and smoothly decelerates at beginning of contraction
and returns to baseline at end of contraction.
Nursing Actions:
1. No nursing interventions required except to monitor for the progress of
labor.
2. Document the progress of labor.
3.
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3. Variable Decelerations:
Variable Shape
a. Bradycardia: FHR below 110 BPM; tachycardia: FHR above 160 BPM.
b. Most common periodic pattern.
c. Occurs in 40% of all labors and is caused mainly by cord compression
but can also indicate rapid fetal descent characterized by an abrupt
transitory decrease in the FHR that is variable, depth of fall and timing
relative to the contraction cycle.
d. Occasional variable is usually benign.
Nursing Actions:
Variable Decelerations
a. Change maternal position
b. Stimulate fetus if indicated.
c. Discontinue oxytocin if infusing.
d. Administer oxygen at 10 l/min. by tight face mask.
e. Perform vaginal exam to check for cord prolapsed.
f. Report findings to physician and document
4. Late Decelerations:
Uniform Shape
a. FHR below 70 BPM lasting longer than 30-60seconds.
b. Slow return to baseline.
c. Decreasing or absent variability.
d. Ominous/potential disastrous, non-reassuring sign.
e. Indicative of uteroplacental insufficiency.
f. The shape of the deceleration is uniformed and FHR returns to baseline
after the contraction is over
g. Depth of deceleration does not indicate severity, FHR rarely falls below
100BPM.
Nursing Actions:
Late Decelerations
a. Immediately turn client to side.
b. Check scalp compression for accelerations (a non-compromised fetus
will demonstrate accelerations with scalp compression).
c. Administer oxygen at 10 l/min. by tight face mask.
d. Assist with fetal blood sampling if indicated.
e. Maintain intravenous line and, if possible, elevate legs to increase
venous return.
f. Correct underlying hypotension.
g. Determine presence of FHR variability.
h. Notify physician.
i. Document pattern and response to each nursing action
5. Non-Stress Test (NST)

“The nonstress test is a common test for pregnant women. You may need it if
you're overdue or have complications during pregnancy. Your doctor may suggest it
if your baby seems to be moving less than usual” (Griffin, 2005-2020).
a. Used to determine fetal well-being in high risk pregnancy, especially
useful in post-maturity.
b. A healthy fetus will usually respond to own movement by FHR
acceleration of 15 beats lasting for at least 15 seconds after the
movement.
c. The fetus that responds with the 15/15 acceleration is considered
reactive and healthy.
Nursing Care:
Non - Stress Test (NST)
“It's called a nonstress test because the test won’t bother your baby. Your
doctor won't use medications to make your baby move. The NST records what
your baby is doing naturally” (Griffin, 2005-2020).
P a g e 47 | 84
a. Apply fetal monitor, ultrasound, and tocodynamometer to maternal
abdomen.
b. Give mother hand-held event marker and instruct her to push the button
whenever fetal movement is felt or recorded FM on the FTR strip.
c. Monitor client for 20-30 minutes observing for reactivity.
d. Suspect fetus sleeping if no fetal movement. Stimulate fetus acoustically
or physically, or have mother move fetus around and begin test again.
6. Contraction Stress Test (CST) or Oxytocin Challenge Test (OCT)
“The contraction stress test helps predict how your baby will do during labor.
The test triggers contractions and registers how your baby's heart reacts. A normal
heartbeat is a good sign that your baby will be healthy during labor” (Griffin, 2005-
2020). (Chandraharan, 2014)
a. The fetus is challenge with the stress of labor by inducing uterine

contractions, and the fetal response to physiologically decreased oxygen
supply during uterine contractions is noted.
b. An unhealthy fetus will develop non-assuring FHR patterns in response
to uterine contractions: late decelerations indicative of ureteroplacental
insufficiency.
c. Contractions can be induced by nipple stimulation or by infusing a dilute
solution of oxytocin IV
Nursing Care: Contraction Stress Test (CST)
or Oxytocin Challenge Test (OCT)
1. Assess for contraindications: prematurity, placenta previa, hydramios,
multiple gestation, and previous classical scar, ruptured membranes.
2. Place external monitors on abdomen.
3. Record a 20 minute baseline strip to determine fetal well being and
presence/absence of contractions.
4. To assess fetal well-being, a recording of at least 3 contractions in 10
minutes must be obtained.
5. If nipple stimulation attempted, have woman apply warm, wet
washcloths to nipples and roll the nipple of one breast for 10 minutes.
Begin rolling both breast nipples if contractions do not begin in 10
minutes. Proceed with oxytocin infusion if unsuccessful.
6. Piggyback oxytocin (10 units of Pitocin) to main IV line. Begin at 0.5
mu/min and increase by 0.5 mu/min q 20 minutes to achieve 3 firm
contractions, each lasting 40 seconds, over a period of 10 minutes.
7. A negative test suggest fetal well-being, ex., no occurrence of late
decelerations.
8. The dander of nipple stimulation lies in controlling the dose of oxytocin
stimulated from the posterior pituitary. The chance of hyper-
stimulation or tetany (contractions over 90 seconds or contractions
with less than 30 seconds in between) is increased.
7. Fetal pH Blood Sampling
“Fetal scalp blood sampling during labour: is it a useful diagnostic test or a

historical test that no longer has a place in modern clinical obstetrics?”
(Chandraharan, 2014).
a. Performed in the intrapartum period when the fetal blood from the
presenting part (breech or scalp) can be taken, ex., when the membranes
are ruptured and the cervix is dilated 2-3 cm.
b. Used to determine true acidosis when non-assuring FHR is noted (late
decelerations, severe variable decelerations unresponsive to treatment,
decreased variability unrelated to non-asphyxial causes, tachycardia
unrelated to maternal variables.
c. Normal pH in labor is 7.25-7.35. Any value below 7.2 is considered true
acidosis and delivery should be scheduled within the hour.
P a g e 48 | 84
Nursing Care:
Fetal Ph Blood Sampling
a. Client in lithotomy position at end of labor bed and prepare with perineal
cleansing and sterile draping
b. Nurse assists MD with sterile supplies and provides ice cap or emesis
basin to carry pipette filled with blood to unit pH machine or lab.
8. Biophysical Profile (BPP)

a. Ultrasonography used to elevate fetal health by assessing five variables:
a. Fetal Breathing Movements (FBM);
b. Gross Body Movements (FM);
c. Fetal Tone (FT);
d. Reactive Fetal Heart Rate (n0n-stress test);
e. Qualitative Amniotic Fluid Volume (AFV).
b. Each variable receives 2 points for a normal response.
Nursing Care: Biophysical Profile (BPP)

a. Prepare client for the procedure.
b. Inform client of the purpose for exam.
c. Provide psychological support, especially if testing will continue throughout
the pregnancy.
d. Advice client that a low score may indicate fetal compromise which would
warrant more detailed investigation.
9. Percutaneous Umbilical Blood Sampling (PUBS)

Can be done during pregnancy under ultrasound for prenatal diagnosis and
therapy. Hemoglobinopathies, clotting disorders, sepsis and some genetic
testing can be done using this method.
Late in pregnancy, vaginal examination is performed to obtain data about
presenting part, pelvic measurements, cervical effacement, dilatation and
station.
10. Vaginal Examination Preparation

“Vaginal examinations may be done either between contractions or during
contractions. More of the fetal skull may be palpated during a contraction, because the
cervix retracts more at that time” (Pillitteri, 2010).
1. Preceded by antiseptic cleansing with client in modified lithotomy position.
2. wear sterile gloves.
3. Exams are not done routinely. Sharply curtailed after membranes rupture
to prevent infection.
4. Exams are done:
5. Prior to analgesia/anesthesia.
6. To determine progress of labor.
7. To determine if 2nd stage pushing can begin
Purpose of Vaginal Examination is to Determine:

“A vaginal examination is necessary to determine the extent of cervical
effacement and dilatation and to confirm the fetal presentation, position, and degree
of descent” (Pillitteri, 2010).
a. Cervical Dilatation: 0-10 cm
b. Cervical Effacement: Cervix is taken up into the upper uterine segment-

expressed in 0-100%; cervix is shortened from 3cm to < 0.5 cm in length-
thinning of cervix.
c. Cervical position: cervix can be directly anterior and palpated easily or

posterior and difficult to palpate.
d. Cervical consistency: firm or soft.
e. Fetal Station: Location of presenting part in relation to mid-pelvis or ischial

spine. Expressed as cm above or below spines:
P a g e 49 | 84
1. Station 0 is ENGAGED.
2. Station -2 is 2 cm above the ischial spines.
f. Fetal Presentation: Part of the fetus that presents to the inlet:

a. Shoulder (acromion).
b. Breech (buttocks).
c. Other variations include: brow (sinciput), chin (mentum).
g. Fetal Position:
The relationship of the point of reference (occiput sacrum, acromion) on the
fetal presenting part (vertex, breech, shoulder) to the mother’s pelvis. Most
common is left occiput anterior). The point of reference on the vertex (occiput)
is pointed up toward the symphysis and directed toward the left side of
maternal pelvis.
h. Fetal Lie:
The relationship of the long axis (spine) of the fetus to the long axis (spine) of
the mother. It can be either longitudinal (up and down), transverse
(perpendicular), or oblique (slated).
i. Fetal Attitude :
Relationship of the fetal parts to one another.
a. Flexion and extension.
b. Flexion is desired so that the smallest diameter of the presenting part
moves through the pelvis.
8. Meconium-stained fluid is yellow green or gold-yellow and may indicate fetal

distress.
9. Hyperventilation during labor and delivery-results in respiratory alkalosis due to

blowing off too much CO2. Have woman breath into her cupped hands or a paper
bag in order to rebreathe CO2. S/S include:
a. dizziness
b. tingling of fingers
c. stiff mouth.
13. Schedule of clinic visits
“Screening includes an extensive health history, a complete physical examination,

including a pelvic examination, and blood and urine specimens for laboratory work.
Manual pelvic measurements can be taken to determine pelvic adequacy” (Pillitteri,
2010).
1. First visit:
as soon as the mother missed a menstrual period, when pregnancy is suspected.
2. Schedule of visit
a. Every 4 weeks, up to 32 weeks
b. Every 2 weeks from 32-36 weeks (more frequently if problems exist)
c. Every week from 36-40 weeks
10. Schedule future visit/prenatal check-up:

a. Low risk clients
1. Every month until 28 weeks.
2. Every 2 weeks from 28 weeks until 36 weeks.
3. Every week from 36 weeks until delivery.
b. High risk clients schedule is determined by client’s needs; visits are
scheduled as needed.
11. Obtained laboratory data:

1. Hgb, pregnant valuees10-14 f/dl.
2. Hct, pregnant values 32-42 %.
P a g e 50 | 84
3. WBC and differential.
4. Hgb electrophoresis (sickle cell).
5. Pap Smear and cytology
6. Antibody Screens: HIV, HBsAg, Toxoplasmosis,Rubella (>
1:8=immunity), SY/VDRL, Cytomegalovirus.
7. PPD.
8. Rh and BT.
9. Urinalysis.
12. at approximately 28-32 weeks AOG,

the maximum plasma volume increase of 25-40 % occurs, resulting in
normal hem dilution of pregnancy and Hct.values of 32-42% . High Hct
values may look good, but in reality represent pregnancy induced HPN and
depleted vascular space.
13. Hgb/Hct. data can be used to evaluate nutritional status. A weight gain of 2-
4 lbs during the first trimester is recommended and this client is anemic.
Supplemental iron and a diet higher in iron are needed:
a. Fish and dairy products.
b. Cereal and yellow vegetables.
c. Green leafy vegetables and citrus fruits.
d. Egg yolks and dried fruits.
14. Danger Signs of Pregnancy
“Although most signs indicating complications of pregnancy occur toward the

end of pregnancy, women need to know what these are from the beginning Any
bleeding from the vagina (Pillitteri, 2010).”
1. Gush of fluid from the vagina (clear, not urine)
2. Regular contractions occurring before due date
3. Severe headaches or changes in vision
4. Epigastric pain
5. Vomitting that persist and so severe
6. Changes in fetal activity pattern
7. Temperature elevataton, chills or sick feeling
8. Swelling in upper body, especially face and fingers
Learning Activity
Question 1. Define key terms associated with anteparal care.(15pts.)
Question 2.Give the classification of pregnancy signs, danger signs.(15pts.)
Question 2.1.Write in matrix form the signs and symptoms of pregnancy according to
each category.( 25pts.)
Question: 3.Give the formula and how to compute Gravida differ from Para.(10pts.)
Instruction: Explain not more than 30 words.

Question 4. Give the meaning of GPAL in pregnancy?(5pts)
Question 5.Describe maternal changes and stages of fetal development.(40pts.)
P a g e 51 | 84
UNIT 1V
Learning Objectives
At the end of the unit, I can able to:
1. identify dangers signs during pregnancy.
2. Interpret diagnostic tests procedures for selected complication of pregnancy.
3. Identify expected outcomes of treatment modalities for clients experiencing selected
complications of pregnancy.
4. Use critical thinking to manage nursing care for clients experiencing selected
complications of pregnancy.
5. Evaluate expected outcomes of nursing care for clients experiencing complications of
pregnancy
A. Pregnancy Intrapartum Care
1. Intrapartum period
It extends from the beginning of contractions that cause cervical dilation to the first
1-4 hours after delivery of the newborn and placenta.
Labor It is a series of processes by which the product of conception are expelled from
the maternal body.
Delivery is referring to the actual event of birth.
2. Theories of labor onset
“Labor normally begins when a fetus is sufficiently mature to cope with extrauterine
life yet not too large to cause mechanical difficulty with birth” (Pillitteri, 2010).
1. Uterine stretch theory/ over distention theory

As the uterus is growing and distended
Which results in the release of prostaglandin
2. Oxytocin theory
pressure on the cervix releases oxytocin from the posterior pituitary that stimulate
uterine contraction. Receptors for oxytocin in the uterus increases as term
approaches
3. Theory of aging placenta

Which trigger contraction at a set point
4. Changes in the ratio of estrogen to Progesterone theory

Increasing estrogen in relation to progesterone stimulates uterine contraction due
to rising fetal cortisol level w/c reduce progesterone level)
Level of progesterone assayed (analyzed) in preterm and term pregnancy
a.Preterm: Progesterone level is still high
b. approaching Term: level of progesterone decreases causing contraction of
uterus.
5. Prostaglandin theory
Fetal membrane production of prostaglandin which stimulates contraction.
a. Premature: high levels of prostaglandin
b. Term/post term: low levels
Coitus is contraindicated if you have a history of prematurity since semen
contains prostaglandin.
P a g e 52 | 84
3. Signs of Impending Labor
“Before labor, a woman often experiences subtle signs that signal labor is
imminent. It is important to review these with women during the last trimester of
pregnancy so they can more easily recognize beginning signs. (Pillitteri, 2010)”
1. Lightening
The descent of the fetus and uterus into pelvic cavity before labor onset. It
occurs 2-3 weeks earlier in primipara. In multipara, it may not occur until
labor begins.
a. Gives a woman relief from diaphragmatic pressure shortness of
breath. Gives the word“lightens”her load.
b. The mother may experience shooting leg pains from the increased
pressure on the sciatic nerve, increased vaginal discharge, urinary
2. Cervical Changes
a. Effacement
progressive softening “ripening” and thinning of the cervix.
“Bloody Show” (expulsion of mucous plug)
b. Dilation
increase in diameter of cervical opening measured in centimeter.
(opening of cervical os during labor.)
3. Regular Braxton Hicks’ contractions. (painless contraction)

4. Rupture of amniotic membranes.
a. Labor may begin with rapture of membrane either sudden gush or
as scanty
b. Early rapture of the membranes can be advantageous, if it causes
the fetal head to settle snugly into the pelvis, this can cause to
shorten labor
2 Risk Associated with Raptured Membranes
1. Intrauterine infection
2. Prolapse of the umbilical cord
5. Nestling behaviors
Sudden burst of energy by the mother or increase level of energy of
the mother due to production of epinephrine that is initiated by decrease
production of progesterone
6. Weight loss
Weight loss of about 1-3 lbs. 2-3 days before labor
Duration of Labor
a. Primi - 6-8 hrs.
b. Multi – 3-5 hrs
c. long labor 14 hrs.
4. Variables Affecting Labor

(4 P’s of labor)
“A successful labor depends on four integrated concepts (Pillitteri, 2010).”
1. Passageway
Refers to the adequacy of the pelvis and birth canal in allowing fetal descent. Refers to the
route a fetus must travel from the uterus through the cervix and vagina to the external
perineum.
5. 4 Types of Pelvic Shapes
“Two pelvic measurements are important to determine the adequacy of the

pelvic size: the diagonal conjugate (the anteroposterior diameter of the inlet) and
the transverse diameter of the outlet” (Pillitteri, 2010).
P a g e 53 | 84
a) Android: It is narrow, heart-shaped, male type of pelvis. The
Anterior part is pointed and the posterior part is shallow.
b) Anthropoid: It is narrow, oval shaped, the AP diameter is equal to or greater
than the transverse diameter and resembles ape pelvis.
c) Gynecoid is the classic female pelvis, suitable for pregnancy and ideal for
childbirth. The inlet is well rounded forward and backward and the pubic
arch is wide and round.
d) Platypelloid is Flattened, oval, transverse shape, But with broad pelvis and
with shortened AP diameter.
6. Pelvic Divisions
“ In most instances, if a disproportion between fetus and pelvis occurs, the pelvis is the
structure at fault. If the fetus is the cause of the disproportion” (Pillitteri, 2010).
1. False Pelvis
a. Shallow upper basin of the pelvis
b. Supports the enlarging uterus but not important obstetrically
c. Linea Terminalis
d. Plane dividing upper or false pelvis from lower or true pelvis
2. True Pelvis
a. Consists of the pelvic inlet (diagonal conjugate),
b. pelvic cavity, and pelvic outlet ( Tuber-ischial diameter/
Intertuberous diameter)
c. Bony canal through which the infant pass
d. Measurements of true pelvis influence the conduct and
progress of labor and delivery.
7. Affected by the following Factors in Determining the Adequacy of the Pelvic

size:
1. Pelvic measurements
A. Diagonal conjugate of the Pelvic inlet. The AP diameter is the narrowest

diameter. AP diameter of pelvic inlet should be 12.5 cm is rated as adequate for childbirth;
may be obtained through vaginal examination. the one that is most apt to cause a misfit with
the fetal head. Fetal head average 9 cm. in diameter. To measure it two fingers are introduced
vaginally and pressed inwards and upward until the middle finger touches the sacral
prominence.
B. True conjugate or conjugate vera Is the measurement between the anterior

surface of the sacral prominence and the posterior surface of the inferior margin of the
symphysis pubis.The actual diameter of pelvic inlet should be at least 11 cm, may be obtained
by x-ray (Pelvimetry/ u/s- to determine if the fetus can pass through NSD)
C. Tuber-ischial diameter/ Interrupters diameter ( Pelvic outlet)

1. Measures the outlet between the inner borders of ischial
tuberosities, should be at least 11 cm.
2. The transverse diameter of the pelvic outlet is the narrowest
diameter. (most apt to cause misfit) estimated on pelvic
exam. If disproportion occurs , the pelvis is at fault
3. Ability of the uterine segment to distend, the cervix to dilate

and the vaginal canal and introitus to distend.
4. Structure of pelvis ( false pelvis vs. true pelvis)
P a g e 54 | 84
Passenger
The passenger is affected by the following Factors: Size of the fetal head and capability of
molding to passageway. The head is the body part of the fetus that has the widest diameter.
This is the part least likely to pass through the pelvic ring. ¼ of the fetus length.
Cranium is composed of 8 Bones:

A. Little significance in childbirth because they are never a presenting parts.
1. Sphenoid
2. Ethmoid
3. Temporal(2x)
B. Important In childbirth:
4. Frontal
5. Parietal (2x)
6. Occipital
The bones of the skull meet at suture lines:
“The cranium, the uppermost portion of the skull, is composed of eight bones. The
four superior bones—the frontal (actually two fused bones), the two parietals, and the
occipital—are the bones that are important in childbirth” (Pillitteri, 2010).
1. Sutures
Are Internal membranous spaces that allows the cranial bones to move
and overlap, molding or diminishing the size of skull to pass through the
birth canal.
a. Molding – The overlapping of the sutures of the skull to permit passage
on the head to
b. Fetal Attitude – the relationship of fetal parts to one another
c. Fetal presentation– part of the fetus that enters the maternal pelvis first.
Cephalic - vertex, face, brow. Breech – frank, footling, complete.
d. Fetal Lie (spine to spine) may be longitudinal (parallel), transverse (right
angles), oblique (slight angle off true transverse lie)
2. Fontanels
Are membrane filled spaces where sutures intersect and compress during
birth to aid in molding of the fetal head and help to establish the position
of the fetal head whether it is in favorable position for birth.
1. Anterior fontanel- (bregma) diamond shape (lies at the junction of
the coronal and sagittal sutures (4 bones)
2. Posterior fontanel - small; irregular (lies at the junction of the
lambdoidal and sagittal sutures. (3 sutures = 2 parietal and 1
occipital bones) The space bet 2 fontanels referred to as vertex. The
area over the frontal bone is referred to as sinciput. The area over
the occipital bone is referred to as the occiput.
Fetal Head Measurements
1. Biparietal Diameter (side to side)
NB :(AP diameter of the pelvis 11 cm.)
The narrowest fetal head diameter is 9.5 cm. in diameter.
2. Anterior posterior diameter
NB: (maternal transverse diameter of the pelvis 11cm.)
3. Suboccipitobregmatic diameter
From the inferior aspect of the occiput to the center of the anterior
fontanel (full flexion) The smallest AP diameter; 9.5 cm.
4. Occipitofrontal diameter
From the bridge of the nose to the occipital prominence
Presented in moderate flexion; 12 cm
5. Occipitomental Diameter:
Widest anteroposterior diameter, and is measured from the
chin to the posterior fontanels. The largest AP diameter ; 13.5cm
Presented in poor flexion
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3. Fetal Attitude:
Is the relationship of fetal parts to one another. The degree of flexion the
fetus assumes during labor
a. Flexion: normal
b. Hyperextension: abnormal
4. Fetal Lie:
The relationship of fetal longitudinal axis to maternal longitudinal axis
(spine of mother and spine of fetus are parallel)
a. Longitudinal: Fetal spine is parallel to mother’s spine
b. Transverse: the long axis of the fetus is perpendicular to the long
axis of the mother
5. Fetal Presentations:
Fetal part entering pelvis first (felt on vaginal exam or U/S)
a. Cephalic: The most frequent type. Occiput presents in vertex,
brow, face or military are other cephalic presentations.
b. Breech: either the buttocks or the feet are the first body parts
that will contact the cervix or be born first.
c. Complete breech: In full flexion. Thighs are tightly flexed on the
abdomen
d. Frank breech: In moderate flexion, Hips are flexed but the knees
are extended to rest on the chest.
e. Footling breech: In poor flexion. Neither the thighs nor the lower
legs are flexed
f. Shoulder: Scapula presents (transverse)
6. Fetal Position:
The relationship of the fetal presenting part to a specific quadrant of a
woman’s pelvis. A series of 3 letters.
Maternal Reference Point
1. First letter: Side of maternal pelvis that presenting part is toward:
A. Left (L) B. Right (R) C. Transverse (T)
2. Middle letter: Fetal landmark (O, M, S, A)
3. Third letter: Mother’s anterior or posterior (A) for anterior, ( P )of
Posterior
a. Most common: (LOA ) left occiput anterior
b. Second most common :( ROA) right occiput anterior
7. Fetal Station
Relationship of presenting part to ischial spines of maternal pelvis.
Ischial spines mark the narrowest diameter through which fetus must
pass.
a. Station at level of spine is 0
b. If higher than spines, -5 to –1 indicates a presenting part above zero
station (Floating)
c. If lower than spines + 1 to + 5 indicates a presenting part below zero
station (crowning)
Engagement: Is when largest diameter of presenting part reaches pelvic
inlet and can detect by vaginal examination.
Floating: presenting part directed toward pelvis but can easily be moved
out of inlet, it is floating
Ballotable: Presenting part dips into inlet but can be displaced with upward
pressure
Engaged: Takes in pelvic inlet it cannot be dislodged
Power: Refers to the frequency, duration, and strength of uterine contractions to cause
complete cervical effacement and dilation.
The forces acting to expel the fetus and placenta based on the following:
1. Involuntary contraction
2. Voluntary bearing down
3. Characteristic: wave like
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4. Timing: frequency, duration, intensity
8. Three Phases of Labor Contraction
1. Increment- when the intensity of the contraction increases.

2. Acme/Peak–when the contraction is at its strongest intensity.
3. Decrement – when the intensity decreases.
Between contractions uterus relaxes. As labor progresses, the relaxation
interval decreases from 10 minutes early in labor to only 2-3 minutes. The
duration of contraction also changes increasing from 20 to 30 seconds to range
of 60 to 90 seconds
9. Characteristics of Contractions
Frequency– beginning of one contraction to beginning of next contraction. Less than 2

minutes should be reported.
Duration – beginning of one contraction to end of first contraction. More than 90 seconds
should be reported because of uterine rupture or fetal distress.
Interval - beginning of end of first contraction to next contraction
Intensity – the strength of contraction at its peak. May be mild, moderate or strong
10. Comparison of True and False Labor

False labor True labor
Irregular contractions Regular contractions
11. Decrease in frequency & intensity Progressive frequency & intensity

Stages
During
Longer intervals bet. Contractions Shorter intervals bet. contractions
Labor and
Delivery
Discomfort in lower abdomen & groin Discomfort begins in back & radiates
to the abdomen
Activity such as walking either has no Activity such as walking, increases

effect or decreases contraction contractions
Disappear while sleeping Continue while sleeping
Sedation decreases or stops Sedation does not stop contractions

contractions
Bloody show usually not present Bloody show usually present
No appreciable change in the cervix Progressive thinning & opening of

the cervix
Stage 1 is the beginning of true labor to full cervical dilation (0-10 cm). There is
effacement: The shortening and thinning of the cervical canal. In primiparas,
effacement is accomplished before dilatation begins. In multiparas, dilatation
may proceed before effacement is complete Dilatation: The enlargement or
widening of the cervical canal
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3 phases of Stage 1
1. Latent Phase
Time: Primipara (6 hrs.)
Multipara (4 ½ hrs.)
Cervix:
Effacement - 0-50%
Dilation - 0-3 cm
Contractions
Frequency - 10 minutes apart
Duration - 20-40 seconds
Intensity
Mild : < 50 mm Hg
Manifestations: cause minimal abdominal cramps; backache; Client generally
excited, alert, talkative and in control; can walk;may rupture membrane
Reason for prolonged latent phase is:

a. CPD
b. Analgesia given too early
c. Non ripe cervix
2. Active Phase
Time: Primipara (3 hrs.)
Multipara (2 hrs.)
Cervix:
Effacement - 100%
Dilation - 4-7 cm
Contractions:
Frequency - 3-5 minutes
Intensity:
Moderate: 50 – 75 mm Hg
Manifestations: SHOW; Moderate increase in pain; Client more apprehensive,
fear of losing control; focusing on self; skin warm and flushed
3. Transition Phase
Time:
Primipara (1 hour)
Multipara (10 - 15 minutes)
Cervix:
Effacement: 100%
Dilation: 8-10 minutes
Contractions:
Frequency: 2-3 minutes
Duration: 60-90 seconds
Intensity:
Hard: 75-100 mmhg
Manifestations: Client may be irritable and panicky: perspiring, nauseous and
vomiting is common: Trembling of legs: pressure on bladder and rectum:
backache Increased show; pallor and when reached 10 cm of dilatation, a new
sensation an irresistible urge to push occurs.
12. Nursing Care During the First Stage of Labor
“begins at the onset of regularly perceived uterine contractions and ends when
rapid cervical dilatation begins. Contractions during this phase are mild and short,
lasting 20 to 40 seconds. Cervical effacement occurs, and the cervix dilates from 0 to
3 cm” (Pillitteri, 2010).
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1. Ambulation – encourage ambulation to shorten the first stage of labor,
encourage walking around the unit Contraindicated if membranes raptured
2. Bladder care: Encourage every 2 hours
3. Breathing through chest
4. Positioning: Position of comfort , Left side- lying position is encouraged
5. Pain relief measure: Relaxation and breathing techniques, focusing and
imagery, therapeutic touch and massage. Narcotic analgesics: meperidine
hydrochloride (demerol), morphine sulfate, nalbuphine (nubain),fentanyl,
(sublimaze), butorphanol (stadol)
6. Assessment of amniotic fluid
a. Clear – normal color
b. Yellow stained- blood incompatibility
c. Green – meconium staining
d. Gray/ cloudy – infection
e. Pink/red – bleeding
f. Brown-fetal death
Stage II:
“Is from the complete cervical dilation of the cervix to birth of babThe second stage
of labor is the period from full dilatation and cervical effacement to birth of the infant; with
uncomplicated birth, this stage takes about 1 hour (Archie, 2007). A woman feels contractions
change from the characteristic crescendo–decrescendo pattern to an overwhelming,
uncontrollable urge to push or bear down with each contraction as if to move her bowels”
(Pillitteri, 2010)
Time:
Primipara (30-50 minutes)
Multipara (20 minutes)
Contractions:
Frequency - 2-3 minutes
Intensity:
Very Hard: 100 mm Hg
Manifestations: Decrease in pain from transitional level; increased bloody
show; Excited eager and in control. Contraction change from crescendo-
decrescendo pattern to an overwhelming, uncontrollable urge to push or bear
down
Imminent Signs
Uncontrollable urge to push with each contraction. Dilatation of the orifice.
Bulging of the perineum, the vaginal introitus opens and the fetal scalp appears
in the opening to the vagina.First, slit like, then becomes oval and then circular
and enlarge from the size of a dime ,then quarter, then a half dollar, this is
called CROWNING. As she pushes, using her abdominal
muscles to aid the involuntary uterine contraction, the fetus is pushed out of
the birth canal.
13. Mechanism of Labor
“Passage of a fetus through the birth canal involves several different position changes to keep
the smallest diameter of the fetal head (in cephalic presentations) always presenting to the
smallest diameter of the pelvis. These position changes are termed the cardinal movements
of labor” (Pillitteri, 2010)
1. Engagement,
2. Descent/effacement
3. Flexion
4. Internal rotation
5. Extension
6. External rotation
7. Expulsion.
P a g e 59 | 84
Descent is the downward movement of the biparietal diameter of the fetal head to the
pelvic inlet. Descent occurs because of the pressure on the fetus by uterine fundus.
Flexion as it reaches the pelvic floor, the head bends forward onto the chest, making the
smallest AP diameter as the one presented to the birth canal.
Flexion is aided by abdominal muscle contraction during pushing
Internal Rotation the occiput rotates until it is superior, the AP diameter of the head is now
in the AP plane of the pelvic outlet
Extension the head extends, the face and chin are born.
External Rotation (Restitution) the head rotates back to its transverse position of early
labor; the anterior shoulder is born first.
Expulsion the rest of the fetal body is born; the end of the pelvic division of labor
14. Nursing Care During 2nd Stage
1. Preparing place of birth
a. Primipara: When cervix is fully dilated and perineum is bulging

b. Multipara: When cervix is 7-9- cm dilated
A table set with sterile equipment such as:
a. Sponges d. clamps
b. drapes e. bulb syringe
c. Scissors f. vaginal packing
d. Basins g. sterile gowns, gloves & towels
To provide newborn care:

Radiant heat warmer
Suction and resuscitation
Supplies for eye care
Identification of the newborn
2. Positioning
Lithotomy Position-the best position for performing episiotomy or forceps assisted birth.
less tension and fewer perineal tears.
Other Alternative Birth Position:

a. Sim’s or lateral
b. Dorsal recumbent (on the back with knees flexed)
c. Semi squatting
d. Squatting
3. Pushing
a. Push with contraction and rest in between contractions
b. Urge to breath out during a pushing effort
c. For multipara, urge to pant with contractions
4. Perineal Cleaning
1. Clean the perineum with warm antiseptic (cold solution causes clamping)and
then rinse with it with a designated solution according to the policy of the
physician/ nurse/midwives/ agency.
2. Always clean from the vagina outward, using a clean compress for each
stroke.
3. Be sure to include a wide area (vulva, upper inner thighs, pubis and anus)
4. After cleaning place sterile drape around the perineum.
5.
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5. Episiotomy: Surgical incision of the perineum
Advantage
1. Prevents tearing of the perineum
2. Minimizes pressure on the fetal head
3. Shortens the second stage
15. Two Types of Episiotomy
1. Midline episiotomy: in the midline of the perineum

2. Mediolateral episiotomy: began in the midline but directed laterally away from
the rectum
16. Advantage of Mediolateral Episiotom
If tearing occurs beyond the incision, it will be away from the ectum.
17. Advantage of median episiotomy
a. Heal more easily

b. less blood loss
c. and less post partal discomfort
Birth of the baby
a. Place a sterile towel over the rectum.

b. Immediately after birth of the baby’s head, suction out the infants mouth with
a bulb syringe and then passes her fingers along the occiput to the newborn’s
neck.
c. To determine whether a loop of umbilical cord is encircling the neck. If such a
loop is felt, loosened and drawn down over the fetal head before the shoulders
are born.(nuchal cord)
d. External rotation occurs. Gentle pressure is exerted downward on the side of
the infant’s head and the anterior shoulder is born and slightly upward allows
the posterior shoulder is born.
e. The remainder of the body then slides free without any further difficulty.
Note : the time and record the time of birth . This is the nursing responsibility
to announce the sex of the infant.
f. Cutting and clamping the cord
1-3 minutes. Depends on the maturity of the infant
Advantages of late clamping

1. Delaying the cutting until pulsation ceases allowing 100 ml of blood to pass
from the placenta into the fetus.
2. Ensures an adequate RBC count in term newborn
Disadvantage of late clamping

Causes polycythemia and hyper bilirubinemia in preterm infants.
The cord is clamped with two kelly hemostats placed 8-10 inches from the infant’s umbilicus
and then is cut between them. A cord blood sample is taken to provide a ready source of
infant’s blood if bld. typing or other emergency measures. An umbilical clamp is then applied
and the vessels in the cord is counted. Immediate care of the newborn and introducing the
Infant to parents.
3. Stage III is from birth of baby to delivery of placenta.

Time: 5-30 minutes
Contractions:
Strong and well-contracted uterus changing to globular shape
P a g e 61 | 84
Manifestations:
a. Increased gush of blood
b. Uterus becoming globular with fundus rising in the abdomen
c. Apparent lengthening of cord
Client focuses on newborn
a. Excited about birth
b. Feeling of relief
18. Signs of Placental Separation
“If the placenta separates first at its center and last at its edges, it tends to fold onto itself
like an umbrella and presents at the vaginal opening with the fetal surface evident. Appearing
shiny and glistening from the fetal membranes, this is called a Schultze presentation”
(Pillitteri, 2010).
a. Change in the shape of the uterus Calkin’s sign= fundus becomes

globular and rises (early sign of placental separation)
b. Lengthening of the cord – most reliable sign
c.Sudden gush of blood
d. Rising of the uterus into the abdomen up to the level of the
umbilicus, 1 cm after the delivery of the placenta.
Note: application of the Brandt Andrews Maneuver (Delivery)
19. 2 types of placental delivery
1. Schultz: Shiny fetal membrane surface; the placenta separate first at

its center. cotyledon is not seen
2. Duncan: dirty; maternal side; Red, irregular maternal surface; the
placenta separate first at it’s edges. cotyledons are easily visible.
Nursing Actions
1. Check the completeness of placenta 15- 20 of cotyledons
2. Best time to clamp and cut the cord: when the cord stops pulsating.
3. Check the fundus
4. Uterine massage should be at the level of umbilicus
5. Check BP: Administer Methergine or methylgonovine maleate to
prevent hemorrhage.
S/E: Hypertension, avoid with pre eclamptic client.
Nursing alert: should not be given to pre eclampsia, eclampsia or with
high BP. It is given in Bolus pitocin/ocin.
Oxytocins: oxytocin synthetic (Pitocin, Syntocinon)

Intro
a. Indication: Uterine atony
b. Adverse Reactions: severe after pains in multipara and
hypertension.
c. Nursing Implications: Give immediately after delivery of placenta to
avoid “trapped” placenta.10-20units added to remaining IVF at
(least 500ml). May stimulate let-down milk reflex and flow of milk
when engorge,pain of contractions- decrease
20. Local anesthesia
a. Used for pain relief during episiotomy and perineal repair.

b. Safe for mother.
21. Regional blocks
a. Used for relief of perineal and uterine pain.

b. Usually safe for mother unless severe HPN occurs
P a g e 62 | 84
Types:
1. Pudendal block: to deaden pudendal nerve plexus w/c deadens the

perineum and vagina.
2. Peridural (epidural, caudal): blocks nerve impulses from T7 to S5
thereby deadening the effectiveness of pushing.
3. Intradural (subarchnoid, spinal): to deaden uterine and perineal pain-
client must remain flat 6-8 hrs after delivery.
Meperidine HCL (Demerol, Pethidine)
a. Indications: synthetic opiate; narcotic used to produce
analgesia; euphoria and sedation in labor
b. Adverse reactions: respiratory depression, fetal
narcosis/distress; hypotension; may compromise the fetus.
c. Nursing Implications: store in narcotic’s cabinet; do not give if
RR < 12/min; have narcotic antagonist available; monitor VS.
Naloxone HCL (Narcan)
a. Indication: narcotic antagonist-used to counteract narcotic
effects
b. Adverse reaction: decrease respirations rarely occurs
c. Nursing implications: monitor RR since drug action is shorter
than the narcotic (may need to be re administer); pain returns
after administration; can be administered to newborn to
counteract narcotic depression
Butorphanol tartrate (Stadol)
a. Indication: provision of analgesia.
b. Adverse reactions: respiratory depression; woman with
preexisting narcotic dependency will experience withdrawal S/S
immediately.
c. Nursing Implications: give IM or IV; obtain drug hx before
administration; monitor S/S.
Morphine sulfate (MS Contin)
a. Indication: routine use for analgesia
b. Adverse reaction: respiratory depression.
c. Nursing implications: monitor S/S
3. Check for laceration in the perineum\

Laceration
a. 1st degree tear: Involves the epidermis.
b. 2nd degree: involves dermis, muscles and fascia.
c. 3rd degree: extends into the anal sphincter
d. 4th degree: extends up to rectal mucosa.
4. Assist in episiorrhapy
5. Wash with saline and betadine
6. Flat on bed to prevent dizziness/ hypotension
7. Give additional blanket if chilling occurs- caused by dehydration
8. Clear liquid diet to full or general liquid diet
Stage 1V: is the first 1-4 hours after delivery of placenta.
22. Watch for possible complications:
1. Hemorrhage
2. Uterine atony
3. Uterine prolapsed
4. Lacerations
5. Displacement of the uterus
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23. Postpartum PE:
1. Fundus: firm, midline, at or below the umbilicus.

2. Lochia: rubra,moderate, and clots < 2-3 cm
3. Perineum: intact, clean and slightly edematous. Suspect hematomas if very
tender, discolored, or pain is disproportionate to vaginal delivery.
4. Laceration
1st degree tear: Involves the epidermis.
2nd degree: involves dermis, muscles and fascia.
3rd degree: extends into the anal sphincter
4th degree: extends up to rectal mucosa.
4. Psyche
Refers to the client’s psychological state, available support systems,
preparation for birth, experiences, and coping strategies. The readiness and
preparation of the woman for labor and delivery
Learning Activity
Instruction: Write in , wrong spelling will not be counted.

Question1 .You Identify danger signs during pregnancy.(10pts.)
Instruction: Write in not less than 50 words but not more than 60 words.
Question 2. You discuss what are the nutritional requirements and assessment for
antenatal care?(15pts.)
Instruction: Enumeration type in correct spelling.

Question 2.1. You discuss what nursing interventions to manage for a malnutrition
during pregnancy (15pts.)
Instruction: Enumerate, each procedure and diagnostic test.

Question: 3.You discuss fetal diagnostic test /procedure.(25pts.)
Instruction: Discuss in essay form in not less than 50 words.

Question 4. You Identify expected outcomes of nursing care for clients experiencing
complication of pregnancy. (15pts.)
Instruction: matrix form (4P’s)

Question: 5. You identify factors affecting labor and delivery. (10pts.)
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UNIT V
Learning Objectives:
At the end of the unit, I am able to:

1. explain theories related to the onset of labor.
2. Differentiate between true and false labor.
3. Explain induction /augmentation of labor stages and its nursing interventions.
4. Differentiate between stages of labor.
5. Use critical thinking to manage nursing care of placental separation.
A. Post-Partum
Postpartum care
Refers to the medical and nursing care given to a woman during the puerperium, which is
the 6-week period after delivery, beginning with termination of labor and ending with the
return of the reproductive organs to the non-pregnant state.
1. Postpartum Biophysical Changes
Uterus
1. Process of involution takes 4-6 weeks to complete.
2. Weight decreases from 2 lbs to 2 0z.
3. Uterine involution
4. Lochia
Cervix
1. Becomes thicker and firmer.
2. Complete cervical involution may take 3-4 months.
3. Childbirth results in permanent change in the cervical os from round to
elongate.
Vagina
1. Smooth and swollen, with poor tone after delivery.
2. Rugae reappear by 3-4 postpartum weeks.
Perineum
1. Edematous and bruised after delivery.
2. Episiotomy and lacerations may be present.
3. Episiotomy
4. Perineal care
5. Fill bottle with warm water, and if ordered, an ounce of povidone/iodine
solution.
6. Lavage perineum with several squirts and blot dry instead of rubbing;
avoid anal area.
Abdomen
1. Remains soft and flabby for some time after delivery.
2. Striae remain but are silvery white.
Breast
1. Colostrum present at birth;
2. breast milk is produced by the third or fourth postpartum day.
3. Congestion subsides in 1-2 days.
The average amount of milk produced in 24 hours increases with time.

1. First week – 6-10 oz
2. 1-4 Weeks - 20 oz
3. After 4 weeks
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Colostrum is a thin watery, yellow fluid secreted during the first 2 days post-
partum
High in protein, low in sugar and fat; with vitamins, minerals, antibodies
Transitional breast milk forms on the 2nd to 4th day of breastfeeding. The
preferred feeding method for newborns and the ideal nutritional source for
infants through the 1st year of life.
Mother:
1. Aids in uterine involution
2. Enhances bonding between mother and
3. Causes a delay in menstruation
4. Prevents breast cancer
Infant:
1. Contains antibodies (immunity to specific germs.)
2. Has lactoferrin
3. Has interferon (protein)
4. has bifidus factor
5. high in lactose (milk sugar)
Contraindications
1. HIV- Positive women
2. Herpes lesions on a mothers nipples
3. Infant with galactosemia (inability to convert galactose to
glucose causing mental retardation)
4. Maternal medication
5. Breast cancer
Health teachings
Breastfeeding should begin after birth as soon as possible. And
should be fed every 2-3 hours. During breastfeeding, the Infant
should grasp both the nipple and areola, and should be
positioned slightly differently for each feeding. Begin next
feeding on the breast that newborn used most recently. Break
suction by inserting a finger in the corner of the infant’s mouth.
Burp the infant after they have emptied the first breast and again
after the total feeding. Infant wets 6-8 diapers per day with the
passage of two or more loose, light yellow, seedy stools
Endocrine System
Ovulation and resumption of menstruation are influenced by whether or not the client
breast feeds.
a. 48% (Lactating women) resume menstruation by 12 weeks. 80%
have one or more an ovulatory cycles before the first ovulation.
b. 40% (Non-lactating women) resume menstruation by 6 -10 weeks
after birth.
Cardiovascular System
a. Transient bradycardia (50-70 bpm) occurs for 24-48 hours after

delivery;may persist for 6-8 days(inc. stroke volume)
b. Hematocrit rises by 3rd – 7th postpartum.
c. Leukocytosis (20,000-30,000/mm3) for several days after delivery.
d. BP and PR returns to nonpregnant state by 3 months postpartum.
Circulatory system
a. 300-500 blood loss with vaginal birth

b. 500- 1000 ml blood loss with cesarean birth
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Respiratory System
The pulmonary functions return to no pregnant state by 6 months post-

delivery.
Immune System
There is Slight increase in temperature after delivery and is normal.
Renal and Urinary Changes
a. Over distention of the bladder common due to:

1. increased bladder capacity
2. bruising of the tissues around urethra
3. diminished sensation to increased pressure
b. adequate bladder emptying resumes in 5-7 days after delivery.
c. Puerperal diaphoresis and diuresis occur within 24 hours post-delivery.
Gastrointestinal System
Intro
a. Constipation is common.
b. Client ‘s pre-pregnant weight returns after 6-8 weeks.
c. Hemorrhoids common.
Post partal blues: Or “Baby blues” is a temporary feeling of sadness after birth. (3-
7 days) – Normal occurrence of “coaster” emotions or (mood swing)
a. Caused by hormonal changes particularly decrease in estrogen and
progesterone that occurs with delivery of placenta.
b. Or due to exhaustion, being away from home, physical discomfort and tension
by assuming new roles especially if not receiving support from her partner.
2. Postpartum Nursing Care
a. Assess lochia and color volume.

i. Check episiotomy and perineum for signs of infection.
b. Assess for attachment and bonding.
c. Promote successful feeding.
Non-nursing woman- tight bra for 72 hours, ice packs, minimizes breast
stimulation.
Nursing woman- success depends on infant sucking and maternal production of
milk.
d. “Postpartum Blues” (3-7 days) – Normal occurrence of “roller coaster” emotion
e. Sexual activities- abstain from intercourse until episiotomy is healed and lochia
ceased around 3-4 weeks. Remind that breastfeeding does not give adequate
protection.
3.Postpartum Warnings Signs and Symptoms to Report to the Physicial
1. Increased bleeding, clots or passage of tissue.

2. Bright red vaginal bleeding any time after birth.
3. Pain greater than expected
4. Temperature elevation to 100.4º F.
5. Feeling of full bladder accompanied by inability to void.
6. Enlarging hematoma.
7. Feeling restless accompanied by pallor; cool, clammy skin; rapid HR; dizziness;
and visual disturbance.
8. Pain, redness, and warmth accompanied by a firm area in the calf.
9. Feeling restless accompanied by pallor; cool, clammy skin
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UNIT -V1
Learning Objectives
At the end of the unit, I can able to:
1. describe the various aspect of normal puerperium key terms associated with
postpartum care.
2. describe postpartum physiologic changes.
3. describe postnatal psychosocial changes.
4. explain various postnatal nursing intervention.
5. recognize selected complications of postnatal to report immediately to
physician.
A. Puerperium
Puerperium is achieved after 6 weeks of delivery
1. Postpartum Psychosocial Adaptation

“A transition is a movement or passage from one position or concept to another or
a pause between what was and what is to be. It represents the internal process
experienced by people when change occurs” (Pillitteri, 2010).
1. “Taking In “
a. First 2 days
b. Mother is very dependent for care for self and the newborn
c. rejecting rooming-in is normal.
2. “Taking hold “
a. After 2nd day
b. Mother is now independent of self-care
c. Time of evidence of post-partum blues/ depression is overt.
d. If poor support system is present-predisposing to post-partum
blues/psychosis.
e. Brief psychotic episode last for 3 months.
3. “Letting go”
completely accepted role as a new mother.
2. Normal Puerperium Changes
Uterus
a. Myometrial contractions occur 12-24 pp due to high oxytocin levels
(prominent in multiparas, BF clients and women who experienced over
distention of the uterus.
b. Process of involution takes 4-6 weeks to complete.
c. Weight decreases from 2 lbs to 2 0z. Fundus steadily descends into true
pelvis;
d. Fundal height decreases about 1 fingerbreadth (1 cm)/day; by 10-14
days postpartum, cannot be palpated abdominally.
a. Level of umbilicus --------------- 1st 24 hours
b. 1 cm / fingerbreath below umbilicus------1st day
c. 2 cm/ fingerbreath below umbilicus-------2nd day
d. No longer palpable---------------------------10th day
Placenta site contracts and heals without scaring.
Lochia – discharge from the uterus during the first 3 weeks after delivery.
1. Lochia Rubra
a. Dark red discharge occurring in the first 2-3 days.
b. Contains epithelial cells, erythrocytes and decidua.
c. Characteristic human odor.
2. Lochia Serosa
a. Pinkish to brownish discharge occurring 3-10 days after
delivery.
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b. Serosanguineous discharge containing decidua, erythrocytes,
leukocytes, cervical mucus and microorganisms.
c. Has a strong odor.
3. Lochia Alba
a. Almost colorless to creamy yellowish discharge occurring from 10 days
to 3 weeks after delivery.
b. Contains leukocytes, decidua, epithelial cells,
c. Has no odor.
Assessment of lochial flow

a. Saturating a perineal pad in less than 1 hr. is heavy flow
b. Should not contain large clots
c. Pattern of lochia should not reverse
d. Same odor as menstrual blood
Cervix
a. Becomes parous with transverse slit.
b. Heals within 6 weeks.
c. and dry.
Breast
a. Non-lactating: nodules palpable; engorgement may occur 2-3 days pp.
b. Lactating: milk sinuses (lumps) palpable; colostrum (yellowish fluid)
expressed first, then milk (bluish white); may feel warm, firm, tender for
48 hours.
CVS
At delivery: maternal vascular bed reduced by 15 %; pulse may decrease to 50
(puerperal bradycardia) due to shivering; BP and PR should quickly return to pre-pregnant
levels. b.24-48 hours post-partum: cardiac output remains elevated(returns to non-
pregnant levels in 2-3 weeks); plasma loss>RBC loss, reverses hem dilution of
pregnancy(Hematocrit rises); diaphoresis (especially at night) helps restore normal plasma
volume.
Hematological system
Hematocrit rises; WBC counts elevated (12, 000 to 25, 000); clotting factors elevated,
increased risk for thromboembolism
Urinary system
“Like other systems, the urinary system undergoes many physiologic changes during
pregnancy. These include alterations in fluid retention and renal, ureter, and bladder function”
(Pillitteri, 2010).
a. diuresis occurs, excretes up to 3000 ml/day;
b. bladder distension and incontinence are possible.
c. persistent dilation of Ureter/renal pelvis increase risk of UTI;
d. urine glucose, creatinine, and BUN level normalized after 7 days.
e. Kegel exercises increase integrity of interisland improve uterine
retention (alternate contraction and relaxation).
Gastro Intestinal Tract

“At least 50% of women experience some nausea and vomiting early in pregnancy. This is
one of the first sensations a woman may experience with pregnancy (sometimes it is noticed
even before the first missed menstrual period)” (Pillitteri, 2010).
This is due to excess analgesia/anesthesia that may decrease peristalsis; no bowel
movement expected for 2-3 days.
Integumentary:
“As the uterus increases in size, the abdominal wall must stretch to accommodate it. This
stretching (plus possibly increased adrenal cortex activity) can cause rupture and atrophy of
small segments of the connective layer of the skin. This leads to pink or reddish streaks (striae
gravidarum) appearing on the sides of the abdominal wall and sometimes on the thighs.
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During the weeks after birth, striae gravidarum lighten to a silvery-white color (striae
albicantes or atrophicae), and, although permanent, they become barely noticeable” (Pillitteri,
2010)
a. Chloasma and hyperpigmentation areas (linear nigral, areola) regress;
some areas may remain permanently darker.
a. Palmar erythema declines quickly.
b. Spider nevi fade, some in legs may remain.
Musculoskeletal
“As pregnancy advances, there is a gradual softening of a woman’s pelvic ligaments and joints
to create pliability and to facilitate passage of the baby through the pelvis at birth” (Pillitteri,
2010).
a. Pelvic muscles regain tone in 3-6 weeks.
b. Abdominal muscles regain tone in 6 weeks unless diastasis recti
(separation of rectus abdominis muscles) remains.
Vital Signs
“Early in pregnancy, body temperature increases slightly because of the secretion of
progesterone from the corpus luteum (the temperature, which increased at ovulation, remains
elevated). As the placenta takes over the function of the corpus luteum at about 16 weeks,
the temperature usually decreases to normal” (Pillitteri, 2010).
a. Temp: may rise to 100 F due to dehydrating effects of labor. Any higher
elevation may be due to infection and must be reported.
b. Pulse: may decrease to 50, may indicate blood loss or infection.
c. BP: should be normal, suspect hypovolemia if decreases, PIH if
increases.
d. Respiration: rarely change; if respirations increases significantly,
suspect pulmonary embolism, uterine atony and/or hemorrhage.
e. Often have syncopal spell (faint) on the 1st ambulation pp R/T vasomotor
changes.
3. Lochia
is a vaginal discharge from the uterus that occur after giving birth during the first 3 weeks.
It has a musty odor.
p
Types of lochia are:
1. Rubra: day 1 to day 3, bright red
2. Serosa: day 3 to day 10; pinkish
3. Alba: day 10 until 3rd to 6th week post-partu
4. Postpartum Teachings
Breast self-exam
Begin with inspection in a mirror. Place both hands at sides and observe; then
look again with hands overhead and bending forward and assess for: changes in
size and shape, dimpling, puckering, scaling, redness, swelling. Lie flat with right
hand under head and pillow or towel under shoulder; use left hand to palpate
using concentric circles around right breast, feeling for lumps, nodules or
thickening; repeat to left breast.
Episiotomy Care
“surgical incision of the perineum that is made both to prevent tearing of the
perineum and to release pressure on the fetal head with birth” (Pillitteri, 2010).
1. Perineal care
2. Fill bottle with warm water, and if ordered, an ounce of povidine/iodine
solution.
3. Lavage perineum with several squirts and blot dry instead of rubbing;
avoid anal area.
Breastfeeding
Advantages of breast feeding, It is economical, with distinct
immunologic advantages for newborn. Milk production is stimulated by the
decrease estrogen production w/c allows release of prolactin from the pituitary
gland. The prolactin is responsible for milk production the Let-down reflex (milk
ejection) caused by action of oxytocin released from posterior pituitary w/c
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stimulates myoepithelial cells around milk ducts/sinuses. Breast size is not an
issue in breastfeeding. For those with inverted and retractable nipples can wear
shields w/c may help the infant latch onto nipple. The mothe should avoid
dieting, and may add 500 calories to pre-pregnant intake and may drink 2
quarts (8 glasses) of non-caffeinated/day. Lifestyle: avoid smoking and drugs;
alcohol and caffeine; and stress-most common caused for decreased milk
supply. encourage rest.
a. Care: let NB suck on 1st breast for 10 min, switch to 2nd breast and suck
until satisfied; take warm water,not drying soap on nipples; let nipples
air dry for 15 min 2-3x/day; may use lanolin, vit E or aloe vera on
nipples for dryness; best to use nothing that precludes air getting to
nipples.
b. Engorgement: nurses more frequently and manually express milk to
soften areola before feeding; wear supportive bra; take warm/hot
showers over breast to promote milk flow; watch for S/S of mastitis.
c. Position: make sure baby has as much of areola as possible in mouth;
break suction with insertion of little finger into baby’s mouth.
Learning Activity
Question 1. You discuss intrapartum care.(5pts.)
Question 2.You discuss differentiation between normal fetal heart rate and abnormal
fetal heart rate (10pts.)
Instruction: essay type write in 100words.
Question 3.You discuss first and second stage of labor. (15pts.)
Instruction: essay type write in not less than 60 words.

Question 3.1.You discuss the nursing care of 2 nd stage of labour (10pts.)
Instruction: essay type write in not less than 60 words.

Question 4.You describe placental separation/type of expulsion.(10pts.)
Question 5. You discuss fourth stage of labor.
Instruction: essay type write in 60 words but not less than 50 words.
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UNIT –VII
Learning Objectives
At the end of this unit I am able to:

1. Recognize problems / disorder including gynecologic disorder.
2. Identify nursing interventions to high risk pregnancy.
3. Differentiate classification of diabetes during pregnancy.
4. Explain aspect of Health promotions with regards to medical and nursing management
during antepartum and its classification.
5. Discuss cellular aberrations of the reproductive organ (diseases) Cancer its causes, risk
factors/S , laboratory test, Types of cancer and stages of cancer.
A. Problem/Disorders in Mothers including Gynecologic Disorders
1. High Risk Maternal Conditions:
According to Adelle Pillitteri a high-risk pregnancy is one in which a concurrent disorder,

pregnancy-related complication, or external factor jeopardizes the health of the woman, the
fetus, or both and these includes the following (Pillitteri, 2010):
1. Age under 17 or over 34.

2. High parity > 5.
3. Pregnancy (3 months since last delivery).
4. HPN, PIH in current pregnancy.
5. Anemia, history of hemorrhage
6. Multiple gestation.
7. Rh incompatibility.
8. History of dystocia or previous operative delivery.
9. Under 60 inches (5 feet ) of height.
10. Malnutrition: 15 under and 20 % over ideal wt.
11. Medical diseases: DM, hyperthyroidism, HPN, clotting disorders).
12. Infections: influenza, HIV, STD/VDRL
13. History of family violence, lack of social support.
14. Examination results: US/pelvimetry, etc.
2. Nursing interventions for high risk pregnancy
“Remembering that the term “high risk” rarely refers to just one causative factor helps in the
planning of holistic and ultimately effective nursing care” (Pillitteri, 2010)
a. Encourage the development of Rubins task (learning to give of oneself on behalf of
the child) by acknowledging the woman’s sacrifices and providing positive
reinforcement for her effort to protect the fetus.
b. The nurse clarifies information about the high-risk conditions, treatment options,
test results, and possible outcomes to help the family
c. Encourage the woman to participate in care and decision making.
d. Encourage the woman to continue some of her family roles
e. The woman and her family continue to prepare to give birth and become parents thru childbirth
education and parenting information
f. Encourage family support and care throughout the entire pregnancy
3. Pregnancy Related Conditions
1. Severe bleeding
a. is defined as any blood loss of more than 500 ml within 24 hours after birth.
b. Possible causes are: Failure of the uterus to contract, genital tract trauma, rapture
of the uterus, retained placental tissue or maternal bleeding disorders
2. Unsafe abortion
Is the termination of unwanted pregnancy either by persons lacking of necessary
skills or an environment lacking the minimal medical standards, or both.
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a. Obstructed labor
1. Occurs when the passage of the fetus through the pelvis is impeded. The most
common causes are:large fetal head passing through a small pelvis
2. Abnormal position of the fetus while going thru the birth canal, and fetal
defects
3. Foetal death is common
b. Obstetric fistula
Long term consequences of prolonged and obstructed labor which is an
abnormal opening between the vagina and urinary bladder or rectal wall. can
be treated with surgical reconstruction
B. Metabolic, Cardiac, Hematologic, Aberrations in pregnancy
1. Diabetes Mellitus=
Is a metabolic disorder of carbohydrate metabolism resulting from insufficient
production or use of insulin.
Classification of Diabetes Mellitus

Type 1: formerly called juvenile onset or insulin dependent diabetes; is an
autoimmune destruction of the pancreatic cells that produce insulin
Onset: before age 40
Type 2: formerly called maturity onset or non insulin dependent;occurs when

receptor sites at the tissue level are not reponsive thus causing resistance to
the insulin produced
Onset: after age 40
Type 3: formerly called gestational;

Onset: during pregnancy, the needs of the growing fetus increase glucose
production by the maternal liver, the placental hormones stimulate the
pancreas to produce increase insulin but also it increases insulin
resistance, requiring additional insulin production and hyperglycemia develops.
Reversal after termination of pregnancy
Maternal Risk
1. Miscarriage is related to inadequate glucose control
2. PIH is related to vascular changes
3. Preterm labor is related to increase uterine volume from a macrosomic
fetus.
4. Hydramnious is increase blood and fluid volume
5. Infection is hyperglycemia and glycosuria increased
6. Hypoglycemia may occur during first trimester, during early post-partum and
when breastfeeding
7. Retinopathy, difficult labor, induction of labor, fetal distress or C/S delivery
Assessment findings:
Polyuria= glucose attracts water so that when it is excreted in the kidney, it
brings along with it large amounts of water resulting in the woman excreting
large amounts of urine
Polydipsia = the excretion of large amounts of fluid from the body leads to
dehydration. Excessive thirst or polydipsia is an important symptom of
dehydration
Polyphagia=
Glycosuria =when blood glucose levels goes beyond the renal threshold for
sugar, glucose spills on the urine.
Hyperglycemiae – pancreas does not produce enough insulin , thus glucose is
unable to enter the cells & accumulates in the bloodstream resulting in
hyperglycemia
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Nursing Interventions
1. Teach client the effects and interactions of diabetes and pregnancy and
signs and symptoms of hyperglycemia and hypoglycemia
2. Teach client how to control diabetes in pregnancy
3. Observe and report any signs of pre - eclampsia
4. Monitor fetal status throughout pregnancy
5. Assess status of mother and baby frequently
6. Infant:
7. Macrosomia
8. Hydramnios
9. Prematurity
10. Intrauterine growth retardation ( IUGR)
11. Hypoglycemia ( lowered serum glucose levels)
12. Predisposition to diabetes mellitus later in life as the disease is hereditary
Prenatal Management:
“Screening includes an extensive health history, a complete physical
examination, including a pelvic examination, and blood and urine specimens for
laboratory work. Manual pelvic measurements can be taken to determine pelvic
adequacy” (Pillitteri, 2010)
1. Diagnosis; Suspect DM in a woman With family history of DM
a. With history of unexplained repeated abortions and
b. Stillbirth With glycosuria
c. Who are obese
d. Who have history of giving birth to large infants, over 10 lbs. and infants with
congenital anomaly
2. Screening test
a. Universal screening- 50 gram oral glucose tolerance test ( OGTT) between
24-28 weeks, If the plasma value is more than 140 mg/dl after one hour,
100 gram three hour oral glucose tolerance test is performed to confirm
b. Blood tests for sugar by Testape and Clinistix.
c. Urine test for acetone by acetest
3. Diet
a. Caloric intake should be enough to meet needs of pregnancy, fetus and
mother (1,800 to 2,400 cal/day)
4. Teach and instruct to:
1. Reduce saturated fat
2. Reduce cholesterol
3. Increase dietary fiber
4. Avoid fasting and feasting
5. Exercise
6. Insulin therapy
Insulin requirements increase during pregnancy. Oral hypoglycemic such as:
Tolbutamide and Diamicron are contraindicated during pregnancy because
they are teratogenic.
Combined fast acting and intermediate insulin made up of human
derivative/humulin.
Humulin is the insulin of choice during pregnancy because it is the least
allergenic
6. Observe for urinary and vaginal tract infections particularly candidiasis
7. Home blood glucose monitoring-
8. Fetal well-being assessment
a. Uteroplacental Function Tests
b. Amniocentesis to determine fetal lung maturity
Postpartum Health Teachings

1. Recurrence of diabetes may occur in subsequent pregnancies.
2. Women who develop gestational diabetes have higher tendency to develop overt
diabetes later in life.
3. Newborn Care:
1. Keep warm because of poor temperature control mechanism
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2. Observe respiration (stomach aspiration necessary at time of birth,since
hydramnios inflates stomach which pushes up and interferes with diaphragm
and lung expansion)
2. Heart Disease
Classification of heart disease is usually based upon the functional capacity of the
heart:
1. Maternal hypoxemia in woman with cardiac complications increases the incidence
of miscarriage, IUGR, fetal hypoxemia, preterm labor and birth and stillbirth.
Congenital heart disease increased the risk of congenital cardiac abnormality
2. Cardiac decompensation increased workload of pregnancy can stress the heart.
Signs and Symptoms are fatigue, dyspnea, palpitation and edema. The
pregnant women is most vulnerable from this complication from 28 to 32 weeks
of gestation and in the 1st 24 hours post partum.
Medical and Nursing Management during Antepartum:

1. Control of weight
2. Activity restriction or bed rest yo control symptoms
3. Detection and treatment of anemia or hypertension
4. Fetal surveillance for signs of hypoxia
5. Treatment of preterm labor
Note: Tocolysis with terbutaline is contraindicated with maternal cardiac disease

because it increases the pulse rate and the cardiac workload. Drugs that are safe to
used in the treatment of cardiac disease include:
digitalis
heparin
furosemide
Classification of Heart Disease

Class1. No limitations, uncompromised Asymptomatic, no discomfort with
ordinary physical activity.
Class II Slight limitation, slightly compromised, ordinary activity causes

dyspnea, fatigue, chest pain and palpitations
Class III Marked compromised, marked limitation less than ordinary activities
cause excessive fatigue,palpitations, chest pain and dyspnea.
Class IV Severely compromised, severe limitations, patient experiences

symptoms even at rest; unable to perform any physical activity without
discomfort.
Nurse Alert: Remember a pregnant woman with heart disease with these conditions
increases the workload of the heart and should avoid :
1. Infection
2. Excessive weight gain
3. Edema
4. Anemia
Management:
Prenatal Care:
1. Promotion of rest (Class I & Class II)
a. 8 Hours of sleep during the night and have frequent rest periods
during the day.
b. Light work is allowed but no heavy work, no stair climbing, no
exhaustion.
2. Diet
a. High in iron, protein, minerals and vitamins
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b. Avoid high altitudes, smoking areas, unpressurized planes and
overcrowded places.
3. Prevention of infection.
a. avoid persons with active cough
b. early treatment of infections
4. Provide instructions on danger signs of heart failure:
a. Cough with crackles is usually the first sign of an impending heart
failure.
b. Increasing dyspnea, tachycardia and rales.
Medications:
a. Iron supplementation to prevent anemia
b. Digitalis to strenghten myocardial contraction and slowdown heart rate
c. Nitroglycerine to relieve chest pain
d. Antibiotics to prevent and treat infection
e. Diuretics may be prescribed in case of heart failure.
Intrapartal Care
1. Early hospitalization
2. Woman is hospitalized before labor begins to promote rest, for closer
supervision and prevent infection
3. Woman in labor is in semi- fowlers position or left lateral recumbent
position.
4. No lithotomy positions.
5. Vital signs are monitored continuously. Tachycardia and respiratory rate
more than 24 are signs of impending cardiac decompensating.
NB: During the first stage monitor vital signs every 1 minutes and more
frequently during the 2nd Stage.
5. Epidural anesthesia is instituted for painless and pushless delivery.
6. Forceps is used to shorten the second stage.
7. Pushing is contraindicated.
8.Women with heart disease are poor candidate for C/S due to increased risk
for hemorrhage, infections and thromboembolism.
Postpartum care:
a. The most dangerous period is the immediate postpartum because of the sudden
increase in circulatory blood volume.
b. 1. Monitor vital signs.
2. Promote rest restrict visitors to allow patient to rest, the woman stay in the
hospital longer, until cardiac status has stabilized.
3. Early but gradual ambulation to prevent thrombophlebitis.
4. Promote rest restrict visitors to allow patient to rest, the woman stay in
the hospital longer, until cardiac status has stabilized.
5. Early but gradual ambulation to prevent thrombophlebitis.
c. 6. Medications:
a. Antibiotics
b. Stool softeners to prevent straining at stool caused by constipation.
c. Sedatives may be ordered to promote rest
7. Breast feeding is allowed, if there are no signs of cardiac decompensating
during pregnancy, labor and puerperium.
3. Anemias of Pregnancy
Decrease in the oxygen carrying capacity of the blood. Hemoglobin level of less
than 11g/dl in the first and third trimester and less than 10.5g/dl in the second
trimester. Hematocrit less than 35%. The increase blood volume that occurs
during pregnancy can lead to physiologic anemia. It complicates 25% of
pregnancy. Most common medical disorder of pregnancy.
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1. Iron Defficiency Anemia
Most common type of anemia during pregnancy. Most women enter pregnancy
nd
without enough iron reserve so that deficiency develops particularly on the 2 and
rd
3 trimester when iron requirement increases. It increases the risk of infection,
delays healing time and decreases the energy level post-partum.
Predisposing Factors:
1. Low socio economic levels (Poor diet and poor nutrition)
2. Heavy menses
3. Pregnancies at close intervals, successive pregnancies. (less than 2 years),
4. Unwise reducing programs
Signs and Symptoms:

1. Pale, shortness of breath
2. Easy fatigability
3. Sensitivity to cold
4. Proneness to infection
5. Dizziness
Laboratory findings
a. reveal low hgb
b. (microcytic- small RBC)
c. Hypochromic-(less hgb. than the average red cell)
Effects of Anemia to Pregnancy

a. Decreased resistance to infection
b. Associated with prematurity & low birth weight infants
c. Predispose to heavy bleeding during labor & puerperium
d. May increase digestive discomfort of pregnancy
Nursing Management
1. Oral iron supplementation –200 mg of elemental iron daily in the form of:
2. Ferrous Sulfate – the most absorbable form of iron
3. Ferrous Fumarate
4. Ferrous Gluconate
5. Inform the mother about the possible side effects. Such as Tarry stool,
constipation, GI discomfort
6. Never take with milk but with citrus juice
7. If given in liquid form, use straw to prevent staining the teeth. Tell patient
to rinse mouth.
8. If iron is to be given parenterally, give IM by Z tract technique to prevent
tissue staining.
9. Do not massage after injection.
10. Oral iron should be continued until 3 months after anemia has been
corrected.
11. Increase intake of iron rich foods:
lean meat, liver, dark green leafy vegetables.
Good food sources of iron include the following:
Meats – beef, pork, lamb, liver,& other organ meats
Fish – shellfish, including clams, mussels, oysters, sardines and anchovi
Leafy greens of the cabbage family such as broccoli
Legumes such as lima beans & green peas; dry beans & peas
Yeast-leavened whole wheat bread & rolls
Iron enriched, white bread, pasta, rice & cereals
Poultry – chicken, duck, turkey, liver (especially dark meat)
Folic Acid Deficiency Anemia

Folic acid is necessary for the normal formation and nutrition of red blood cells.
Deficiency in folic acid leads to the formation of large and immature blood cells
P a g e 77 | 84
that have shorter life span than normal red blood cells. Women who have folic
acid deficiency during pregnancy are more at risk of giving birth to babies with
neural tube defects.
Effects on Pregnancy:
Abortion, Abruptions placenta, Neural defect in fetus
Predisposing Factors:
1. Long term use of oral contraceptives

2. Poor nutrition
3. Multiple pregnancies
4. Successive pregnancies
Signs and Symptoms

a. Nausea
b. Vomiting
c. Anorexia – lack of appetite
Management
1. Folic acid supplementation of 1 mg/day accompanied oral iron. for all women
– 0.4mg/day
2. Vitamin supplements containing 400 micrograms of folic acid are now
recommended for all women of childbearing age and during pregnancy. Food
sources of folate include the ff: Leafy dark green vegetables, dried beans &
peas, nuts, citrus fruits & juices & most berries, fortified breakfast cereals,
enriched grain products.
4. Menopause
Is a time in a woman’s life when her period stops for a period of one year. It usually
occurs naturally most often at the age of 45. It happens when the woman’s ovaries
stop producing the hormones estrogen and progesterone
Signs and Symptoms

1. Hot flushes
2. Night sweats
3. Irregular periods
4. Mood swings
5. Vaginal dryness
6. Decreased libido
7. Headaches
8. Joint pain
9. Breast soreness
10. Digestive problem
11. Fatigue
12. Anxiety
Common complications include:

1. Vulvovaginal atrophy
2. Dyspareunia
3. Slower metabolic rate
4. Osteoporosis
5. Mood swing
6. Cataract
7. Periodontal disease
8. Incontinence
9. Heart or blood vessel disease
P a g e 78 | 84
Treatment
1. Hormone therapy may be an effective treatment in women under the age of
60, or within 10 years of menopause onset.
2. Other medications may be used to treat more specific menopause symptoms,
like hair loss and vaginal dryness. Additional medications sometimes used for
menopause symptoms include:
a. topical minoxidil 5 percent, used once daily for hair thinning and loss
b. antidandruff shampoos, commonly ketoconazole 2 percent and zinc
pyrithione 1 percent, used for hair loss
c. eflornithine hydrochloride topical cream for unwanted hair growth
d. selective serotonin reuptake inhibitors (SSRIs), commonly paroxetine 7.5
milligrams for hot flashes, anxiety, and depression
e. nonhormonal vaginal moisturizers and lubricants
f. low-dose estrogen-based vaginal lubricants in the form of a cream, ring, or
tablet
g. ospemifene for vaginal dryness and painful intercourse
h. prophylactic antibiotics for recurrent UTIs
i. sleep medications for insomnia
j. denosumab, teriparatide, raloxifene, or calcitonin for postmenstrual
osteoporosis
Management:
a. Keeping cool and staying comfortable
b. Exercise
c. Weight management
d. Communicating your needs
e. Diet
f. Practicing relaxation techniques
C. Cellular Aberrations of the Reproductive Organs
1. Cervical Cancer
Develops in the cervix in the lower portion of the uterus.
Causes:
Usually results from infection with the human papillomavirus (HPV),
transmitted during sexual intercourse.
Risk Factors
1. Sexual intercourse at young age
2. Multiple sexual partner
3. Cigarette smoking
4. having a weakened immune system
Signs and Symptoms:

Irregular vaginal bleeding or bleeding after sexual intercourse, but symptoms
may not occur until the cancer has enlarged or spread, lower back pain,
urinary tract maybe blocked, kidney failure
Screening Test:
a. Papanicolaou or Pap test: Cells from the cervix are examined under a
microscope to determine whether any are cancerous or abnormal. Abnormal
cells may, without treatment, progress to cancer (precancerous cells).
b. HPV test: A sample from the cervix is tested to determine whether HPV is
present
c. Biopsy
P a g e 79 | 84
2 Types of Test are:
1. Punch biopsy: A tiny piece of the cervix, selected using the colposcope, is
removed
2. Endocervical curettage: Tissue that cannot be viewed is scraped from inside
the cervix
Stages of Cervical Cancer

Stage I: The cancer is confined to the cervix.
Stage II: The cancer has spread outside the cervix, including the upper part
of the vagina, but is still within the pelvis (which contains the internal
reproductive organs, bladder, and rectum).
Stage III: The cancer has spread throughout the pelvis and/or the lower part
of the vagina and/or blocks the ureters and/or causes a kidney to malfunction
and/or spreads to the lymph nodes near the aorta (the largest artery in the
body).
Stage IV: The cancer has spread outside the pelvis and/or to the bladder or
rectum or to distant organs.
Prognosis
Depends on the stage of the cervical cancer. The percentages of women who
are alive 5 years after diagnosis and treatment are:
Stage I: 80 to 90% of women
Stage II: 60 to 75%
Stage III: 30 to 40%
Stage IV: 15% or fewer
Prevention
1. The Human Papilloma Virus Vaccine
2. Condoms
Treatment
Surgery, radiation therapy and chemotherapy.
2. Cancer of the Uterus or Endometrial Cancer; Uterine Cancer)
Develops in the lining of the uterus (endometrium) and is thus also called
endometrial cancer.
Causes
1. Diet high in fat
2. Affects women after menopause.
3. high level of estrogen but not progesterone
4. Early menarche and late menopause more than 52 years
5. Having menstrual problem related to release of the egg
6. Not having any children
7. Having polycystic ovary syndrome
8. Taking drugs that contain estrogen, such as estrogen therapy without a
progestin
9. Obesity
10. Diabetes
Other Risk Factors

1.Having had cancer of the ovaries or the breast
2.Hereditary
3.Having had radiation therapy directed at the pelvis
4.Using Tamoxifen for 5 years or longer. a drug used to treat breast cancer,
blocks the effects of estrogen in the breast, but it has the same effects
as estrogen in the uterus.
5.Having High blood pressure
P a g e 80 | 84
Diagnostic test:
a. Biopsy
b. dilation and curettage with hysteroscopy
Classification:
1. Type I cancers are more common, respond to estrogen, and are not very
aggressive. They tend to occur in younger or obese women or in women going
through perimenopause (the years just before and the year after the last
menstrual period).
2. Type II cancers are more aggressive and tend to occur in older women. About
10% of endometrial cancers are type II.
Symptoms:
1. Bleeding after menopause
2. Bleeding between menstrual periods
3. Periods that are irregular, heavy or longer than normal
Staging of Endometrial Cancer.

Stages are based on how far the cancer has spread
Stage I: The cancer occurs only in the upper part of the uterus, not in the
lower part (cervix)
Stage II: The cancer has spread to the cervix.
Stage III: cancer has spread to nearby tissues, the vagina, or lymph nodes.
Stage IV: The cancer has spread to nearby tissues, the vagina, or lymph
nodes.
Prognosis
Depends on the stage of the endometrial cancer.5year survival rate:
1.Stage I or II: 70 to 95% (most are cured)
2.Stage III or IV: 10 to 60%
Management:
Surgery, radiation therapy and sometimes by chemotherapy.
Prevention:
Healthy lifestyle
3. Fallopian Tube Cancer
Fallopian tube cancer develops in the tubes that lead from the ovaries to the uterus. Most
cancers that affect the fallopian tubes have spread from other parts of the body
Risk factors
1.Older age
2.Long-term (chronic) inflammation of the fallopian tubes
3.Infertility
Symptoms include:
Vague abdominal discomfort, bloating, and pain in the pelvic area or
abdomen, watery discharge from the vagina. When cancer is advanced, the
abdominal cavity may fill with fluid (a condition called ascites), an and
abdomen and eventually to distant parts of the body.
Diagnosis:
1. CT Scan
2. Biopsy
P a g e 81 | 84
Treatment and Management:
1.Surgery is done to confirm the diagnosis determine the extent of the
spread(staging), and remove as much of the cancer as possible.
2.Chemotherapy
Staging: stage the cancer based on how far it has spread:

Stage I: The cancer occurs only in one or both fallopian tubes.
Stage II: The cancer has spread to nearby tissues but is still within the pelvis
(which contains the internal reproductive organs, bladder, and rectum).
Stage III: The cancer has spread outside the pelvis to lymph nodes and/or to
abdominal organs (such as the surface of the liver).
Stage IV: The cancer has to distant organs.
Staging of fallopian tube

Cancer requires surgery to biopsy the abnormal areas and remove and check nearby
lymph nodes.
Prognosis
The percentages of women who are alive5 years after diagnosis and treatment (the
5-year survival rate) are:
Stage I: About 81%
Stage II: About 67%
Stage III: About 41%
Stage IV: About 33%
Cervical Cancer
Symptoms occur only if it is large or has spread. Develops in women between 50
– 70 years of age
Risk Factors
1. Age
2. Not having children
3. Having the first child late in life
4. Early onset of periods
5. Delayed menopause
6. Family history of breast, colon or ovarian cancers
Symptoms
a. Vague discomfort in the lower abdomen
b. Bloating, loss of appetite
c. Backache
Diagnosis
1. Ultrasound of abdomen
2. CT and MRI
3. Laparoscopy
Stages are based on how far the cancer has spread

Stage I: The cancer occurs only in one or both ovaries
Stage II: The cancer has spread to the uterus, fallopian tubes, or nearby tissues
within the pelvis (which contains the internal reproductive organs, bladder and
rectum.
Stage III: : The cancer has spread outside the pelvis to the lymph nodes, the
surface of the liver, the small intestine, or the lining of the abdomen.
Treatment
1. Surgery: All visible cancer tissue is removed
2. Chemotherapy: In advanced cases
P a g e 82 | 84
4. Reproductive cancers in Men are:
1. Testicular Cancer
2. Penile
3. Prostate
Early symptoms of Male reproductive Cancers:

a. Testicular cancer: pain, discomfort, lump, or swelling in the testes, aching in
the lower abdomen
b. Penile cancer: Redness, discomfort, sore, or lump on the penis
c. Prostate cancer: Weak flow of urine, blood in urine, pain in the back, hips, or
pelvis (lower belly between the hips), or needing to pass urine often.
Risk factors for male reproductive cancers:

Such as age, race, and family history, the environment, and lifestyle
Risks that Increase the Likelihood of Developing Male Reproductive Cancer

for:
a. Testicular cancer: descended testicle, having a family history of testicular
cancer, abnormal testicle
b. Penile cancer: Having human papillomavirus (HPV) ,being uncircumcised, being
age 60 or older, multiple sexual partner, smoking
c. Prostate cancer: Being aged 50 years old or older, having a family history of
prostate cancer.
More common in African American men and tends to start at younger ages,
grow faster among African American men.
Screening test for male Reproductive cancers:

1. Lab tests:
2. Ultrasound test
3. Biopsy
Treatment:
Surgery, chemotherapy (medicine to kill cancer cells), hormone therapy
(medicine to block hormones that are related to cancer growth), radiation, or
a combination used together.
Learning Activity
Instruction: Write in enumerated form. Some may write in narrative.

Question 1. You recognize problems / disorder including gynecologic
disorder. (20pts.)
Instruction: Narrative form.
Question 2. You can identify nursing interventions to high risk
pregnancy.(20pts.)
Instruction: write in matrix form
Question 3. You can differentiate classification of diabetes during
pregnancy.(10 pts.)
Instruction: essay form.
Question 4. You can explain aspect of health promotions with regards to
medical and nursing management during antepartum and
its classification.(30pts.)
Instruction: essay form write in not less than 150words.

Question: 5.I can discuss cellular aberration of the reproductive organ. (diseases)
Cancer its:
Causes , Risk factor, Signs and Symptom, Laboratory Test, Types, Stages of Cervical
Cancer
P a g e 83 | 84
REFERENCES
Textbooks
Pillitteri, Adelle. (2020) Textbook of Maternal and Child Health Nursing Care
of the Childbearing and Childrearing Family, Lippincott Williams and Wilkins
Towle, Mary Ann (2010) Maternal Newborn Nursing Care,Pearson Education

Inc.,Publishing as Prentice Hall
Nettina, Sandra M. (2006). Lippincott Manual of Nursing Practice.

Maryland:Lippincott Williams and Wilkins
Websites
http://www.atitesting.com/ati_next_gen/skillsmodules/content/maternal-
newborn/viewing/maternal.html
*http://www.atitesting.com/ati_next_gen/skillsmodules/content/maternal-
newborn/viewing/kc.html
*http://www.atitesting.com/ati_next_gen/skillsmodules/content/maternal-
newborn/viewing/apgar.html
https://obgyn.onlinelibrary.wiley.com/doi/abs/10.1111/1471-0528.12614
https://www.webmd.com/baby/nonstress-test-nst
https://bpac.org.nz/BT/2011/July/pregnancy.aspx
P a g e 84 | 84

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Table of Contents

Pre-activity: Case Scenarios

Case 3-Phases of Health Care

A. Foundation of Maternal and Child Health Nursing Practices/Biophysical Aspects

1. The philosophy of Maternal and Child Health Nursing includes

1 Maternal and child health nursing is family-centered.

3. What is the childbearing-childrearing continuum?

4. The 2 Pillars of the 2020 National Health Goals are:

1. Increase quality and years of healthy life

5. The New Objectives Recommend as Part of Healthy 2020

6. The Global Health Goals of 2020

B. Concepts, Theories, Principles and Standards of Care

1. Consider the family as a whole as well as its individual members.

Standard VII: Research The nurse uses research findings in practice.

5. The Nursing Process

C. Anatomy and Physiology

1. Female Reproductive System

(*sperm maturation begins at 13 years old*)

Sertoli cells – nourished the sperm cells; “nurse cells”

Stimulates APG (Anterior pituitary gland) = secrete FSH & LH = stimulates

Epididymis – maturation of the sperm cell occurs. ( 12- 24 days)

Vas deferens – passageway of the matures sperm.

Seminal vesicle – produce sugar fluid known as fructose to increase motility.

Ejaculatory duct – passageway

Cowper’s gland – bulbourethral gland - Secretes alkaline fluid that helps

1. Several Theories Exist Regarding the Development of Gender Identity arises

c) Gender role is also culturally influenced.

2. Four discrete stages in sexual response are

Plateau: stage is reached just before orgasm.

3. Types of Sexual Orientation

Trans-sexuality or transgender person is an individual who, although of one biologic gender,

Other Types of Sexual Expression

Masturbation is self-stimulation for erotic pleasure.

Sadomasochism involves inflicting pain (sadism) or receiving pain (masochism) to achieve

Other Types of Sexual Expression

Exhibitionism: is revealing one’s genitals in public.

Bestiality: is sexual relations with animals.

Nursing role in the Reproductive and Sexual health.

Instruction: Explain your answer in 5-7 sentences in each question.

2. How would you counsel Samantha and Joshua de Guzman?

At the end of the unit, Iam able to

A. The Menstrual Cycle

2. Four body structures are involved in physiology of Menstrual Cycle

Menstrual flow is composed of:

3. Description: Composed of four phases

2. Proliferative (Follicular) Phase -Day 5 of ovulation. Endometrium is restored under

3. Secretory Phase -Ovulation to approximately 3 days before menstrual cycle.

2. Reproductive Life Planning

Includes all decisions an individual or couple make about having children:

3. The concept of family planning includes these elements:

a. Responsibility of parents to themselves and to each other

4. Purposes of Family Planning

5. The ultimate goal of family planning is directed towards:

6. Advantages of family planning to the mother:

1. Enables the mother to regain her health after the delivery

The Considerations are:

4. Intrauterine device (IUD)

2. Natural Family Planning Method

1. Calendar/ Rhythm (Natural Family Planning)

(sperm maturation begins at 13 years old)