Care of Mother, Child, Adolescent (Well Clients )

NCM 207 / MCN / PRELIMS

Objectives 8. Circumstances such as illness or pregnancy are

meaningful only in the context of total life.
At the end of the learning discussion, the students will
9. MCHN is a challenging role for nurses and a major factor
be able to:
in keeping families well and optimally functioning.
• Identify the goals and philosophy of maternal and child
health nursing.
• Describe the evolution, scope, standards in maternal Standards of Care
and child health nursing. 1. Comprehensive pediatric nursing care focuses on
• Identify nursing theories related to maternal and child helping children and their families and communities
health nursing. achieve their optimum health potentials (family-
• Recognize the 17 Sustainable Development Goals of centered)
WHO 2. Standards have been developed by the:
• American Nurses Association in collaboration
with the Society of Pediatric Nurses
Goal and Philosophies of MCN
• Association of Women’s Health, Obstetric and
Obstetric – the care of women during childbirth Neonatal Nurses (AWHONN)
From the Greek word, obstare, which means • American Nurses Association in collaboration
“to keep watch”
with the Society of Pediatric Nurses
Pediatrics – from the Greek word, pais, meaning “child”
American Nurses Association/Society of Pediatric Nurses
Major Focus of Nursing: The care for childbearing and
Standards of Care and Professional Performance
childrearing families because to Standards of Care
have healthy adults you must - Comprehensive pediatric nursing care focuses on helping
have healthy children children and their families and communities achieve their
optimum health potentials. This is best achieved within the
Primary Goal of MCHN framework of family-centered care and the nursing process,
including primary, secondary, and tertiary care coordinated
o Promotion and maintenance of optimal family health to across health care and community settings.
ensure cycles of optimal childbearing and childrearing Standard I: Assessment
o Keeping the family at the center of care or keeping the - The pediatric nurse collects patient health data.
family as the primary unit of care Standard II: Diagnosis
- The pediatric nurse analyzes the assessment data in
determining diagnoses.
Scope of Practice Standard III: Outcome Identification
1. Preconceptual health care - The pediatric nurse identifies expected outcomes
2. Care of women during 3 trimesters of pregnancy and the individualized to the child and the family.
puerperium Standard IV: Planning
3. Care of infants during the perinatal period - The pediatric nurse develops a plan of care that prescribes
4. Care of children from birth to adolescence interventions to obtain expected outcomes.
Standard V: Implementation
5. Care in settings as varied as the birthing room, the
- The pediatric nurse implements the interventions identified
pediatric intensive care unit, the home in the plan of care.
Standard VI: Evaluation
Philosophies of MCHN - The pediatric nurse evaluates the child’s and family’s
progress toward attainment of outcomes.
1. MCHN is family centered; assessment should include
Standards of Professional Performance
both family and individual assessment data Standard I: Quality of Care
2. MCHN is community-centered; the health of families - The pediatric nurse systemically evaluates the quality and
depends on and influences the health of communities. effectiveness of pediatric nursing practice.
3. MCHN is evidence based, because this is the means Standard II: Performance Appraisal
whereby critical knowledge increases. - The pediatric nurse evaluates his or her own nursing practice
4. A maternal and child health nurse serves as an advocate in relation to professional practice standards and relevant
to protect the right of all family members, including the statutes and regulations.
fetus. Standard III: Education
- The pediatric nurse acquires and maintains current
5. MCHN includes a high degree of independent nursing knowledge and competency in pediatric nursing practice.
functions, because teaching and counselling are major Standard IV: Collegiality
interventions. - The pediatric nurse interacts with and contributes to the
6. Promoting health and disease prevention are important professional development of peers, colleagues, and other
nursing roles because this protect the health of the next health care providers.
generation. MCH nurses serve as important resources Standard V: Ethics
for families during childbirth and childrearing as these - The pediatric nurse’s assessment, actions, and
can be extremely stressful times in a life cycle. recommendations on behalf of children and their families are
determined in an ethical manner.
7. Personal, cultural, and religious attitudes and beliefs
influence the meaning and impact of childbearing and
childrearing of families.

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Standard VI: Collaboration 3. Approaching towards a New Normal (Informal) –
- The pediatric nurse collaborates with the child, family, and 2weeks to 4 mos.
other health care providers in providing client care. – Begins as the mother develops unique
ways of dealing with the role not conveyed
Standard VII: Research
- The pediatric nurse contributes to nursing and pediatric
by the social system.
health care through the use of research methods and 4. Achievement of Maternal Identity (Personal) –
findings. 4mos and beyond
Standard VIII: Resource Utilization – The woman internalizes her role.
The pediatric nurse considers factors related to safety, effectiveness,
and cost in planning and delivering patient care.
Ø Post-Partum Depression Theory (Cheryl Tatano Beck)
Association of Women’s Health, Obstetric, and Neonatal – The birth of a baby is an occasion for joy – or
Nurses Standards and Guidelines so the saying goes. But for some women, joy
Standards of Professional Performance is not an option.
Standard I: Quality of Care
- The nurse systematically evaluates the quality and Symptoms:
effectiveness of nursing practice. o Tearfulness; excessive crying
Standard II: Performance Appraisal o Extreme mood changes
- The nurse evaluates his/her own nursing practice in relation o Loss of appetite (lengthened period
to professional practice standards and relevant statues and postpartum)
regulations. o Suicidal ideation
Standard III: Education
o Feelings of inadequacy and inability to cope
- The nurse acquires and maintains current knowledge and
competency in nursing practice.
with the infant
Standard IV: Collegiality Predictors:
- The nurse contributes to the professional development of 1. Prenatal depression
peers, colleagues, and others. 2. Childcare stress
Standard V: Ethics 3. Prenatal anxiety
- The nurse’s decisions and actions on behalf of patients are 4. Life stress
determined in an ethical manner. 5. Social support
Standard VI: Collaboration
6. Marital relationship
- The nurse collaborates with the patient, significant others,
and other health care providers in providing client care. 7. History of previous depression
Standard VII: Research 8. Infant temperament
- The nurse uses research findings in practice. 9. Maternity blues
Standard VIII: Resource Utilization 10. Low self-esteem
- The nurse considers factors related to safety, effectiveness, 11. Single marital status
and cost in planning and delivering patient care. 12. Low socio-economic status
Standard IX: Practice Environment 13. Unplanned or unwanted pregnancy
- 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.

Nursing Theories Related to MCN

Ø Maternal Role Attainment Theory – Becoming a
Mother
Ramona T. Mercer (1929-Present)
– Nurses have an extraordinary opportunity to
help women learn, gain confidence, and
experience growth as they assume the mother
identity.
Four Stages of Becoming a Mother
1. Commitment, Attachment, and Preparation
(Anticipatory) – pregnancy
– Begins during pregnancy and includes the
initial social and psychological
adjustments to pregnancy.
2. Acquaintance, Learning, and Physical Restoration
(Formal) – first 2 weeks
– Begins with the birth of the infant and
includes learning and taking on the role of
mother.

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 MATERNAL AND CHILD NURSING
“Principles and techniques of caring for the normal mothers,
infants, children and family and the application of principles
and concepts on family and family health nursing process.”

Anatomy and Physiology

Gonad is a body organ that produces the cells necessary for

reproduction (the ovary in females, the testis in
males).
In testes:
• Seminiferous tubules – produces SPERMATOZOA
• Leydig Cells – found in the lobules of the capsule of
each testis, produces TESTOSTERONE

• ZONA PELLUCIDA – a ring of

mucopolysaccharide fluid
• CORONA RADIATA – a circle of cells

LAYERS OF THE UTERUS:

The uterine wall consists of three separate coats or
layers of tissue:
- an inner one of mucous membrane (the
endometrium),
- a middle one of muscle fibers (the myometrium),
- and an outer one of connective tissue (the
perimetrium)
The endometrium layer:
- the one that is important for menstrual function
- It grows and becomes so thick and responsive
each month under the influence of estrogen and
progesterone that it is capable of supporting a
pregnancy.
- If pregnancy does not occur, this is the layer that
is shed as the menstrual flow.

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The myometrium layer: – As the ovary begins to produce estrogen (in
- Aids in the expulsion of the fetus the follicular fluid, under the direction of the
- Smooth muscle layer pituitary FSH), the endometrium begins to
proliferate which occurs during the first 4 or 5
Menstruation days of a cycle
– Menarche (onset), menopause (termination) 2) Second Phase of Menstrual Cycle (Secretory)
– Formation of progesterone in the corpus
– 300,000 to 400,000 oozytes per ovary
luteum (under the direction of LH) causes the
– Average cycle is 28 days, duration of 3 -5 days
glands of the uterine endometrium to become
– Unovulatory state 1-2 years after menarch
corkscrew or twisted in appearance and
– Menstrual flow contains 30-80 ml of blood dilated
– Structures involve: hypothalamus, APG, ovaries, § capillaries of the endometrium
uterus, vagina increase in amount until the lining
– Hormones that regulate – FSH (estrogen) and LH takes on the appearance of rich,
(progesterone) spongy velvet
3) Third Phase of Menstrual Cycle (Ischemic)
– Mittelschmerz
– If fertilization does not occur, the corpus
– First 14 days is variable, last 14 days is fixed
luteum in the ovary begins to regress
– Menstruation can occur without ovulation § progesterone and estrogen
(Anovulation) decreases (LOW PROGESTERONE
= DEGENERATION OF
ESTROGEN ENDOMETRIUM)
o Inhibits production of FSH 4) Fourth Phase of a Menstrual Cycle (Menses)
o Causes hypertrophy of the myometrium – As the corpus luteum regresses, it is gradually
o Stimulates growth of breasts ducts replaced by white fibrous tissue called corpus
o Increases ph of cervical mucus causing it to albicans
become thin and watery (Spinnbarkheit test)
o Proliferates the endometrium Pregnancy
PROGESTRONE w Normal amount of semen/ejaculation: 3.5 cc
o Inhibits production of LH o Number of sperm per cc of semen: 40 – 80
o Increases endometrial tortuosity million
o Increases endometrial secretions o Number of sperm per ejaculation: 300 – 500
o Inhibits uterine motility million
o Facilitate transport of fertilized ovum through w Mature ovum is capable of being fertilized for 12 to 24
fallopian tube hours after ovulation
o Increases body temperature after ovulation w Sperm is capable of fertilizing for 3 to 4 days after
ejaculation
w Normal lifespan of sperm is 7 days
w Sperm can reach ovum in 1-5 mins.
w Fallopian tube will contract due to estrogen
w Sperm must remain in female genital tract 4-6 hours
before they are capable of fertilizing the ovum
w Sperm has 22 autosomes and 1 X or Y sex chromosomes
w Ova contains 22 autosomes and 1 X sex chromosomes

STAGES OF PREGNANCY
1. Fertilization
– the process in which a sperm penetrates outer
layer of the ovum.
2. Implantation
Graafian follicle (an ovum about to be discharged) – when the blastocyst attaches the
– unruptured, glistening, clear, fluid-filled
endometrium (7-9 days after fertilization)
Corpus Luteum (the structure left behind after the ovum has
3. Pre-placental stage
been discharged)
– when the endometrium becomes highly
– small, yellow
vascular (week 2).
4. Placental and fetal development
PHASES OF MENSTRUATION:
1) First Phase of Menstrual Cycle (Proliferative)

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 Ø Trophoblast cells erode the endometrium of the uterus
so that the blastocyst burrows into the uterine wall.
Ø Endometrium covers the embryo and the blood supply
becomes established.

Primary Germ Layers

Ø At the time of implantation, a blastocyst already has
differentiated to a point at which two separate cavities
appear in the inner structure:
(1) a large one, the amniotic cavity, which is lined
with a distinctive layer of cells, the ectoderm, and
(2) a smaller cavity, the yolk sac, which is lined with
endoderm cells
Between the amniotic cavity and the yolk sac, a third
layer of primary cells, the mesoderm, forms.
Ø Yolk sac - appears to supply nourishment only until
implantation. After that, its main purpose is to provide a
source of red blood cells until the embryo’s
IMPLANTATION hematopoietic system is mature enough to perform this
Ø 50% of zygote never achieve implantation
function
Ø Small amount of vaginal spotting is occasionally present
Ø Endometrium turned to decidua:
– decidua basalis
– decidua capsularis
– decidua vera
Ø It has 3 processes:
– apposition
– adhesion
– invasion

Human Development
Late Blastocyst
– The cells begin to differentiate into:
• Inner Cell Mass (embryo) Ø Chorion – outermost membrane surrounding the embryo
• Trophoblast Cells (attach to uterus) Ø Amnion – the innermost membrane enclosing the embryo

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Ø Yolk sac – yolk sac then atrophies and remains only as a
thin white streak discernible in the cord at birth.
Ø Allantois - future umbilical cord; the fetal membrane lying
below the chorion in many vertebrates, formed as an
outgrowth of the embryo's gut
- It helps the embryo exchange gases and
handle liquid waste
UMBILICAL CORD
Ø 21 inches long
Ø 2 arteries and 1 vein
Ø Wharton’s jelly – bulk of the cord
Ø Transport oxygen, nutrients, minerals, and waste
products
AMNIOTIC FLUID
Ø 500 – 1000 ml inside the amniotic sac (BOW)
Ø Produced by the amniotic membrane
Ø Shields fetus from pressure or blow
Ø Protects fetus from sudden change in temperature
Ø Aids in muscular development
FOCUS OF FETAL DEVELOPMENT
Ø Aids in descent
Ø First Trimester
Ø Protects umbilical cord from pressure
o Organogenesis
Ø Protects fetus from infection Ø Second Trimester
o Period of continued growth and
development
Ø Third Trimester
o Period of most rapid growth and
development

Normal Adaptation in Pregnancy

REPRODUCTIVE SYSTEM
PLACENTA Uterus - uterine growth and enlargement
1. Respiratory system length : 6.5 cms to 32 cms
2. Renal system width : 4 cms to 24 cms
3. Gastrointestinal system depth : 2.5 cms to 22 cms
4. Endocrine system: weight : 50 gms to 1000 gms
- Human chorionic gonadotropin volume : 1–2 ml to 1000 ml
- Braxton Hicks contraction
- Human placental lactogen
- becomes globular (4th month)
- Estrogen and Progesterone - Goodell’s sign (4th week)
5. Protective functions - Hegar’s sign (8th week)
IgG – as early as 20th week and certainly at - Chadwick’s sign (8th to 10th week)
the 24th week for temporary passive Ovaries - no ovulation
immunity Vagina - more acidic (ph 3.5 to 6)
Breasts - enlarged
MUSCULOSKELETAL SYSTEM
> waddling walk
> symphysis pubis may separate slightly
CIRCULATORY SYSTEM
> increased blood volume 40% to 50%
> physiologic anemia
> heart is displaced upward
> increased cardiac output to 30%
> supine hypotension
> increased WBC
> CR & PR increased to 10 -15 beats/min.
> varicosities

***(refer to your assignments OR book for detailed

development)

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INTEGUMENTARY SYSTEM FIRST TRIMESTER
> increased pigmentation • Presumptive signs:
> chloasma/melasma – amenorrhea, morning sickness, breast
> striae gravidarum changes, fatigue, urinary frequency,
> linea nigra
enlarging of uterus
> increased perspiration
GASTROINTESTINAL SYSTEM • Probable signs:
> morning sickness – Chadwick’s sign, Goodell’s, Hegar’s,
> heartburn (+)hCG
> constipation • Positive sign:
RESPIRATORY SYSTEM – ultrasound result
> Increased RR SECOND TRIMESTER
> dyspnea • Presumptive signs:
> increased tidal volume
– quickening, skin pigmentation, Chloasma,
> increased vital lung capacity
> decreased residual volume linea nigra, striae gravidarum
URINARY • Probable signs:
> increased urinary frequency – enlarged abdomen, Braxton Hick’s,
> increased GFR Ballottement
ENDOCRINE SYSTEM • Positive sign:
> increased metabolism of CHON and CHO
– FHT, fetal movements, fetal X-ray
> increased insulin production

Terms Related to Pregnancy Status

Term Definition
Para Number of pregnancies that have
reached viability, regardless of whether
the infants were born alive
Gravida Woman who is or has been pregnant
Primigravida Woman who is pregnant for the first
time
Primipara Woman who has given birth to one child
past age of viability
Multigravida Woman who has been pregnant
previously
WEIGHT GAIN Multipara Woman who has carried two or more
> weight distribution: pregnancies to viability
fetus – 7 lbs Nulligravida Woman who has never been and is not
placenta – 1 lb currently pregnant
amniotic fluid – 1.5 lbs
uterus – 2 lbs
bld volume – 1 lb OBSTETRICAL DATA
breasts – 1.5-3 lbs Ø Last Menstrual Period (LMP)
fluid – 2 lbs
Ø Age of Gestation (AOG)
fats – 4-6 lbs
- by weeks
Total: 20-25 lbs.
- Mc Donald’s Method
- Bartholomew’s rule
Signs of Pregnancy Ø Gravida Para Abortion (GPA)
• PRESUMPTIVE Ø Term Preterm Abortion Living (TPAL)
– Least indicative of pregnancy Ø Expected Date of Confinement (EDC)
– Could indicate other conditions - Naegel’s rule
– Largely subjective Ø Obstetrical History
• PROBABLE a) McDonald’s Rule/Method
– Can be documented by examiner o Measuring from fundus to
– Ex: lab tests, pregnancy test
symphysis
• POSITIVE
Gestational age Fundal height landmark
– Fetal Heartbeat
12-14 weeks Pubic symphysis
– Fetal movement felt by examiner
20-22 weeks Umbilicus
– USD visualization of fetus
36-40 weeks Xiphoid process of sternum
37-40 weeks Regression of fundal height
between 36-32 cm

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b) Bartholomew’s Rule e) Naegel’s Rule
– Bartholomew's rule of fourths does - +1 YEAR -3 MONTHS +7 DAYS
not use a numerical height value to or
compute gestational age, but - +9 MONTHS +7DAYS
landmarks. § If the LMP is around January
§ If the fundus is at the to March
symphysis pubis, then the
PHYSICAL ASSESSMENT
age of gestation is about 12 • Void (MSCC)
weeks. • Baseline Height, Weight
§ If the fundus is midway • VS
between the symphysis – Sudden increase in BP and weight gain are
pubis and the umbilicus, the danger signs of hypertension in pregnancy
age of gestation is about 16 – Sudden drop of pulse or respirations may
weeks. suggest bleeding
§ If the fundus is at the • Cephalocaudal PA
umbilicus, the age of • Observe for danger signs of pregnancy:
gestation is about 20 weeks. a. Vaginal bleeding - may indicate:
§ If the fundus is at the > placenta previa > premature labor
xiphoid process, the age of > abruptio placenta > threatened abortion
gestation is about 36 weeks. b. Persistent vomiting
c) GPA (number of pregnancies) hyperemesis gravidarum
– Gravida, Parity (or Para), Abortus persistent infection
c. Chills and fever – may indicate:
(or Abortion)
infection
§ G: indicates the number of
dehydration
times a woman is or has gastroenteritis
been pregnant, regardless of d. Sudden escape of fluid from the vagina
the pregnancy outcome e. Abdominal or chest pain
§ P: indicates the number of ectopic pregnancy appendicitis
pregnancies reaching viable abruptio placenta ulcer
gestational age which is at uterine rupture pancreatitis
28 weeks (including live pulmonary embolism
births and stillbirths) f. Pregnancy-induced hypertension:
§ A: the number of Swelling of face and fingers
Rapid weight gain
pregnancies that were lost
Flashes of lights or dots before the eyes
for any reason, including Dimness or blurring of vision
induced abortions Severe headache
or miscarriages. The abortus Decrease urine output
term is sometimes dropped g. Increase or Decrease in Fetal Movement
when no pregnancies have fetus might be needing oxygen; for further
been lost. Stillbirths are not testing
included
Pelvic Examination
d) TPAL (number of infants/babies) 1. Internal Examination (IE)
– Term, Preterm, Abortion, Living 2. Vaginal Speculum
§ T: Number of full-term 3. Transvaginal Ultrasound
infants born (infants born at 4. Papanicolou (Pop smear)
37 weeks or after)
§ P: Number of preterm LEOPOLD’S MANEUVER
infants born (infants born • Non-invasive procedure to determine fetal presentation,
before 37 weeks) position, and attitude
§ A: Number of spontaneous • Used to locate fetal back before applying the fetal monitor
miscarriages or therapeutic • Equipment: Warm, clean hands
abortions A. FUNDAL GRIP - determines presentation
§ L: Number of living children B. UMBILICAL GRIP – determines position
C. PELVIC GRIP – confirms presentation
D. PAWLICK’S GRIP – determines attitude

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FETAL HEART MONITORING 10. VARICOSE VEINS
• Stethoscope, doppler, fetoscope, external/internal a. Wear support stockings
electronic machine b. Elevate feet when sitting
• FHR every 30 minutes during beginning labor, every c. Lying with feet and hips elevated
d. Move out while standing
15 minutes during active labor, and every 5 minutes
e. Avoid pressure on lower legs
during the second stage of labor f. Avoid leg crossing
g. Avoid standing or sitting in long period of
Discomforts During Pregnancy time
First Trimester h. Avoid constricting clothing
1. NAUSEA AND VOMITING 11. HEADACHES
a. Eat dry crackers a. Change position slowly
b. Small frequent feeding b. Apply cool cloth at forehead
c. Eat small snack
c. Low fat meals
d. Use pain relievers when prescribed
d. Avoid fried foods 12. HEMORRHOIDS
e. Avoid antiemetics a. Warm sitz bath
2. SYNCOPE b. High fiber diet
a. Sit with feet elevated c. Increase oral fluid intake
b. Change position slowly d. Exercise
c. Left lateral position e. Apply ointments/suppositories as
prescribed
13. CONSTIPATION
First through Third Trimesters
3. BREATS TENDERNESS a. High fiber diet
b. Increase oral fluid intake
a. Use supportive bra with elastic strap
c. Exercise
b. Avoid soap in the nipples and areola d. Avoid laxatives
4. INCREASED VAGINAL DISCHARGES 14. SHORTNESS OF BREATH
a. Proper cleaning and hygiene a. Rest periods
b. Wear cotton underwear b. Elevate head while sleeping
c. Avoid douching c. Avoid overexertion
d. Consult physician if infection is suspected 15. BACKACHE
5. NASAL STUFFINESS a. Encourage rest
a. Use humidifier b. Use body mechanics
b. Avoid nasal sprays and antihistamines c. Wear low-heeled shoes
d. Exercises
First and Third Trimester
e. Sleep on firm mattress
6. FATIGUE
a. Frequent rest periods 16. LEG CRAMPS
b. Regular exercise a. Exercise
c. Avoid stimulants b. Elevate and dorsiflex the feet while resting
7. URINARY FREQUENCY AND URGENCY c. Increase calcium intake
a. Increase oral fluid intake
RECOMMENDED EXERCISES
b. Limit fluid intake in the evening
• Tailor Sitting
c. Void at regular intervals
• Squatting
d. Sleep on the side at night
• Kegel’s Exercise (Pelvic Floor Contraction)
e. Wear perineal pads if necessary
• Abdominal Muscle Contraction
• Pelvic rocking
Second and Third Trimester
8. HEARTBURN
a. Small frequent feeding Labor
b. Sit upright for 30 minutes after meal Ø A series of events when the product of conception is
c. Drink milk between meal expelled out from the woman’s body.
d. Avoid fatty and spicy foods Ø Regular uterine contractions cause progressive
e. Avoid antacids unless prescribed by dilatation of the cervix and sufficient muscular force
physician to allow the baby to be pushed outside.
9. ANKLE EDEMA Ø Usually begins when the fetus is sufficiently mature.
a. Elevate legs at least twice a day
b. Wear support stockings
c. Avoid one position for long periods of time
d. Avoid diuretics

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THEORIES OF LABOR LIGHTENING
1. Uterine Stretch Theory - nestling of the fetal presenting part into the pelvis
– The idea is based on the concept that any ENGAGEMENT
hollow body organ when stretched to its - settling of the fetal presenting part into the ischial
capacity will inevitably contract to expel its spine
contents - e to uterine contraction and amniotic fluid
2. Oxytocin Theory
– Presence of this hormone causes the initiation EFFACEMENT
of contraction of the smooth muscles of the - thinning of the cervical canal
body (uterus is composed of smooth muscles) - expressed in % (100% is a fully dilated cervix)
3. Progesterone Deprivation Theory
PASSAGEWAY: THE VAGINA
– A decrease in progesterone results in increase
Vaginal Canal
in prostaglandin
- has rugae and capable of stretching but can be
4. Prostaglandin theory
lacerated:
– A decrease in progesterone amount elevates a. 1st degree – skin
the prostaglandin level. Synthesis of b. 2nd degree – skin and muscles
prostaglandin, in return, causes uterine c. 3rd degree – external sphincter of
contraction thus, labor is initiated.
rectum
5. Placental Aging Theory
d. 4th degree – mucus membrane of
– Advance placental age decreases blood supply rectum
to the uterus. This event triggers uterine Perineum - site of episiotomy:
contractions thereby, starting the labor. a. Median episiotomy
b. Right mediolateral
COMPONENTS OF LABOR c. Left mediolateral
1. PASSAGEWAY
2. PASSENGER
The Passengers: Fetus
3. POWER
4. PSYCHE
1) Fetal Skull
Membrane Spaces
a. SUTURE LINES
o where the bones of the skull
meet
o allow the cranial bones to move
and overlap
b. FONTANELLES
Posterior
o Closes at 2mos or 8weeks of age
Anterior
o Closes at 12-18 months of age
c. ANTEROPOSTERIOR DIAMETER

VARIATIONS IN PELVIC SHAPES

1. GYNECOID - normal female
2. ANDROID - normal male
3. ANTHROPOID - the pelvic brim is longer
anteroposteriorly than transversely
4. PLATYPELLOID - the pelvic brim is much wider
transversely and foreshortened anteroposteriorly

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2) Fetal Attitude Right Occiput Anterior (ROA)

The Passengers: Fetus

1. Placental Separation
a. Calkin sign/ globular sign of the fundus
b. Sudden gush of blood
c. Lengthening of the cord
2. Placental Delivery
GOOD ATTITUDE a. Duncan delivery
– Suboccipitobregmatic, Vertex Presentation b. Schultz delivery
(well-flexed)
MILITARY ATTITUDE Power
– Occipitofrontal, no felxion, no extension
A. Uterine Contraction (Phases)
POOR ATTITUDE
– Partial Extension, Occipitomentum, Brow
Presentation
POOR ATTITUDE
– Full Extension, Submentobregmatic, Face
presentation

3) Fetal Lie - Relationship of the long axis of the fetus to

the long axis of the mother
a. Vertical Lie
b. Transverse Lie
B. Uterine Contraction (Contour Changes)
4) Fetal Presentation - Body parts that will first contact
the cervix
a. Vertical Cephalic Presentation
b. Vertical Breech Presentation
i. Frank Breech
ii. Footling Breech
iii. Complete Breech
c. Transverse Presentation - the presenting
part is usually one of the shoulders
(acromion process), an iliac crest, a hand,
or an elbow C. Cervical Changes
**FETAL LANDMARKS - Effacement
Occiput – vertex/cephalic presentation (O)
Mentum- chin/ face presentation (M) Psyche
Sacrum - in breech presentation (Sa) • Woman’s psychological outlook
Acromion – scapula/shoulder presentation (A) • Refers to the psychological state or feelings that a
**FETAL POSITION – represented by 3-letter
woman brings into labor
abbreviation
1st letter - L (left) or R (right) • For many women, this is a feeling of apprehension or
2nd - fetal land marks fright. For almost everyone, it includes a sense of
3rd - A (anterior), P (posterior) excitement or awe
T (transverse)
Ex: Left Occiput Anterior (LOA) Stages of Labor

1. DILATATION STAGE
- Starts on the onset of true labor up to the
expulsion of the fetus.
- Phases of Labor:
Ø LATENT

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 § Begins at the onset of regularly – Perineal and vaginal laceration
perceived uterine contractions • Mechanism of Labor
and ends when rapid cervical o D – DESCENT
dilatation begins o F - FLEXION
§ Measuring the length of the latent o I - INTERNAL ROTATION
phase is important because a o E - EXTENSION
reason for a prolonged latent o E - EXTERNAL ROTATION
phase is cephalopelvic o E - EXPULSION
disproportion (a disproportion
between the fetal head and pelvis) NURSING RESPONSIBILITIES (2ND STAGE)
that could require a cesarean NURSING CARE ON SECOND STAGE
birth. 1) Lithotomy position
Ø ACTIVE 2) Perineal flushing
§ Cervical dilatation occurs more 3) Drape aseptically
rapidly 4) Teach breathing technique during uterine relaxation
§ Show (increased vaginal 5) Teach pushing technique during uterine contraction
secretions) and perhaps 6) Assist episiotomy
spontaneous rupture of the 7) Do Ritgen’s maneuver
membranes may occur during this 8) Ease head out, wipe face
time 9) Assist for external rotation
§ Contractions grow strong, last 10) Pull head downward and upward to deliver the
longer, and begin to cause true shoulders
discomfort 11) Deliver the body
Ø TRANSITIONAL 12) Take note of time of delivery and sex of the baby
§ Contractions reach their peak of 13) Place baby on mother’s abdomen
intensity 14) Dry thoroughly the baby
§ Causing maximum cervical 15) Palpate for the pulsation of the cord
dilatation of 8 to 10 cm 16) Clamp the cord 1 inch from the base once pulsation
§ Membranes should be ruptured at stops
full dilatation (rule), if not, 17) Milk the cord from the cord clamp up to 2 inches
AMNIOTOMY towards the mother
§ FULL DILATION, COMPLETE 18) Clamp 1 inch apart from initial clamping using
EFFACEMENT forceps
19) Cut the cord.
NURSING RESPONSIBILITIES (1ST STAGE)
1) Admission care 3. PLACENTAL DELIVERY
2) Data gathering – begins with the birth of the infant and ends
3) Assisting IE with the delivery of the placenta
4) Leopold’s maneuver – Signs:
5) Fetal Heart Tone (FHT) Monitoring a. Calkin’s sign (the change of shape
6) Uterine Contraction Monitoring of the uterus from discoid to ovoid,
7) Promote change in position indicating placental separation from
8) Empty the bladder the uterine wall)
9) Hygiene b. Sudden gush of blood
10) Enema administration c. Lenghtening of the cord
11) Perineal preparation Placental delivery:
12) Analgesic administration as ordered
13) Assist in the administration of regional
• Schultz Delivery
anesthesia – Fetal surface presentation
14) Start IVF as ordered – Shiny and glistening
15) Assist in Amniotomy – Detaches from center to edges
16) Watch out for SUBIRBA
o S - Severe uterine contraction
• Duncan Delivery
o U - Urge to defecate – Maternal surface
o B - Bearing down sensation – Raw, red, irregular
o I - Increased Bloody Show – Cotyledons showing (around 15 to 25
o R - RBOW cotyledons)
o B - Bulging of Perineum
– Detaches from edges to center
o A - Anal Dilatation
17) Emotional support
NURSING CARE ON THIRD STAGE
1) Perform Crede’s maneuver:
2. EXPULSION
- Apply pressure on hypogastric area
– Begins from full dilatation of the cervix up to
- Gentle traction of the cord
the delivery of the fetus
2) Do Brandt Andrew’s Manuever
– Mechanism of labor
3) Gently pull the placenta downward

AMARILLE, DE VERA, LAPINIG, TENEBROSO 12

 4) Take note for the time of placental delivery 0 1 2
5) Check for type of placental delivery: Heart rate Absent <100 >100
6) Take BP RR Absent Slow/irregular Good cry
7) Check for completeness of cotyledons Muscle tone Absent/limp Some flexion Active
8) Promote uterine contraction: Reflexes No response Grimace Cry
Color Blue/pale Acrocyanosis All pink
o massage the hypogastric area
o Apply ice pack on the hypogastric area
o Administer medication: Oxytocin/Maleate SCORE INTERPRETATION
o Empty the bladder 0-4 = Poor (in serious danger and needs
9) Inspect perineum for lacerations resuscitation)
10) Assist in episiorrhaphy/repair of lacerations 5-6 = Condition is guarded (may need
11) Do perineal care airway
12) Apply contoured brief/adult diaper clearing and oxygen)
13) Make patient comfortable 7-10 = Good (newborn is doing well)
14) Monitor vital signs every 5 minutes
8. Anthropometric Measurements
Birth weight = 2.5-3.5 kgs
4. RECOVERY PERIOD Length = 45-55 cms
- From the delivery of the placenta up to 2 Head circumference = 32-35.5
hours post-partum cms
- Most critical period of the mother Chest circumference = 30-33 cms
- Continue skin to skin contact for at least 90 abdominal circumference = 28-30 cms
minutes.

NURSING CARE ON FOUTH STAGE

1) Assess fundus 9. Vital Signs
2) Check for bleeding Heart rate = 110-160 bpm
3) Check the bladder Respiratory = 30 – 60 bpm
4) Check the perineum Temp (rectal) = 36-37.6
5) Take vital signs every 5 minutes for 15 minutes, every 10. Head to Toe Assessment
15 minutes for 30 minutes, every 30 minutes for 1 a. Head
hour. o moldings
6) Promote rest
• an elongated shape
because of pressure
Neonatal Period
against the cervix
1. Airway
before birth
wipe mouth and nose
o fontanelles
suction
o caput succedaneum
stimulate to cry
• edema of the scalp at
oxygen administration
the presenting part of
hook to respiratory machine
the head caused by the
2. Temperature
pressure of the
dry the baby presenting part of the
wrap with towel scalp against the
goose neck lamp dilating cervix
avoid unnecessary exposure (gradually absorbed
place inside incubator and disappears at
skin to skin contact about the third day of
3. Proper Identification life)
name band o cephalhematoma
4. Care of the Cord • collection of blood
keep the cord dry between the
5. Care of the Eyes periosteum of a skull
Crede’s prophylaxis (prevents ophthalmia bone and the bone
neonatorum) - Teramycin itself
6. Vitamin K Injection – prevent bleeding • caused by rupture of a
7. Newborn Assessment periosteal capillary
APGAR scoring - done on the after 1 and because of the
5mins of life pressure of birth
o suture lines
o anencephaly (absence of cranium)

AMARILLE, DE VERA, LAPINIG, TENEBROSO 13

 b. Face o immediately after delivery =
o blink reflex 1000 gm
o nystagmus/strabismus o after end of 1st week = 500 gm
o ears should be even or above outer eye o after 6 weeks = 50 gm
canthus placental site is sealed off
c. Chest cervical os are narrowed
o witch milk painful during contraction
contracted
d. Abdomen
o check the umbilical cord Note: The first hour after birth is potentially the
o gastroschisis (absence of abdominal most dangerous time for a woman. If her uterus
wall) should become relaxed during this time (uterine
e. Genitals atony), she will lose blood very rapidly, because
o should void within the 1st 24 hours no permanent thrombi have yet formed at the
o pseudomenses placental site.
o Subinvolution – a medical condition in
o testes should be descended
which after childbirth, theuterus does
(cryptorchidism- undescended testes)
not return to its normal size
o preterm male has less rugae in the
• Lochia
scrotum
- discharges of the uterus
o labia minora is prominent
- pattern should not reverse
f. Extremities
- increase in activity
o flexed
- decrease in breastfeeding
o creases on the palm (Simian crease-
- not offensive in odor
only one crease)
- without large clots
o polydactyly - extra toes or fingers
- present in CS
o syndactyly - webbing of fingers
o amelia - absence of upper extremities
Characteristics of Lochia
o tocophilia - absence of lower
extremeties Type of Color Postpartal Day Composition
o clubfoot Lochia
g. Skin
o color Lochia rubra Red 1-3 Blood, fragments
of decidua, and
o mongolian spots
mucus
o vernix caseosa
o lanugo Lochia serosa Pink 3-10 Blood, mucus, and
o milia invading
leukocytes
Puerperium
Lochia alba White 10-14 Largely mucus;
- the period of about six weeks after childbirth during
(may last 6 leukocyte count
which the mother's reproductive organs return to
their original nonpregnant condition weeks) high

Termination of labor Involution

(Involution - the process whereby the reproductive • Vagina
organs return to their nonpregnant state) - soft, swollen
- hymen is permanently torn
1. Maintain infection-free environment • Perineum
2. Promote healing - edematous
3. Watch for bleeding - with laceration or episiorrhaphy
4. Encourage early ambulation - labia minora and majora remains atrophic
5. Provide comfort and rest - ecchymosis from ruptured capillaries may
6. Provide emotional support show on the surface
7. Establish successful lactation • Abdomen
- soft and flobby
PHYSIOLOGIC CHANGES IN POST PARTAL PERIOD
- striae gravidarum lightens
1. Reproductive Changes
- linea negra disappears in 6th week
• Uterus
size is reduced:

AMARILLE, DE VERA, LAPINIG, TENEBROSO 14

 • Breasts • Integumentary System
- drop in estrogen and progesterone o linea negra and chloasma barely detectable
- Lactating in 6th week
- colostrum is present 3. Vital Signs
- Let-down reflex Temperature
- warm and tender increase on the 1st 24 hrs - dehydration
- engorged after 24 hours - infection
- milk is produced by the 3rd – 4th day after 3-4 days - milk production
- veins are apparent Pulse - decrease due to decrease cardiac output
Blood pressure - slightly decrease
2. Systemic Changes
Respiratory rate - no changes
• Hormonal
o after 1 week – prepregnant state 4. Retrogressive Changes
1) human chorionic gonadotropin Exhaustion (due to…)
(hCG) and human placental • Sleeplessness
lactogen (hPL) are almost • fetal movements
negligible by 24 hours • labor pains
2) progestine, estrone, estriol go • energy expenditures
back to prepregnancy levels after • NPO
1week Weight Loss
3) FSH – remains low for about 12 • diuresis
days and then begins to rise as a • diaphoresis
new menstrual cycle is initiated. • return to prepregnant weight at
• Urinary System 6th week
- During pregnancy, as much as 2000 to
5. Progressive Changes
3000 mL excess fluid accumulates in the
body = DIURESIS (2ND and 5TH day) • Return of menses
- voiding maybe difficult immediately after • Lactation
birth o primary engorgement - feeling
- urinary retention of tension in the breasts on the
- after 12 hours – diuresis third or fourth day after birth
- voiding time should be after 4-6 hours o Breast milk forms in response to
post-partum the decrease in estrogen and
progesterone levels that follows
• Circulatory System delivery of the placenta (which
o decrease blood volume (blood loss + diuresis stimulates prolactin production
= decrease blood volume, but volume and, consequently, milk
returns to normal at 1st – 2nd week) production)
o return to normal at 1st – 2nd week
o blood loss : NSVD - 300-500 ml
CS - 500-1000 ml
o increase plasma fibrinogen (Plasma
Fibrinogen - protective measure against
hemorrhage. However, this high level also
increases the risk of thrombus formation)
o increase WBC (This, too, is part of the body’s
defense system, a defense against infection
and an aid to healing)

• Gastrointestinal System
o hungry and thirsty
o slow passage of stool (passage of stool
through the bowel may be slow because of
the still-present effect of relaxin on the
bowel HEALTH TEACHINGS FOR BREAST BEEFING
o positive bowel sounds 1. Hand washing before and after
o difficult bowel evacuation 2. Clean nipple with water
3. Expose nipple to air

AMARILLE, DE VERA, LAPINIG, TENEBROSO 15

 4. Feed the baby in short frequent intervals and Legal Implications of Maternal &
lengthen gradually
Newborn Health
5. Alternate the breasts
6. Proper positioning
1. EXPANDED BREASTFEEDING PROMOTION ACT OF
7. Adequate maternal nutrition and increase OFI
2009 (RA 10028)
8. Wear well-fitted bra
§ Availability of Lactation stations
§ Deductible expenses
PROPER ATTACHMENT
a. Baby should grasp not only the nipple but also the § Lactation period for breastfeeding
areola employees
b. Lower lip turned outward § Milk banks/storage
c. Chin of the baby touches mother’s breast § Inclusion of breastfeeding in the curriculum
PROPER POSITIONING
a. Head and lower body part must be aligned 2. NEWBORN SCREENING ACT OF 2004 (RA 9288)
b. Baby is facing the mother § The National Newborn Screening System
c. Tummy to tummy shall ensure that every baby born in the
Philippines is offered the opportunity to
POST PARTUM ASSESSMENT undergo newborn screening and thus be
(AV BUBBLEHER) spared from heritable conditions that can
A = Appearance lead to mental retardation and death if
V = Vital Signs undetected and untreated.
B = Breasts
U = Uterus 3. MILK CODE OF THE PHILIPPINES (EO 51)
B = Bladder
§ Ensures adequate and safe nutrition for
B = Bowel
L = Lochia infants through promotion of
E = Episiotomy/Episiorrhaphy breastfeeding and the regulation of
H = Homan’s sign promotion, distribution, selling,
E = Emotion advertising, product public relations, and
R = Rhesus information services artificial milk formulas
and other covered products
EMOTIONAL PHASES OF PUERPERIUM
1. Taking-in Phase
4. ESSENTIAL NEWBORN CARE: UNANG YAKAP
• woman is passive and dependent
CAMPAIGN OF THE DOH (AO 2009-0025)
• prefers talking about pregnancy, labor and delivery
§ Immediate drying of the newborn
• uncertain in caring for newborn
§ Uninterrupted skin to skin contact
2. Taking-hold Phase
§ Proper cord clamping and cutting
o woman begins to initiate action
§ Non-separation of the newborn from the
o interested in taking care of newborn
mother for breastfeeding initiation and
o asserts independence
rooming-in
3. Letting-go Phase
o gives up old role 5. THE PHILIPPINE NURSING LAW (The Philippine
o ready for her new role Nursing Act of 2002 – RA 9173)
§ This bill seeks to institute reforms to
FAMILY PLANNING METHODS
further protect and develop the nursing
1. Natural Methods:
profession, amending for the
a. Fertility Awareness Method (FAB)
purpose Republic Act (RA) No. 9173,
b. Lactation Amenorrhea Method (LAM)
c. Billing’s Method otherwise known as the "Philippine
d. Basal Body Temperature (BBT) Nursing Act of 2002.". RA 9173 was
e. Symptothermal Method enacted in 2002 to provide a
comprehensive definition and
2. Artificial Family Planning Methods: understanding of the nursing profession.
a. Intrauterine Device (IUD)
Functions:
b. Oral Contraceptive Pills
- Provides legal framework for establishing what
c. Depo Provera Injectables
d. Implant nursing actions in the care of patients are legal
e. Condom - Delineates the nurse’s responsibilities from
f. cervical cap those of other professionals
g. spermicidal gel - Helps to establish the boundaries of
independent nursing actions

AMARILLE, DE VERA, LAPINIG, TENEBROSO 16

 - Assists in maintaining a standard of nursing THE MATERNAL, NEWBORN, CHILD HEALTH and
practice by making nurses accountable to law NUTRITION (MNCHN) STRATEGY
- The DOH issued Administrative Order 2008-
NATIONAL SAFE MOTHERHOOD PROGRAM 0029 “Implementing Health Reforms for Rapid
- Vision: for Filipino women to have full access to Reduction of Maternal and Neonatal Mortality”
health services towards making their pregnancy - This policy issuance provides the strategy for
and delivery safer rapidly reducing maternal and neonatal deaths
- Mission: Guided by the DOH FOURmula One through the provision of a package of maternal,
Plus thrust and the Universal Health Care Frame, newborn, child health and nutrition (MNCHN)
the National Safe Motherhood Program is services
committed to provide rational and responsive - The goal of rapidly reducing maternal and
policy direction to its local government partners neonatal mortality shall be achieved through
in the delivery of quality maternal and newborn effective population-wide provision and use of
health services with integrity and accountability integrated MNCHN services as appropriate to
using proven and innovative approaches any locality in the country
- Objectives:
o The Program contributes to the
national goal of improving women’s
health and well-being by:
§ Collaborating with Local
Government Units in
establishing sustainable, cost-
effective approach of delivering
health services that ensure
access of disadvantages women
to acceptable and high quality
maternal and newborn health
services and enable them to
safely give birth in health
facilities near their homes
§ Establishing core knowledge
base and support systems that
facilitate the delivery of quality
maternal and newborn health
services in the country.

THE RESPONSIBLE PARENTHOOD AND REPRODUCTIVE

HEALTH ACT OF 2012 (RA 10354)
- Informally known as the Reproductive Health
Law or RH Law, is a law in the Philippines, which
guarantees universal access to methods on
contraception, fertility control, sexual
education, and maternal care
- These principles are based on the four (4) pillars
of:
o Responsible Parenthood
o Respect for Life
o Birth Spacing
o Informed Choice
- Health services, including Reproductive Health
services, are devolved by the Local Government
Code to the local government units

AMARILLE, DE VERA, LAPINIG, TENEBROSO 17