September 14 & 21, 2021 (Miss Regis) NURSING PROCESS FOR THE WOMAN IN

LABOR
Intrapartum
ASSESSMENT
Objectives:
Pain is a subjective symptom. Assess how much
• Describe the common theories explaining
discomfort she is experiencing.
the onset of labor and the role of passenger,
passage, powers, and psyche in labor. Pain scale Facial expressions Flushing or paleness
• Assess a family labor and birth and identify of the face. Hands clenched in a fist Rapid
the woman's readiness, stage, and Breathing Rapid pulse rate.
progression.
NURSING DIAGNOSIS
• Formulate nursing diagnoses related to the
physiologic and psychological aspects of • relates to a woman's reaction to labor.
labor and birth.
• Develop expected outcomes to meet the 1. Pain related to process of labor and birth.
needs of a family throughout the labor 2. Anxiety related to process of labor and birth
process as well as manage seamless 3. Health seeking behaviors related to
transitions across differing healthcare management of discomfort of labor.
settings 4. Situational low self-esteem related to
• Implement nursing care for a family during inability to use planned childbirth method.
labor such as teaching about the stages of Outcome Identification and Planning
labor.
• Evaluate expected outcomes for • Be certain they are realistic and can be met.
achievement and effectiveness of care. • Be certain to incorporate a support person as
well as the woman in planning so the
INTRAPARTUM experience is a shared one.
Intrapartum Period- extends from the beginning • Be certain that planning is flexible and
of contractions that cause cervical dilation to the Pt individualized allowing the woman to
1 to 4 hours after delivery of the newborn and experience the full significance of the event
placenta. IMPLEMENTATION
Intrapartum Care- refers to the medical and • Interventions during labor should always be
nursing care given to a pregnant woman and her carried out between contractions so the woman can
family during labor and deliver. use a prepared childbirth technique to limit the
LABOR discomfort of contractions.

Labor is a series of events by which uterine • The person a woman chooses to stay with her
contractions and abdominal pressure expel a fetus during childbirth is often culturally determined and
and placenta from the uterus. varies from:

Regular contractions cause progressive dilatation - being a husband - a sister

of the cervix and create sufficient muscular uterine - significant others or partner - parent
force to allow a baby to be pushed out into the - the father of the child - close friend
extrauterine world. OUTCOME EVALUATION
Labor represents a time of change as it is both an • An evaluation during labor should be on
ending and a beginning for the woman, her fetus going to preserve the safety of the woman
and her family (Archie and Roman, 2013) and her newborn.
 • After birth an evaluation helps to determine 7. The fetal membrane begins to produce
the woman's opinion of her experience with prostaglandins, which stimulates
labor and birth. contractions (Impey and Child 2012;
Bienstock, Fox and Wallach, 2015)
• Possible outcome criteria:
SIGNS OF LABOR
1. Patient states that pain during labor was
tolerable because of her advance Preliminary signs of Labor
preparation.
1. Lightening - descent of the fetal presenting
2. Patient verbalizes that her need for
part into the pelvis, occurs approximately 10
nonpharmacologic comfort measures were
to 14 days before labor begins
met.
2. Increase in level of Activity - This increase
3. Patient and family members state that the
in activity is related to an increase in
labor and birth experience was a positive
epinephrine release initiated by a decrease in
growth experience for them both the
progesterone produced by the placenta. This
individually and as a family.
additional epinephrine prepares a woman's
THEORIES OF LABOR ONSET body for the work of labor ahead.
3. Slight loss of weight - As progesterone
Labor usually begins between 37 and 42 weeks of
level falls, body fluid is more easily excreted
pregnancy when the fetus is sufficiently mature to
from the body.
adapt to extrauterine life yet not too large to cause
4. Braxton Hicks Contractions - In the last
mechanical difficulty with birth.
week or days before labor begins, a woman
Labor begins before a fetus is matured (preterm usually notices extremely strong Braxton
birth) Hicks contractions.
5. Ripening of the Cervix - is an internal sign
Labor is delayed until the fetus and placenta have seen only on pelvic examination.
both passed the optimal point for birth (post term
birth) Throughout pregnancy, the cervix feels softer than
normal to palpation, similar to the consistency of an
Some of the theories include: earlobe (Goodell’s sign). At term, the cervix
1. The uterine muscle stretches from the becomes still softer (described as “butter-soft”), and
increasing size of the fetus which results in it tips forward.
release of prostaglandin. Signs of True Labor – involves uterine and
2. The fetus presses on the cervix which cervical changes
stimulates the release of oxytocin from
posterior pituitary. 1. Uterine Contractions - The surest sign that
labor has begun is productive uterine
• Ferguson reflex contractions.
3. Oxytocin stimulation works together with 2. Show - As the cervix softens and ripens, the
prostaglandin to initiate contraction. mucus plug that filled the cervical canal
4. Changes in the ratio of estrogen to during pregnancy (operculum)
progesterone occurs increasing estrogen in 3. Rupture of Membrane - Labor may begin
relation to progesterone, which is interpreted with rupture of the membranes, experienced
as progesterone withdrawal. either as a sudden gush or as scanty, slow
5. The placenta reaches a set age which seeping of clear fluid from the vagina. Early
triggers contractions. rupture of the membranes can be
6. Rising fetal cortisol levels reduce advantageous as it can cause the fetal head
progesterone formation and increase to settle snugly into the pelvis, actually
prostaglandin formation. shortening labor.
Two risks associated with ruptured membranes • Factors include the type of pelvis:
are:
Types of Pelvises:
a. intrauterine infection and
Gynecoid - typical female pelvis with rounded inlet
b. prolapses of the umbilical cord, which could cut
Android - normal male pelvis with a heart shaped
off the oxygen supply to the fetus
inlet
if labor has not spontaneously occurred by 24 hours
Anthropoid - is an apelike pelvis with an oval inlet
after membrane rupture and the pregnancy is at
term, labor will be induced to help reduce these Platypelloid - flat female type pelvis with a
risks. transverse
COMPONENTS OF LABOR
A successful labor depends on the integration of 4Ps
1. The Passage (woman's pelvis is of adequate
size and contour)
2. The Passenger (the fetus) is of appropriate
size and in advantageous position and
presentation.
3. The Power of labor (uterine factors) are
adequate.
4. A woman's Psychological outlook is
preserved, so afterward labor can be viewed
as a positive experience.
PASSENGER
PASSAGE
• Refers to the fetus.
• refers to a route the fetus must travel from the • The body part of the fetus that has the widest
uterus to the cervix and vagina to the external diameter is the head
perineum.
• the 2 pelvic measurements that are important to
determine the adequacy of the pelvis are the:
a. Diagonal conjugate (AP diameter of the inlet)
b. Transverse diameter of the outlet

• The passageway refers to the adequacy of the

pelvis and birth canal in allowing fetal descent
CRANIUM Occipitofrontal diameter- measured from the
occipital prominence to the bridge of the nose is
• the uppermost portion of the skull, is
approximately 12cm.
composed of eight bones.
FONTANELLES
• Anterior fontanelle is diamond shaped. It
closes when the infant is 12 to 18 months of
age.
• Posterior fontanelle is triangular shaped. It
closes when an infant is about 2 months of
age.
Occipitomental diameter — widest AP diameter
Diameter of the fetal skull approximately 13.5 measured from the posterior
fontanelle to the chin.
Biparietal diameter or the transverse diameter— is
the smallest diameter of the fetal skull which
measure about 9.25cm.

Molding
Is overlapping of skull bone along the suture line,
which causes a change in the shape of the fetal skull
to one , long and narrow, a shape that facilitates
passage to the rigid pelvis.
Parents can be reassured that molding only last a
day or two and will not be a permanent condition
Suboccipitobregmatic — is the smallest AP
diameter and is measured from the inferior aspect of
the occiput to the center of the anterior fontanel
approximately 9.5cm.
Fetal Presentation and Position 4. Face (Poor flexion, complete extension)
Fetal Attitude — refers to the degree of flexion a
fetus assumes during labor or the relation of the
fetal parts to each other.
Fetus in Good attitude is in complete flexion
1. Vertex (Full flexion)

Fetal Lie - the relationship between the long axis of

the fetal body and the long axis of the woman's
body.
1. Transverse lie — fetus is lying in a horizontal
position.
• Shoulder Presentation - In a transverse lie,
a fetus lies horizontally in the pelvis so that
2. Sinciput{Moderate flexion ( Military the longest fetal axis is perpendicular to that
Position)} of the mother. The presenting part is usually
one of the shoulders (acromion process), an
iliac crest, a hand, or an elbow.

3. Brow (Partial extension) presents the brow of

• Neglected shoulder
the head to the birth canal.
>Prolonged labor >Membrane ruptured
>liquor drained >Arm maybe prolapse
>Fetus dead or dying
>Lower segment overstretched
>Signs and symptoms of obstructed labor
2. Longitudinal lie — fetus is lying in a vertical a. Complete b. Frank c. Footling
position.
Complete Breech
• Cephalic presentation — fetal head will be
The thigh tightly flexed on the abdomen; both the
the first part to contact the cervix.
buttocks and the tightly flexed feet present to the
cervix.
• Longitudinal lie
• Full Flexion

Frank Breech
Attitude is moderate. The hips are flexed but the
knees are extended to rest on the chest. The
buttocks alone present to the cervix.

• Breech presentation — either the buttocks

or the feet are the first body parts that will
contact the cervix. A good attitude brings Footling Breech
the fetal knees up against the fetal abd. A
Neither the thighs nor the legs are flexed If one foot
poor attitude means the knees and legs are
presents — single footling breech If both present —
extended
double footling breech

3 Types of Breech Presentation:

Fetal Positions

➢ reflects the orientation of the fetal head or butt

within the birth canal.

• Fetal position refers to the relationship of a

designated landmark on the presenting fetal part to
the front, sides, or back of the maternal pelvis
• The landmark on the fetal presenting part is
related 4 to 4 imaginary quadrants of the pelvis: left
anterior (LA), right anterior (RA), left posterior
(LP), and right posterior (RP)

Engagement
• Refers to the settling of the presenting part of the
fetus far enough into the pelvis to be at the level of
the ischial spines, a midpoint of the pelvis

A presenting part that is not engaged is said to be

floating.
One that is descending but has not reached the
ischial spine may be referred to as: dipping.
 • Descent
• Flexion
• Internal Rotation
• Extension
• External Rotation
• Expulsion

Station - refers to the relationship of the presenting

part of the fetus to the level of ischial spine.
• 0 station — presenting part is at the level of
the ischial spine.
• Minus stations — presenting part is above
the ischial spine. (-1 to — 4)
• Plus stations — presenting part is below the
ischial spine (+1 to +4)
• +3 or +4 station — the presenting part is at
the perineum and can be seen if the vulva is
separated. (crowning)

POWER
- Uterine contraction/ the source of power
- Should not bear down with their abdominal
muscles to push until the cervix is fully dilated-+
impedes the primary force and could cause fetal and
Cardinal Movements of Labor cervical damage.
Uterine Contractions
• Braxton Hicks contraction — usually irregular
and are painful but do not cause cervical dilatation.
Effective uterine Contractions have rhythmicity, a
progressive increase in length and intensity and
accompany dilatation of the cervix.
Differentiating Between True and Labor
Contractions
FALSE TRUE
CONTRACTIONS CONTRACTIONS
Begin and remain Begin irregularly but
irregular become regular and
predictable
Felt first abdominally Felt first in the lower
and remained confined back and sweep around
to the abdomen and to the abdomen in a
groin wave.
Often disappear with Continue no matter what
ambulation and sleep the woman's level of
activity
Do not increase in Increase in duration,
Contour Changes:
duration, frequency or frequency and intensity
intensity - As labor contractions progress and become regular
Do not achieve Achieve cervical and strong, the uterus gradually differentiates itself
cervical dilatation dilatation. into two distinct functioning areas. The upper
portion becomes thicker and active, preparing it to
Phases of Contraction be able to exert the strength necessary to expel the
fetus when the expulsion phase of labor is reached.
3 Phases:
- The lower segment becomes thin walled, supple,
1. Increment — when the intensity of the and passive, so that the fetus can be easily pushed
contraction increases. out of the uterus.
2. Acne — when the contraction is at its strongest. - As these events occur, the boundary between the
3. Decrement — when the intensity decreases. two portions becomes marked by a ridge on the
inner uterine surface, the physiologic retraction ring
- The normal physiologic retraction ring may
become prominent and observable as an abdominal
indentation ----Termed a pathologic retraction ring
or Bandl's ring, it is a danger sign that signifies
impending rupture of the lower uterine segment if
the obstruction to labor is not relieved.
Characteristics of Contractions
- It is coordinated
- lnvoluntary
- Intermittent rather than sustained allowing
relaxation of the uterus.
Pattern of Contraction
Frequency
Duration
Interval
Cervical Changes
Intensity
Two changes that occur in the cervix: effacement
Mild and dilatation.
Moderate Effacement - shortening and thinning of the
Strong cervical canal.
In primiparas, effacement is accomplished before
dilatation begins.
Be sure to inform women of this fact. Otherwise,
they can become discouraged if, for example, at
noon after a cervical examination a woman is told
she is 2 cm dilated and then at 4 PM is told she is
still 2 cm dilated.
In multiparas, dilatation may proceed before
effacement is complete.

Nursing Considerations Dilatation

Contraction - is affected by maternal position Dilatation refers to the enlargement or widening of

the cervical canal from an opening a few
- decreased blood flow to the uterus 1 millimeters wide to one large enough
(approximately 10 cm) to permit passage of a fetus.
- triggers the FHT to decrease
Dilatation occurs for two reasons.
1. uterine contractions gradually increase the
diameter of the cervical canal lumen by pulling the
cervix up over the presenting part of the fetus.
2. the fluid-filled membranes push ahead of the
fetus and serve as an opening wedge. If they are
ruptured, the presenting part serves this same
function
 Stages of Labor

PSYCHE
Refers to the psychological state or feelings that a
woman brings into labor.
Encouraging women to ask questions at prenatal
visits and to attend preparation for childbirth classes
helps prepare them for labor. Encouraging them to
share their experience after labor serves as
"debriefing time” and helps them integrate the
experience into their total life.
STAGES OF LABOR
First Stage - Stage of dilatation
• begins with the initiation of true labor contractions
and ends when the cervix is fully dilated
Second Stage
• extending from the time of full dilatation until the
infant is born.
Third Stage - Placental stages
• the time the infant is born until delivery of the
placenta.
Fourth stage – the first 1 to 4 hours after birth of
placenta.
 3) Ritgen's method
Characteris FALSE TRUE
tics 4) Clear the airway after delivery of the had
SLEEP/ DISAPPEAR CONTINUES
PAIN
SEDATION TOPS NO CHANGES
Modified Ritgen Maneuver
CONTRACTIONS
BLOODY NOT PRESENT PRESENT As crowning occurs: exert forward pressure on the
SHOW chin of the fetus through the perineum just in front
CERVICAL NO WITH of the coccyx. Concurrently, the other hand exerts
CHANGE DILATION/EFFA DILATION/ pressure superiorly against the occiput
CEMENT EFFACEMENT

Latent phase
• Woman is able to tolerate the discomforts
• Often talkative and smiling
• Encourage pregnant mother to talk with
partner

Active phase Time:

• Assist with breathing and relaxation Primipara - 30-50 mins to 1 hour

technique Multipare - 20 mins
• Woman is more serious and more focus
• less interaction unless have request Contractions:
• Feels anxious and helpless as the contraction Frequency - 2-3 mins
intensifies
Duration - 60-90 seconds
Transition phase
Intensity: Strong
> Becomes restless
Third Stages : "placental"
> Change position frequently
2 Phases:
> Has the feeling of abandonment
• Placental separation
> Often needs to have focus and re-focus with each • Placental expulsion
contraction
> May be nauseated or even vomits
> Becomes irritable and not want to touch during
contraction
III. CONDUCTING THE DELIVERY
DELIVERY OF THE HEAD
1) Control the delivery of the head to prevent
laceration BRANDT ANDREW MANEUVER
► For the Brandt-Andrews maneuver, one hand is
2) Episiotomy if required
placed on the abdomen to push uterus upward and
backward and prevent uterine inversion while the The leading edge of the placenta separates first and
other hand exerts sustained downward traction on the placenta is delivered with its raw surface
the. umbilical cord. exposed.
► In modified technique, cord is held with forceps
instead of hand.
NORMAL LABOUR AND DELIVERY
MANAGEMENT OF THE THIRD STAGE OF
LABOUR
❖ BIRTH OF THE PLACENTA:
BRANDT'S ANDREW METHOD
- Once the signs of placental separation have 2- Schultz mechanism
occurred the obstetrician assists delivery of the
placenta by controlled cord traction as described If the placenta is inserted at the fundus and central
by Brandt-Andrews' method. area separates first, the placenta inverts and draws
the membranes after it, covering the raw surface
(inverted umbrella)

• Modified Brandt Andrews method

• Left hand: palmar surface of fingers placed above
pubic symphysis. Body of uterus pushed upwards &
backwards
• Right hand: cord traction in downward &
backward direction
• Uterus feels hard, contracted

(FUNDAL MASSAGE AFTER DELIVERY OF

THE THIRD STAGE OF LABOUR PLACENTA WHICH FACILITATES THE
EXPULSION OF RETAINED CLOTS IF ANY)
❖ MECHANISM OF PLACENTA
SEPARATION: PLACENTAL SEPARATION

Two mechanisms of placental separation occurs: SIGNS OF SEPARATION

1- Mathews-Duncan mechanism 1. INCREASED BLEEDING

2. LENGTHENING OF CORD
 3. UTERUS RISES , BECOMES • Ths fundus should be midline and at the
GLOBULAR INSTEAD OF DISCORD level of umbilicus
4. UTERUS ENLARGES, APPROACHING • The fundus should be firm, not soft
UMBILICUS • The fundus should be palpated at the midline
Fourth Stage: “Recovery"
(BORMALLY SEPARATES WITHIN A - delivery of the placenta to the 1-4 hours post-
FEW MINUTES AFTER DELIVERY OF partum
FETUS
Nursing Considerations;
➢ Provide warm blanket, hot drink, or soup
➢ Promote parent-infant bonding
➢ Assess maternal vital signs, fundal height, lochia and
bladder distention

Measuring Progress in Labor

➢ A woman's progress in labor is recorded on a labor
record (Partogram) devised by the WHO.
➢ Like a form on which the following are recorded:
❖ Vital signs
NOTE THE FOLLOWING ❖ Cervical dilation
❖ Descent of the fetal head
•.MAKE SURE IT IS COMPLETE ❖ Urine test to
➢ Any drugs administered
• LOOK FOR MISSING PIECES ➢ At the end of the latent phase of the first stage of
labor cervical dilatation is 3 to 4cm.
•.LOOK FOR MALFORMATION
➢ As the woman enters active phase, cervical dilation
• LOOK FOR AREA OF ADHERENT BLOOD proceeds at a minimum of 1cm/hr or about 7
CLOT additional hours to reach full dilatation.
➢ The form shows an alert line which marks when 4
hours has passed.
➢ Four hours beyond that, an action advises a primary
Expulsion of the Placenta
care provider that cervical dilation is taking longer
• The schultz mechanism than usual and that an intervention may be
• Mathew Duncan mechanism necessary to make the labor safe and effective.
➢ Maintaining an ongoing record and alerting the care
provider that the alert line or action line is
approaching is an important nursing
responsibilities.
➢ How to use the partograph
https://www.youtube.com/watch?v=hTh5MJFzgPY

Recommended Nursing Actions:

➢ Monitor closely for hemorrhage
➢ Monitor for signs of pathology with hypertensive
episodes.
➢ Ensure that patients are well hydrated prior to
epidural administration
Nursing Considerations
HEMATOPOIETIC SYSTEM
• Assess umbilical cord ➢ During labor - development of leukocytosis.
• Assess placenta for intactness cat
 ➢ At the end of labor, the average woman has a white able to be open as much as 2cm in labor to allow
blood cell count of 25,000 to 30,000 cells/mm3 for fetal passage.
normal count of 5000 to 10,000 cells/mm3 Recommended Nursing Actions:
Recommended Nursing Actions: ➢ Monitor for appropriate mobility and be mindful of
➢ Continue to monitor for any signs of infection fall risks.

RESPIRATORY SYSTEM GASTROINTESTINAL SYSTEM

➢ an increase in cardiovascular parameters, the body ➢ Becomes inactive during labor because of pressure
responds by increasing the respiratory rate to on the stomach and intestines from the contracting
supply additional oxygen. uterus.
➢ Total 02 needs increases by about 100% during the ➢ Some women may experience of LBM as
2nd stage of labor. contractions grow strong.
Recommended Nursing Actions: Recommended Nursing Actions:
➢ Monitor for any signs of hyperventilation. If ➢ Although many hospital protocols dictate that
hyperventilation occurs, rebreathing into the paper women who present in labor should not partake of
bag can be helpful. oral nutrition, there is little evidence to support this
➢ If needed, use appropriately patterned breathing to restrictive practice.
regulate respiratory rate.
NEUROLOGIC AND SENSORY RESPONSES
TEMPERATURE REGULATION ➢ responses r/t pain are: increased in PR and RR
➢ slight elevation (1° F) in temperature ➢ early in labor causes discomfort at the uterine and
➢ Diaphoresis occurs. cervical nerve plexus at the level of T11 and T12.
Recommended Nursing Actions: ➢ at the moment of birth, pain is centered on the
➢ Monitor for any signs of infection. perineum at the level of S2 to S4.
➢ Offer cool washcloth to the patients forehead for
comfort. MATERNAL PSYCHOLOGICAL RESPONSES TO
LABOR
FLUID BALANCE REGULATION ➢ Labor can lead to emotional distress
➢ Insensible water loss increases during labor due to ➢ Fatigue
diaphoresis and increase in rate and depth of ➢ Fear
respiration. ➢ Cultural Influences
Recommended Nursing Actions:
➢ Encourage women to sip fluid during labor the same RECOMMENDED NURSING ACTIONS:
as they would if they were exercising to keep ➢ Offer expeditious care to the patient.
hydrated. ➢ Continue to encourage the process of labor.
➢ Prior to birth, the woman can investigate the
URINARY SYSTEM services of a doala.
➢ Kidneys begins to concentrate urine. Specific gravity A doala is an individual with specialized training who
may rise to a high normal level of 1.020 to 1.030. provide, physical, emotional.
➢ Pressure of the fetal head as it descends in the birth
canal against the anterior bladder reduces bladder FETAL RESPONSES TO LABOR
tone or the ability of the bladder to sense filling
Recommended Nursing Actions: NEUROLOGIC SYSTEM
➢ Void approximately every 2 hours during labor to ➢ Uterine contractions exerts pressure on the fetal
avoid overfilling because overfilling can decrease head.
peripheral bladder tone. ➢ The FHR decreases by as much as 5 beats per
minute during contraction.
MUSCULOSKELETAL SYSTEM ➢ Early deceleration pattern appear on the fetal
➢ During pregnancy, relaxin is secreted from the monitor.
ovaries causing the cartilage between joints to be
more flexible. This allows joints of the pelvis to be
CARDIOVASCULAR SYSTEM ➢ Falling BP - may be the first sign of intrauterine
➢ During a contraction, the arteries of the uterus are hemorrhage.
sharply constricted and the filling of cotyledons
almost completely halts. ABNORMAL PULSE
➢ The amount of nutrients, including oxygen, ➢ Most pregnant women have a pulse rate of 70 to
exchanged during this time is reduced, causing a 80 bpm.
slight but fetal hypoxia. ➢ This rate normally increases slightly during the
➢ Increased intracranial pressure caused by uterine 2nd stage of labor because of the exertion involved
pressure on the fetal head serves to keep ➢ A maternal pulse rate greater than 100 bpm during
circulation from falling below normal during the the normal course of labor is unusual and should
duration of a contraction be reported.
❖ . may be another indication of hemorrhage.
INTEGUMENTARY SYSTEM
➢ Minimal petechiae or ecchymotic areas on a fetus INADEQUATE OR PROLONGED
(particularly the presenting part). CONTRACTIONS
➢ There may also be edema of the presenting part ➢ Uterine exhaustion (inertia)
(caput succedaneum). ➢ As a rule, uterine contractions lasting longer than
70 seconds are becoming long enough or
MUSCULOSKELETAL compromise fetal well being because this
➢ The force of uterine contractions tends to push a interferes with adequate uterine artery filling.
fetus into a position of full flexion, the most ➢ If this problem cannot be corrected, a cesarean
advantageous position for birth. birth may be necessary.

RESPIRATORY SYSTEM PATHOLOGIC RETRACTION RING

➢ The pressure applied to the chest from ➢ An indentation across a woman's abdomen, where
contractions and passage through the birth canal the upper and lower segments of the uterus join,
helps to clear it of lung fluid. For this reason, an may be a sign of extreme uterine stress and
infant born vaginally is usually able to establish possible impending uterine rupture.
respirations more easily than a fetus born by
cesarean birth. ABNORMAL LOWER ABDOMINAL CONTOUR
DANGER SIGNS OF LABOR ➢ If a woman has a full bladder during labor, a round
✓ MATERNAL DANGER SIGNS bulge on her lower anterior abdomen may appear.
✓ FETAL DANGER SIGNS ➢ A danger signal for two reasons:
MATERNAL DANGER SIGNS a. the bladder may be injured by the pressure of
1. HIGH OR LOW BP a fetal head.
2. ABNORMAL PULSE b. the pressure of the full bladder may not allow
3. INADEQUATE OR PROLONGED the fetal head to descend.
CONTRACTIONS
4. PATHOLOGIC RETRACTION RING INCREASING APPREHENSION
5. ABNORMAL LOWER ABDOMINAL ➢ A woman who is becoming increasingly
CONTOUR apprehensive despite clear explanations of
6. INCREASING APPREHENSION unfolding events may only be approaching the
second stage of labor.
MATERNAL DANGER SIGNS ➢ Increasing apprehension also needs to be
HIGH OR LOW BLOOD PRESSURE investigated for physical reasons, because it can be
➢ the basic criteria for pregnancy-induced hpn a sign of oxygen deprivation or internal
❖ A systolic pressure greater than 140 mm Hg hemorrhage.
and a diastolic pressure greater than 90 mm ➢ Check pathologic, check abdomin, pulse rate
Hg or FETAL DANGER SIGNS
SBP > 30 mm Hg or 1. HIGH OR LOW FETAL HEART BEAT
DBP >15 mm Hg 2. MECONIUM STAINING
3. HYPERACTIVITY
 4. LOW OXYGEN SATURATION f. Assessing Rupture of Membrane
g. Assessment of Pelvic Adequacy
HIGH OR LOW FETAL HEART RATE h. Vital signs
➢ As a rule, a FHR of more than 160 bpm or less than i. Laboratory Analysis
110 bpm is a sign of possible fetal distress. j. Assessment of Uterine Contractions
➢ An equally important sign is a late or variable 3. The Initial Fetal Assessment
deceleration pattern revealed on a fetal monitor.
➢ Frequent monitoring by a fetoscope, Doppler or a
monitor is necessary to detect these changes as Maternal and Fetal Assessment During Labor
they first occur.
1. Immediate assessment of a woman in First Stage of
MECONIUM STAINING Labor
➢ is not always a sign of fetal distress but is highly ➢ Initial interview and Physical Examination
correlated with its occurrence. Ask the following:
➢ a green color in the amniotic fluid reveals the fetus ✓ Her baby's expected date of birth
has had a loss of rectal sphincter control allowing ✓ When her contractions began
the meconium to pass into the amniotic fluid. ✓ Amount and character of any show
➢ lt may indicate that a fetus has or is experiencing ✓ Whether rupture of membrane has occurred
hypoxia, which stimulates the vagal reflex and ✓ Any known drug allergies
leads to increased bowel motility. ✓ Any recreational or prescription drugs
➢ may be usual in breech presentation. ✓ Past pregnancy and present pregnancy history
if prenatal record is not available. It is important
HYPERACTIVITY to note the route of delivery with any prior birth
➢ A fetus is quiet and barely moves during labor. as well as complications which may have
➢ Fetal hyperactivity may be a sign that hypoxia is occurred.
occurring, because frantic motion is a common ✓ Her birth plan or what individualized measures
reaction to the need for oxygen she thinks will create a memorable experience
for her whether she wants analgesia or she
LOW OXYGEN SATURATION would like to cut the cord.
➢ •Oxygen saturation in a fetus is normally 40% to Assess the following:
70%. ✓ Vital signs ( assess between contractions for
➢ A fetus can be assessed for this by a catheter comfort and accuracy)
inserted next to the cheek. ✓ Nature of her contractions (frequency, duration
➢ If fetal blood is obtained by scalp puncture, the and intensity)
finding of acidosis (blood pH lower than 7.2) ✓ Her rating of pain on a 10 point scale
suggest fetal well being is becoming compromised ✓ What she has done to be prepared for labor such
and that further investigation is necessary. as learning breathing techniques.
✓ Urine specimen for protein and glucose
MATERNAL AND FETAL ASSESSMENT DURING ✓ Position and presentation of the fetus
LABOR 2. Detailed assessment During the First Stage of
Labor
Maternal and Fetal Assessment During Labor a. History taking
1. Immediate assessment of a woman in First Current pregnancy history
Stage of Labor - gravida and para status
• Initial interview and Physical Examination - description of pregnancy
2. Detailed assessment During the First Stage of - Pattern and place of prenatal
Labor - Adequacy of nutrition
a. History taking - Any complications
b. Physical Examination - Future child care
c. Leopold's Maneuver
d. Vaginal examination
e. Ultrasound
Past Pregnacy History C. Leopold's Maneuver
Document prior pregnancies, abortion including;
First maneuver:
➢ The superior surface of the fundus is palpated to
determine consistency, shape, and mobility.

A. Past health history

✓ Document previous surgeries
✓ Heart disease or diabetes
✓ Anemia
✓ TB
✓ Kidney disease
✓ Hypertension
✓ STD
Family medical history
Ask if Any Family member is:
✓ cognitively Second maneuver:
✓ challenged ➢ Both sides of the uterus are palpated to determine
✓ heart disease the direction the fetal back is facing.
✓ Diabets
✓ kidney disease
✓ allergies
✓ Seizures

B. Physical Examination
- it includes:
✓ Pelvic examination
✓ Overall appearance
✓ Lymph nodes
✓ Mouth / eyes
✓ Teeth Third maneuver:
✓ Lips ➢ This step determines the part of the fetus at the
✓ Lungs inlet and its mobility.
✓ Heart sounds and rhythm
✓ Breast
✓ Abdomen
✓ Lower Extremities

Fourth maneuver:
➢ This step determines the fetal attitude and degree
of fetal extension into the pelvis.

Procedure:
1. Prepare the client.
a. Explain the procedure
 b.Instruct the client to empty the bladder. 4. Discard one drop of clean lubricating solution and
c.Position the woman supine with knees slightly drop an ample supply on tips of gloved fingers.
flexed. Place a small pillow or rolled towel under 5. Pour antiseptic solution over vulva using
one side. nondominant hand
d. Wash your hands using warm water. 6. Place nondominant hand on the outer edges of the
e. Observe the woman's abdomen for longest woman's vulva and spread her labia while
diameter and where fetal movement is apparent. inspecting the external genitalia for lesions. Look
Procedure: for red, irritated mucous membranes; open,
2. Perform the 1st Maneuver ulcerated sores; clustered, pinpoint vesicles.
a. Stand at the foot of the client, facing her, and 7. Look for escaping amniotic fluid or the presence
place both hands flat on her abdomen. of umbilical cord or bleeding.
b. Palpate the superior surface of the fundus. 8. If there is no bleeding or cord visible, introduce
Determine consistency, shape, and mobility. your index and middle fingers of dominant hand
gently into the vagina, directing them toward the
4. Perform the 4th Maneuver posterior vaginal wall.
a. Place fingers on both sides of the uterus 9. Touch the cervix with your gloved examining
approximately 2 inches above the inguinal fingers.
ligaments, pressing downward and inward in a. Palpate for cervical consistency and rate if firm or
the direction of the birth canal. Allow fingers to soft.
be carried downward b. Measure the extent of dilatation; palpate for an
anterior rim or lip of cervix.
d. Vaginal examination 10. Estimate the degree of effacement.
➢ best done between contractions 11. Estimate whether membranes are intact.
➢ Should not be done in the presence of vaginal 12. Locate the ischial spines. Rate the station of the
bleeding. presenting part. Identify the presenting part.
➢ The cervix feels like a circular rim of tissue around 13. Establish the fetal position
a center depression. 14. Withdraw your hand. Wipe the perineum front to
Firm is similar to the tip of the nose Soft is as pliable as back to remove secretions or examining solution.
an earlobe Cervix before labor is 2cm to 2 12 cm thick Leave client comfortable and turned to side. 15.
If 1 cm thick now it is 50% effaced. Tissue paper thin is 15. Document procedure and assessment findings and
100% effaced how client tolerated procedure.
➢ Station
➢ Palpate the 2 fontanelles
➢ Buttocks feel softer. Identifying the anus may be
possible because the sphincter action will trap the
index finger.
➢ In ROA, the triangular fontanelle will point toward
the right anterior pelvic quadrant
➢ In LOA, the posterior fontanelle will point the left
anterior pelvis

Procedure:
1. Wash your hands; explain procedure to client.
Provide privacy.
2. Assess client status and adjust plan to individual
client need.
3. Assemble equipment: sterile examining gloves,
sterile lubricant, antiseptic solution. Ask the E. Sonography
woman to turn onto her back with knees flexed (a ➢ to determine the diameters of the fetal skull and to
dorsal recumbent position). Put on sterile determine presentation, position, flexion and
examining gloves. degree of descent of the fetus at the beginning of
labor.
F. Assessing Rupture of Membrane Time Intervals for Nursing Intervention During the
➢ Vaginal secretions are obtained (usually with the First stage of labor
use of a sterile, cotton-tipped applicator), test them
with a strip of Nitrazine paper.
- Nitrazine paper test
- Fern test

G. Vital signs
Temperature
➢ Latent/active/transition : on admission and every 4
unless membranes are ruptured then every 2 hours
➢ Report a temperature greater than 99F (37.2C) – it
may indicate a development of infection
➢ Temperature elevation in women who have taken
little fluid by mouth usually reflects dehydration.
Pulse/RR/BP
➢ Latent/active: On admission and q 30 to 60
minutes Transition: 015 to 30 minutes
Pulse should range from 70 and 80 beats /min
➢ >100 beats/min could be tachycardia from
dehydration or hemorrhage.
RR during labor is 18 to 20 breaths /min.
➢ Observe for hyperventilation (rapid, deep
breathing) because prolonged hyperventilation can Assessment of uterine contractions
cause a blowing off of carbon dioxide and ➢ Length of Contractions
accompanying symptoms of dizziness and tingling ➢ Time the duration of a contraction from the
of hands and feet. moment the uterus first tenses until it has relaxed
BP again.
➢ Measure between contractions for a woman's ➢ Intensity of contraction
comfort and for accuracy because maternal BP ➢ Frequency of Contractions
tends to rise 5 to 15mmHg during contraction,
➢ A decrease in BP or decrease in pulse pressure 3. The Initial fetal assessment
may indicate hemorrhage a. Auscultation of fetal heart sounds
➢ A patient taking analgesic agent such as Determine the FHR:
meperidine) tends to cause hypotension, check her ✓ every 30 minutes during beginning labor,
BP 15 minutes after administration to be certain ✓ every 15 minutes during active labor
extreme hypotension did not occur. ✓ every 5 minutes during the second stage of
labor.
H. Laboratory analysis
✓ Hgb and het
✓ Serologic test for syphillis
✓ Hep b antibodies
✓ Blood typing
✓ Urinalysis- protein and glucose

Voiding
➢ Latent/active/transition: every 2 hours
Perineum
➢ Latent - every 30 to 60mins
➢ Active - every 30 minutes
➢ Transition every 15 minutes
 ➢ The FHR is monitored with the use of an ultrasonic
sensor or monitor also strapped against a woman's
abdomen at the level of the fetal chest.

b. External Electronic Monitoring c. Fetal Heart Rate and Uterine Contraction

➢ Contractions are monitored by means of a pressure Records
transducer or tocodynamometer
➢ Uterine contraction information is recorded on the
➢ Place the transducer over the uterine fundus bottom half of the paper, FHR on the top half.
➢ The transducer converts the pressure registered by ➢ Time can be calculated by counting the number of
the contraction into an electronic signal that is bold vertical lines on the paper (the space between
recorded on graph paper.
two bold lines represents 60 seconds).
 ➢ Late deceleration suggest uteroplacental
insufficiency or decreased blood flow through the
intervillous spaces of the uterus during uterine
D. Fetal Heart rate Parameters contraction
Baseline Fetal Heart Rate : ➢ Immediately change the position from supine if
➢ A baseline FHR is determined by analyzing the pace she is lying down to lateral to relieve pressure on
if fetal heart beats recorded in a minimum of 2 the vena cava and supply more blood to the uterus
minutes obtained between contractions. and fetus.
➢ A normal rate is 110 to 160 bpm. ➢ Intravenous fluid or oxygen may be prescribed.
➢ Abnormal patterns in the baseline rate include fetal ➢ Prepare for a prompt cesarean birth of the infant if
bradycardia and fetal tachycardia the late deceleration persist or if FHR variability
becomes abnormal (absent or decreased)
Variability ➢ Prolonged Decelerations are decelerations that are
➢ a difference between the highest and lowest a decrease from the FHR baseline of 15 beats per
rates shown on a strip is one of the most reliable minute or more and last longer than 2 to 3 minutes
indications of fetal well being. but less than 10 minutes.
Variability is recorded as: ➢ May signify a significant event such as cord
➢ Absent- no amplitude range is detected. compression or maternal hypotension. It must be
➢ Minimal- amplitude range is detectable but is reported and documented.
5 beats per minutes or fewer. ➢ If a deceleration last longer than 10 minutes, it is
➢ Moderate (normal)- amplitude range is 6 to considered a baseline change.
25 beats per minute. ➢ Variable deceleration refers to a deceleration that
➢ Marked - amplitude range is greater than 25 occur at a unpredictable times in relation to
beats/min, contractions.
➢ May indicate compression of the cord – may be
Periodic Changes occurring because of prolapsed cord, but is most
➢ fluctuations in FHR occur in response to often occurs because the fetus is simply lying on
contractions and fetal movement. the cord
a. Accelerations ➢ Change the woman's position from supine to
➢ at 32 weeks AOG and beyond, acceleration has a lateral if she is not lying on her side
peak of 15 beats per minute or more above ➢ If prolapsed cord is diagnosed as the cause of
baseline with a duration of 15 seconds but less than variable decelerations, oxygen will be prescribed
2 minutes from onset to return. . as well as changing her position to a knee to chest
➢ Before 32 weeks AOG, an acceleration has a peak to help relieve pressure on the cord
of 10 beats/min or more above baseline , with a
duration of 10 seconds or more but less than 2
minutes from onset to return.
b.Decelerations
➢ Early decelerations follows the pattern of the
contraction, beginning when the contraction
begins and ending when the contraction ends.
➢ a mirror image of the contraction.
CARE OF WOMAN DURING DIFFERENT
STAGES OF LABOR

CARE OF WOMAN DURING FIRST STAGE

6 Major Concepts of Labor
1. Labor should begin on its own, not be artificially
induced.
2. Women should be able to move about freely
throughout labor, not be confined to bed.
3. Women should receive continuous support during
labor
4. No interventions such as IVF should be used
routinely
5. Women should be allowed to assume a non
supine position for birth
6. Mother and baby should be together after the
birth, with unlimited opportunity for breastfeeding

Care of a Woman During the 1st Stage of Labor

A. Powerlessness related to duration of labor
➢ Help empower women
➢ Respect Contraction Time
➢ Promote Change of Positions ➢ Promoting Effective Second-Stage Pushing
➢ Help with Fetal Alignment
➢ Promote Voiding and provide Bladder Care
B. Risk for ineffective breathing pattern related to
breathing exercise

C. Anxiety related to stress of labor

➢ Offer Support
➢ Respect and Promote the Support Person
➢ Support a woman's pain management needs

Care of a Woman During the 2nd Stage of Labor

❖ Preparing the Place of Birth
❖ Positioning for Birth ➢ Perineal Cleaning and massage
❖ Promoting Effective Second-Stage Pushing
❖ Perineal Cleaning and massage
❖ Episiotomy
❖ Cutting and clamping the cord
❖ Introducing the infant

➢ Preparing the Place of Birth

- Birthing Room
- 2 scissors
- 1 forcep
➢ Positioning for Birth
 Classificaton of Perineal Injury

➢ Episiotomy

➢ Birth
 Care of a Woman During the 3rd and 4th Stage of Labor

STAGE 3
➢ Watch for signs of placental separation
➢ Methods of delivery: manual/spontaneous
➢ Brandt andrew's manuever
➢ Administer IM Methergine (deltoid)
➢ Assist episiotomy (prepare lidocaine)
➢ Clean vulva and perineal area after episiorraphy
➢ v/s every 15 min for hour until stable
STAGE 4
➢ Nursing Procedures
➢ Perineal Flushing
➢ Episiorraphy assessment (degree of laceration)
➢ Cutting and clamping the cord
Care of a Woman during the Third and Fourth Stages
of Labor
✓ Placental Delivery
✓ Oxytocin
✓ Perineal Repair
✓ Immediate Postpartum Assessment
✓ After care

2 Phases:
a. placental separation
b. placental expulsion
Signs of Placental Separation
2 Mechanism

Placental grading:
Grade 0 : 12 to 24 weeks
Grade 1: 30 to 32 weeks
Grade 2:36 weeks
➢ Introducing the infant Grade 3: 38 weeks

If excessive bleeding with poor uterine contraction

remains an injection of carboprost tromethamine
(Hemabate) is yet another solution to increase uterine
contractions and to guard against hemorrhage.
 ➢ Anxiety related to lack of knowledge about
“normal labor process
➢ Risk for situational low self esteem related to
ineffectiveness of prepared childbirth breathing
exercises.
➢ Decisional conflict related to the use of analgesia
or anesthesia during labor

OUTCOME IDENTIFICATION AND PLANNING

➢ Be aware that pharmacologic agents used during
labor and birth may pose risk to the mother and
fetus/neonate.
➢ When considering use of pharmacologic
intervention, the benefit to the woman and the
fetus must outweigh the risk of medication use.

IMPLEMENTATION
➢ Keeping the woman and support person informed
about their options and how they differ as labor
progresses.
➢ Supporting and encouraging a woman to use
methods of complementary and alternative
therapies for pain management.
❖ birthing ball
❖ ambulation
❖ relaxation and breathing techniques

Offering analgesia or assisting in anesthesia

administration during labor and birth requires a
nursing judgment and a caring presence to help woman
accept analgesia when she needs it and to encourage
childbirth without pharmacologic intervention when
that is what she desires

OUTCOME EVALUATION
Evaluations are ongoing and typically must occur within
a short time frame.
➢ Patient states pain during labor is within a
Comfort and Pain Relief Measures tolerable level for her.
NURSING PROCESS ➢ Couple reports they feel control throughout the
FOR PAIN RELIEF DURING LABOR AND labor process.
CHILDBIRTH ➢ Patient and fetus remain physiologically stable
ASSESSMENT: with use of pharmacologic interventions.
Pain is the sensation of discomfort, is a subjective and ➢ Patient verbalizes satisfaction with current pain
personal experience. control measures.
✓ what she says
✓ rating COMFORT AND NONPHARMACOLOGIC PAIN
✓ Signs RELIEF MEASURES
1. Support from a Doula or coach
NURSING DIAGNOSIS: 2. Complementary and Alternative Therapies for Pain
➢ Pain related to labor contractions Relief
➢ Powerlessness related to the duration and intensity
of labor.
COMPLEMENTARY AND ALTERNATIVE 5.Herbal Preparations
THERAPIES ➢ Blue cohosh (squaw root), an herb that induces
uterine contractions, is not recommended.
➢ Nonpharmacologic measures used as a woman's 6.Aromatherapy and Essential Oils
total pain management or to complement ➢ Jasmine and lavender are oils thought to be
pharmacologic interventions. responsible for an easier labor
1. Relaxation 7. Heat or Cold Application
➢ taught in most preparation for childbirth classes ➢ Back pain - instant hot pack, heating pad, warm
but can be taught in early labor. compress.
➢ keeps the abdominal wall from becoming tense, ➢ Perineum- heat application provide the dual
allowing the uterus to rise with contractions benefit of soothing and softening the perineum and
without pressing against the hard abdominal wall. decrease risk of perineal tear.
➢ serves as a distraction technique. ➢ Cool washcloth to the forehead, chest or back of
➢ Asking a woman to bring favorite music tapes or the neck comforting
aromatherapy with her to enjoy in the birthing ➢ Sucking ice chipsto relieve mouth dryness is also
room is a good way to aid relaxation. refreshing.
➢ listening to specific music ➢ Immediately following birth ice pack applied on
➢ singing out loud the perineum feels soothing and helps reduce
➢ having someone massage her back edema and swelling.
➢ breathing techniques 8. Bathing or Hydrotherapy
➢ Standing under a warm shower or soaking in a tub
Breathing Exercise of warm water, jet hydrotherapy tub, or whirlpool
✓ Conscious Relaxation is another way to apply heat to help reduce the pain
✓ Focusing or Imagery of labor.
✓ Cleansing Breath ➢ Water is at 370
✓ Effleurage - light abdominal massage 9. Therapeutic Touch and Massage
➢ Touch and massage probably work to relieve pain
by increasing the release of endorphins.
10. Yoga and Meditation
➢ Yoga, a term derived from the Sanskrit word for
“union,” describes a series of exercises
• Increasing the efficiency of the heart
• Slowing the respiratory rate
• Improving fitness
• Lowering BP
• Promoting relaxation
• Reducing stress
• Allaying anxiety
deep breathing exercise body postures to stretch and
strengthen muscles and meditation to focus the mind
and relax the body.
3.Prayer
➢ Prayer is the first measure that they use to relieve 11. Reflexology
stress. ➢ Reflexology is the practice of stimulating the
➢ bring helpful worship objects such as a Bible or hands, feet, and ears as a form of therapy.
➢ cross into a hospital with them to use during ➢ Point that corresponds to the uterus is located ib
prayer. the inside ankle abaut halfway between the ankle
➢ careful when changing sheets during labor that bone (malleolus) and the heel. Massaging this area
you do not accidentally throw away such is believed to begin labor or hurry labor thus
important objects. creating less pain.
12. Crystal or Gemstone Therapy • Anesthesia
➢ Some gemstones or crystals are thought to have ✓ Additional Drugs
healing powers, and women may bring these into ✓ Nitrous Oxide
a birthing room to have with them during labor. ✓ Regional (Local)
13. Hypnosis
➢ Hypnosis is yet another method of pain relief for
labor.
➢ A woman who wants to use this modality needs to
meet with her hypnotherapist during pregnancy.
At these visits, she is evaluated for and further
conditioned for susceptibility to hypnotic
suggestion.
➢ Close to her last weeks of pregnancy she is given
a posthypnotic suggestion that she will experience
a reduction in or absence of pain during labor.
15. Transcutaneous Electrical Nerve Stimulation
➢ relieves pain by counterirritation on nociceptors
(Halls, 2008).
➢ With two pairs of electrodes attached to a woman's
back to coincide with the T10-L1 nerve pathways,
low-intensity electrical stimulation is given
continuously or is applied by the woman herself as
a contraction begins
16. Acupressure and Acupuncture
➢ Acupuncture is based on the concept that illness
results from an imbalance of energy. To correct the
imbalance, needles are inserted into the skin at
designated susceptible body points (tsubos)
located along meridians that course throughout the
body to supply the organs of the body with energy.
➢ Activation of these points apparently results in
release of endorphins, so the system can be
helpful, especially in the first stage of labor
➢ Acupressure, in contrast, is the application of
pressure or massage at these points.
➢ A common point used for a woman in labor is Co4
(Hoku or Hegu point) located between the first
finger and thumb on the back of the hand.

PHARMACOLOGIC MEASURES FOR PAIN

RELIEF DURING LABOR
➢ Analgesia – reduces or decreases awareness of
pain
➢ Anesthesia - causes partial or complete loss of pain
sensation.
Goal: relax the woman and relieve her discomfort and
have minimal systemic effects on uterine contractions,
her pushing effort or the fetus.

Pharmacologic Measures
✓ Opioids Narcotics Analgesics
• Analgesia
September 28, 2021 (Doc Tinagan)
POSTPARTUM Nursing Considerations (Taking-in Phase)
LEARNING OBJECTIVES ▪ Focus: sleep and food
▪ Not a proper time to teach about child care
1. Describe the psychological and physiologic
▪ Nurse must listen and encourage her to talk
changes that occur in a postpartal woman.
about birth
2. Use critical thinking to analyze ways that
▪ Primary concern: meet her own needs
postpartum nursing care can be more family
▪ Provide rests to regain her physical strength
centered.
and to calm and contain her swirling
3. Assess a woman and her family for
thoughts.
physiologic and psychological changes after
▪ Encouraging her to talk about the birth helps
childbirth.
her integrate it into her life experiences
4. Formulate nursing diagnoses related to
physiologic and psychological transitions of Taking-hold Phase (3-10 days period)
the postpartal period.
5. Plan nursing care such as measures to aid • “dependent or independent”
uterine involution or encourage bonding. • Develop strong interest in taking care of her
6. Implement nursing care to aid the child
progression of physiologic and Nursing Considerations (Taking-hold Phase)
psychological transitions occurring in a
postpartal woman and family such as ▪ Teach about child care and demonstrate
teaching about breastfeeding. ▪ Praise woman of her accomplishment and
give positive reinforcement
PUERPERIUM ▪ Let them learn to make decisions
- refers to the 6-week period after childbirth. It is a Letting go Phase (3-10 days period)
time of maternal changes that are both retrogressive
and progressive. • “interdependent”
• “Role transition”: Gives up her old rate
TOPICS: • Accepts reality
• PSYCHOLOGICAL CHANGES • Requires grief work and readjustment
• SYSTEMATIC CHANGES Nursing Considerations (Letting go Phase)
• POSTPARTUM ASSESSMENT
• Lifestyle includes the baby but still focus on
PSYCHOLOGICAL CHANGES entire family as a unit
Reva Rubin - divided the puerperium into 3 separate SAMPLE QUESTIONS
phases
Which of the following actions would alert you that
• Taking-in Phase Joan Cooper, 2 days postpartum, is entering a
• Taking-hold Phase postpartum taking- hold phase?
• Letting go Phase
A. She tells you she has painful contractions for
Taking-in Phase (1-3 day period) 8 hours.
B. She sleeps as if exhausted from the effort of
• “passive dependence”
her labor.
• Verbalizes about the delivery process
C. She urges her baby to stay awake so that she
can breastfeed.
D. She says that she has not selected a name for
her baby as yet.
PSYCHOLOGICAL MALADAPTATION Problems in Involution
Post-Partal Blues AFTER PAIN – due to intermittent uterine
Onset 1-10 days after birth. contraction.
Symptoms Unknown cause,
fatigue, sadness tears Nursing Considerations:
easily, irritable (mood ▪ Give analgesic as ordered before
instability). breastfeeding
Etiology Probable hormonal ▪ Lying prone with pillow/blanket under
changes, stress of life
abdomen
changes
▪ Reassure that afterpains are self-limiting
Subinvolution
Post-Partal Depression
Onset 1-12 months after birth. Causes of subinvolution:
Symptoms Anxiety, feeling of loss
and hopelessness, ▪ Retained placental fragments
appetite and sleep ▪ Multiple fetus
disturbance. ▪ Hydramnious
Etiology History of previous ▪ Exhaustion from prolonged labor
depression, hormonal ▪ Physiologic effects of excessive analgesia
response, lack of social
support. TREATMENT
Other benefits include:
Post-Partal Psychosis - Lorem ipsum dolor sit amet, consectetur
Onset Within first year after adipiscing elit.
birth - Nunc tempus, risus sodales hendrerit, arcu
Symptoms Delusion or dolor commodo libero.
hallucinations of
harming infants or self.
Etiology Hormonal changes,
family history of ▪ Methergine to maintain firm uterine
bipolar disorder. contraction
▪ Antibiotics for infection
▪ Dilation of the cervix and curettage to
PHYSICAL OR SYSTEMIC CHANGES remove
- Postpartum changes you probably didn’t ▪ placental fragm8nts from the uterine
know REPRODUCTIVE CHANGES
REPRODUCTIVE CHANGES LOCHIA
Uterine Involution Lochia Color Days
Two processes of involution: Rubra Red 1-3
Serosa Pinkish 4-9
- Sealing of the placenta Alba White 10-3rd week
- Decrease size of the uterus ▪ Scant – 1 inch
▪ Light – 2-4 inch
▪ Moderate – 4-6 inch
▪ Heavy – Sat pad in 1 hr.
 ▪ Excessive – Sat pad in 15 min.
PERINEUM
▪ Edematous and tender
▪ Ecchymosis may be present
▪ Labia majora and minora remain atrophic
and softer

CERVIX
▪ Soft and malleable
▪ By 7th day – Internal OS close and External
OS slightly open that appears slit-like

PERINEAL LACERATION

VAGINA
▪ Is soft, with few rugae, and its diameter is
greater than normal
▪ Hymen is permanently torn

SYSTEMIC CHANGES
Endocrine System
▪ A decline in placental hormones
▪ Breastfeeding delays the return of both
ovulation and menstruation
▪ For non-nursing mothers’ menstruation
Resumes Within 7-9 weeks
Urinary System POSTPARTUM ASSESMENT
▪ Extensive diuresis B- breast
▪ Transient loss of bladder tone
U- uterus
▪ Loss of bladder sensation
▪ Risk for urinary retention and overdistended B- bladder
bladder
▪ Urine contents: increase nitrogen B- bowel

Circulatory System L- lochia

▪ ↓ 4% Hct; ↓1g E- episiotomy

▪ ↑ Plasma fibrinogen S- skin
▪ ↑ WBC 12000-20000
H- homan’s signs
Digestive System
E- emotions
▪ Active digestion and absorption
▪ Active bowel sounds BREAST
▪ Defecation may resume on the 2nd – 3rd day • Inspect for breast size, shape, color and symmetry
▪ Constipation is a common problem during
post-partum period • Palpate the breast
▪ Drink lots of fluid 1. 1st - 2nd day: soft
▪ Add fiber to her diet 2. 3rd day: firm and warm (filling)
▪ Administer medication as ordered 3. 4th day large; reddened with taut shiny skin
▪ Stool softener: Surfak or Colace;
▪ Laxative: Dulcolax • Check the nipples

Integumentary System • Assess for cracks and redness

▪ Striae gravidarum are still present • DO NOT SQUEEZE THE NIPPLE

▪ Choalasma and linea nigra will become
barely detectable in 6 weeks’ time
Neurologic System
▪ Anesthesia may produce temporary
neurologic changes
▪ Frontal/severe headache is not common
Vital Signs
▪ Slight ↑ during the first 24 hrs
▪ ↑ temp. on the 3rd/4th postpartum period
▪ Postpartal infection: > 38° C excluding the NURSING CARE
first 24-hr period
BREAST DISCOMFORTS:
▪ ↓ PR (60-70 bpm) but returns to normal at
the end of the first week 1. Empty 'Feast regularly and frequently
▪ Rapid and thready pulse is a sign of 2. Express little milk before feeding
hemorrhage 3. Massage breast gently
4. 4.Take warm shower
5. Change areas of nipple (rotate)
 6. Nurse more frequently so that the baby will • Location
not suck vigorously at the beginning of
Midline -A full bladder causes the uterus to
breastfeeding.
be deviated to the right
7. Feed per demand
8. Air dry nipple for 10-20 min
9. wear supportive bra so.
10. Make sure that the baby latched properly
11. Do not use soap on the breast

UTERUS
• Inspect abdomen for contour and appearance
of striae
• Palpate the uterus for firmness, height
location
• Height
Measure height by fingerbreadth (1cm)
1 hr after delivery —at the level of the
umbilicus
decrease one fingerbreadth per day

• Firmness
Soft and boggy -not contracting
Firm - uterine contractions
• If the mother's uterus is soft, massage it
• A full bladder interferes with uterine
contraction

NURSING CONSIDERATION
• If the uterus is not firm on palpation,
massage it gently
• If uterine atony occurs:
- Notify physician
- Administer oxytocin as ordered
BLADDER
• Observe for fullness, output, burning and
pain
Signs of Bladder Distention
• Location of fundus above baseline level
(determine with empty bladder)
• Fundus displaced from midline
• Excessive lochia Promoting Proper Bowel Function
• Bladder discomfort
1. Teach the woman that bowel activity is
• Bulge of bladder above
sluggish because of decreased abdominal
• Symphysis
muscle tone, anesthetic effects, effects of
• Frequent voidings of less than 150 mL each
progesterone, decreased solid food intake
time
during labor, and prelabor enema.
2. Inform the woman that pain from
hemorrhoids, lacerations, and episiotomies
may cause her to delay her first bowel
movement.
3. Review the woman's dietary intake with her.
4. Encourage daily adequate amounts of fresh
fruit, vegetable, fiber, and at least eight
glasses of water. 5. Encourage frequent
ambulation.
5. Administer stool softener as indicated.
LOCHIA
Inspect for:
Encouraging Bladder Emptying
• Color
1. Observe for the woman's first void within 6 • Pattern
to 8 hours after delivery. • Amount (Scant, Light, Moderate, Heavy,
2. Palpate the abdomen for bladder distention Excessive)
if the woman is unable to void or complains • Odor
of fullness after voiding.
a. Uterine displacement from the midline
suggests bladder distention
3. Instruct the woman to void every several
hours and after meals to keep her bladder
empty.
BOWEL
• Determine passage of flatus, bowel sounds
and defecation
The Normal Stages of Lochia (Postpartum
Bleeding And Discharge)
Lochia Rubra
Dark Red
Lasts 3 - 4 Days
Occurring a few days after delivery, it is mainly
made up of blood, bits of fetal membranes,
decidua*, meconium, and cervical discharge.
EPISIOTOMY CARE
Lochia Serosa
Nursing Considerations
Pinkish Brown
1. An ice pack is applied for the first 12 - 24
Lasts 4 - 10 Days
hours
It contains less red blood cells and has more white 2. After 24 hours, heat lamp/peri light/sitz bath
blood cells, wound discharge from the placental and may be applied
other sites, and mucus from the cervix. 3. Administer analgesics as prescribed
4. Teach the woman about perineal care
Lochia Alba
5. Perineal pads should be applied and removed
Whitish Yellow in the same front-to-back direction
6. Abstain sexual activities (3 - 4 weeks)
Lasts 10 - 28 Days
For about another 1 - 2 weeks, whitish turbid fluid
drains from the vagina which mainly consists of
decidual cells, mucus, white blood cells, and
epithelial cells.
Nursing Considerations:
1. Check under the buttocks to observe any
blood
2. Observe a constant trickle of vaginal flow or
a soaked perineal pad within 1 hour
4. Check lochia every 15 minutes for the 1st
hour
5. Encourage woman to change perineal pad HOMAN’S SIGN
frequently as she begins self-care Inspect for:
EPISIOTOMY - Redness
- Assess “REEDA” - Tenderness or Edema
- Redness - Pain
- Edema - Pallor (Deep vein)
- Ecchymosis - Homan’s sign
- Discharge
- Approximation
 - Uterus: firm or boggy?
- Bladder: tender or distended?
- Bowel movement?
- Lochia: amount, odor, color, clots
- Episiotomy location, stitches, edema and
redness
- Homan’s sign - positive?
- Emotional status and bonding
DVT and Homan’s Sign

EMOTIONAL STATUS - A positive Homan’s sign is indicative of a

DVT
- Evaluate family interaction, support and any - The patient’s leg is positioned at a 90 degree
signs of depression angle (either while in supine or sitting)
Nursing Diagnoses: - Dorsiflexion of the foot reveals pain in the
calf if positive
1. Pain related to uterine cramping (afterpains). - Other signs of DVT: redness, sudden, sharp
2. Risk for infection (uterine) related to lochia pain, and warmth in the leg
and denuded uterine surface.
3. Disturbed sleep pattern related to exhaustion RETROGRESSIVE CHANGES IN
from and excitement of childbirth PUERPERIUM
4. Risk for bathing/hygiene self-care deficit 1. Exhaustion
related to exhaustion from childbirth - “sleep hunger”
5. Imbalanced nutrition, less than body 2. Weight loss
requirements, related to lack of knowledge - The rapid diuresis and diaphoresis
about postpartal needs during the 2nd to 5th days after birth,
6. Risk for impaired urinary elimination or lochia flow
constipation related to loss of bladder and - Also, influence by nutrition, exercise,
bowel sensation after childbirth and breastfeeding
7. Risk for ineffective peripheral tissue
perfusion related to immobility and increased 3. Vital Changes
estrogen level - Temp - slightly increase during the
8. Pain related to primary breast enlargement first 24 hours after birth
9. Health-seeking behaviors related to future - Check for high temp - postpartal
breast health infection, engorgement, mastitis
10. Health-seeking behaviors related to client’s - Pulse - slightly lower during
desire to return to prepregnant weight and postpartal period
appearance - Check for rapid and thready pulse -
11. Risk for ineffective sexuality patterns related hemorrhage
to physiologic changes of postpartal period - BP must be monitored closely - if
12. Risk for impaired parenting related to decrease it is a sign of bleeding; if
inadequate bonding behavior after childbirth increase postpartal hypertension
- Oxytocin - inc BP

SUMMARY OF POSTPARTUM ASSESSMENT

B. U. B. B. L. E. - H. E.
- Breast size, shape and engorgement
PROGRESSIVE CHANGES OF THE ● Occurs during pregnancy and initial
PUERPERIUM postpartum period
- Galactopoiesis
● Lactation
● Maintaining the production of milk
● Begins 9 days postpartum
- Involution
● Termination of milk production
● With weaning
Benefits of Breastmilk
1. Carbohydrates
2. Proteins
3. Fats
4. Vitamins and Minerals
5. Water and Electrolytes
6. Immunological Superiority
7. Protection against other illness
8. Mental growth
TRI-CORE BREASTFEEDING MODEL
- Is an evidenced-based practice model that can
4 Phases of Lactogenesis: help guide nurses in providing early
postpartum lactation promotion, or strategies
- The onset of milk secretion and includes all to improved a mother’s chances of a
of the changes in the mammary epithelium successful breastfeeding relation with her
necessary to go from the undifferentiated infant.
mammary gland in early pregnancy to full
lactation sometime after parturition
(childbirth)
● Lactogenesis I (birth to 2 - 5 days) milk
formation begins
● Lactogenesis II (begins 5 - 10 days after
birth) increased blood flow to breast; milk
“comes in”
● Lactogenesis III (begins at - 10 day after
birth) milk composition is stable
● Lactogenesis IV - occurs after complete
weaning and the breast involute to their pre
lactate state
Stages of Lactation:
- Mammogenesis RETURN OF MENSTRUAL FLOW:
● Growth of the breasts - Due to decrease level of estrogen and
● In utero, prepubertal, pubertal progesterone after delivery it causes a rise in
- Lactogenesis production of Follicle Stimulating Hormone
● Functional change of the breasts so - Non-breastfeeding expect her menstrual flow
that they can secrete milk to return in 6 - 10 weeks after birth
 - With breastfeeding menstrual flow return in a. Leana’s fundal height is two fingerbreadths
for 3 or 4 months (lactational amenorrhea) below her umbilicus
b. Leana’s uterus does not become firm when
WHEN WILL MY PERIOD RETURN?
massaged
● A woman’s period return about 6 - 8 weeks c. Firm massage of Leana’s fundus results in
after delivery, if she is not breastfeeding. pain
● For breastfeeding mums, the timing for the d. The fundus is located midline on Leana’s
period to return may vary. abdomen
● For some women, however, periods may
NURSING DIAGNOSES
return even as they are breastfeeding.
1. Risk for fluid volume deficit related to
uterine atony
NURSING CARE OF A WOMAN AND 2. Pain related to perineal discomfort, uterine
FAMILY DURING THE FIRST 24 HOURS cramping (afterpains), or muscular aches
AFTER BIRTH 3. Risk for infection (uterine) related to
presence of lochia and denuded uterine
1. Assessment surface
- Health History 4. Disturbed sleep pattern related to exhaustion
- Family Profile from and excitement of childbirth
- Pregnancy History 5. Risk for bathing/hygiene self-care deficit
- Labor and Birth History related to exhaustion from childbirth
- Infant data 6. Imbalanced nutrition, less than body
- Postpartal Course requirements, related to lack of knowledge
a. Laboratory data about postpartal needs
b. Physical Assessment 7. Risk for impaired urinary elimination or
● General appearance constipation related to loss of bladder and
● Hair bowel sensation after childbirth
● Face 8. Risk for ineffective peripheral tissue
● Breast perfusion related to immobility and increased
● Uterus estrogen level
● Lochia 9. Pain related to primary breast engorgement
● Perineum 10. Health-seeking behavior related to future
UTERUS breast health
11. Health-seeking behaviors related to patient’s
- Firmness: desire to return to prepregnant weight and
● Soft and boggy - not contracting appearance
● Firm - uterine contractions 12. Risk for ineffective sexuality patterns related
Never palpate a uterus without supporting the lower to physiologic changes of postpartal period
segment because the uterus potentially could invert Nursing Care of a Woman and Family in
if not stabilized - resulting in a massive Preparation for Health Agency Discharge
hemorrhage.
● Postpartal Discharge Instructions
SAMPLE QUESTIONS - Work
The nurse is performing massage of Leana’s fundus - Rest
2 days postpartum. What assessment finding should - Exercise
prompt the nurse to contact Leana’s primary care - Hygiene
provider immediately? - Coitus
- Contraception
 - Follow-up 2. Reduce the risk of mortality and morbidity in
● Postpartal Examination the country
- During follow up checkup 4 - 6 weeks
Health Benefits of Family Planning
after birth
a. Mother
Postpartal Home Visit
1. Helps reduce the health risks
- Pregnancy Hx 2. Helps mothers to fully recover
- Newborn Hx 3. Offers safe alternatives to women
- Postpartal Course 4. Offers non-contraceptive health benefits
- Future plans
b. Children
- Family Assessment
1. Helps ensure better chance of survival
- PE of the mother
at birth
- PE of the infant
2. Helps promote better childhood
- Follow-up information
nutrition
FAMILY PLANNING 3. Helps promote physical growth and
development
Objectives:
4. Helps prevent birth defects
1. Avoid unwanted birth c. Father
2. bring about wanted births 1. Allows fathers to keep a constant
3. produce a change in the number of children balance between their physical,
born mental, and social well-being
4. regulate the intervals between pregnancies 2. He can have a more related secual
relationship.
Contraceptives can help you plan your future 3. Increases the father’s sense of respect
Contraceptives can help you prevent unwanted Implications of Family Planning
pregnancies and sexually transmitted infections.
- Planned pregnancy can make difference in
- sterilization the economic future of the entire family
- the pill
- intrauterine device ROLES AND FUNCTIONS OF THE NURSE
- female condom
1. Identifying, counseling, and when
- hormone patches
appropriate, making referrals for clients who
- male condom
are in need of information about family
- emergency contraceptives
planning and its services
- contraceptive injection
2. Providing and interpreting family planning
3 Important Elements: Family Planning instructions, information, and resources
3. Contributing to the development of new
a) Proper spacing methods, services, and programs
b) Proper timing
c) Number of pregnancies Role of the Nurse:

Concept of Family Planning: Responsible 1. Planner

Parenthood 2. Implementor
3. Supervisor
Importance of Family Planning 4. Counselor
1. Promote the physical, mental, and social 5. Educator
well-being of its members 6. Client Advocate
7. Coordinator
 8. Evaluator 1. Listen carefully
9. Researcher 2. Answer questions correctly
3. Reinforce important information
COUNSELING
4. Let the client make her own decision
- a facilitating process-
Skills Essential for Effective Counseling
- a face-to-face communication between the
provider and the client - 1. Relate
2. Observe
Importance of Family Planning Counseling
3. Listen
1. Increased acceptance of family planning by
4. Ask
clients
5. Talk
2. Appropriate method of choice based on the
6. Interpret
client’s health needs and social well being
3. Effective method use ❖ Voluntarism — the client chooses a method out
4. Longer continuation of use of free will after considering all information given
Essentials of Counseling ❖ Informed Choice — right to choose a family
1. Caring attitude - planning method based on clear understanding of the
2. Clear information - risk and benefits

Principles of Counseling ❖ Informed Consent — a written consent

signifying the client's voluntary decision to use
1. Acceptance
surgical contraceptive after undergoing counseling
2. Individualization
3. Confidentiality Elements of Informed Consent
4. Controlled emotional involvement
5. Non-judgmental attitude • B - benefits of the method
6. Self-determination • R - risk of the method
• A - alternatives of the method
Counseling Process • I - inquiries about the method
G greet client • D - decision to withdraw from using the
method is alright
А - ask client about herself • E - explanation of the method
T - tell clients about family planning methods • D – documentation

H - help client choose a method Methods of Contraception

E - explain how to use the method 1. Deals with the different methods of family
planning both natural and artificial.
R - return for follow-up 2. The nurse as a service provider should not
Phases of Counseling choose the method for the client
3. Having comprehensive knowledge of all the
1. Initial counseling methods
2. Method specific
3. Counseling METHODS OF CONTRACEPTION
4. Post-provision 1. Natural Planning Methods
5. counseling 2. Artificial Methods
6. Follow-up counseling
I. Natural Planning Methods
Tips on Good Counseling
A. Cervical Mucus (Billings) Method
 B. Basal Body Temperature Calendar Method
C. Sympto-thermal Method
D. Calendar Method
E. Lactational Amenorrhea Method
F. Standard Day s Method G. Coitus Interruptus
Cervical Mucus (Billings) Method

Lactational Amenorrhea Method

Basal Body Temperature Method

Cycle Beads Method

The Symptothermal Method

- Basal body temperature
- Fertile cervical mucus
- Symptoms

Coitus Interruptus

II. Artificial Methods

 ● Temporary
A. Hormonal Contraceptive
1. Of ay reproductive age
1. Oral Contraceptive
2. Of any parity, including nulliparous women
2. Injectibles
3. With religious of philosophical reasons for
3. Subcutaneous Implants
not using other methods
4. Transdermal Patch
4. Unable to use other methods
B. Mechanical Barriers
5. Willing to abstain from intercourse for more
● Intrauterine Device
than 1 week each cycle
● Male and Female Condoms
6. Willing and motivated to observe, record and
● Cervical Cap and Diaphragm
interpret fertility signs
C. Chemical Barrier
1. Vaginal Spermicide Conditions Requiring Precautions
● Permanent
D. Voluntary Surgical Sterilization 1. Irregular menses
1. Bilateral Tubal Ligation 2. Persistent vaginal discharge
2. Vasectomy 3. Breastfeeding
- Sites of Sterilization (Ligation, Clips, Basal Body Temperature
Cauterization, Essure)
Thermal Shift Rule:
● Take temperature at about same time each
morning (before rising) and record
NATURAL PLANNING METHODS temperature -
● Use temperatures recorded on chart for first
- Defined as the identification of days of 10 days of menstrual cycle -
fertility and infertility on the basis of ● Disregard any temperatures that are
naturally occurring signs in a woman, and the abnormally high due to fever or other
use of this information to avoid or achieve disruptions
pregnancy -
- Effectiveness: NFP failure rate is between Billings Method
2% - 8% depending on the method used.
However, in actual practice the failure rate is
quite high at 20%.
Advantages
1. Safe -
2. Free or inexpensive
3. Acceptable to many religious groups
4. Helpful for planning or avoiding
pregnancy
5. Promotes involvement of the main
6. Increases self-awareness - Involves the ability of a woman to recognize
7. Immediately reversible the characteristic changes of the cervical
Disadvantages mucus discharge throughout the menstrual
1. Requires high degree of motivation cycle.
by both parents ● As mucus may change during the day,
2. Tedious. needs daily attention observe it several times throughout the day -
3. Need several months of practice and ● Abstain from sexual intercourse for at least 1
training cycle. -
4. Less effective than other methods
 ● During dry days after period, it is safe to have - Shortest cycle less 18 = start of unsafe period
intercourse every other night. - Longest cycle less 11 = end of unsafe period
● As soon as any mucus or sensation of wetness
Example: If the shortest cycle is 28 and the longest is
appears, avoid intercourse or sexual contact.
30
● Mark last day of clear, slippery, stretchy
mucus with an “X”. Thus:
● After the peak day, avoid intercourse for next
3 dry days and nights. 28 - 18 = 10
● Beginning on the morning of the fourth dry 30 - 11 = 19
day, it is safe to have intercourse until your
menstrual period begins again. Then: The start of the unsafe period is day 10 and the
end is day 19 of the menstrual cycel
Symptothermal Method
Client Instruction
Client Instructions for Symptothermal Method
1. List down the first day of the last 6 menstrual
● After menstrual bleeding stops, you may cycles (that is the first day of bleeding)
have intercourse on evening of every other 2. Compute for the length of each cycle by
dry day during infertile days before counting the days covering succeeding cycles
ovulation. 3. Subtract 18 from the shortest cycle to
● The fertile phase begins when wet vaginal determine the start of the unsafe period and
sensations or any mucus appears. 11 from the longest cycle to obtain the last
● Abstain from intercourse until fertile phase day of the unsafe period
ends. 4. Mark on the corresponding dates on the
● Abstain from intercourse until both peak day calendar for each cycle. Remember, day 1 is
and thermal shift rules have been applied. the first day bleeding occurs
● When these rules do not identify the same day 5. During fertile, unsafe days:
as end of fertile phase, always follow rule that a. Abstain from all sexual activity
identifies the longest fertile phase. b. Avoid intercourse
Calendar/Rhythm Method c. Have intercourse with a back-up
family planning method
- Involves the calculation of a woman’s safe
and unsafe days for the next menstrual cycle
to predict the fertile periods based on her LACTATIONAL AMNORRHEA METHOD
previous cycles.
- a contraceptive based on fully breastfeeding
1. Ovulation occurs 14 plus 2 minus days before which is characterized by: on-demand
the next menses feeling, breastfeeding even during night time,
2. Sperm can live up to 72 hours in a woman’s and no milk substitute for a breast milk
body feeding
3. Ovum can be fertilized up to 24 hours after - the effective of this method is greatly
ovulation dependent on the frequency and duration of
suckling
Requisites for the Method - a woman uses LAM when she is: fully
1. Woman must have fairly a regular menstrual breastfeeding, amenorrheic, and within 6-
cycle month postpartum period
2. Menstrual history be at least that of the
immediate past 6 cycles
Computation
 ● On the day she starts her period, she
moves the ring to the red bead and
marks that day on her calendar.
● To prevent pregnancy, she avoids
unprotected sex when the ring is on a
white bead day.
2. To track her fertile days
● On all brown-bead days, pregnancy is
very unlikely.
● On the day she starts her next period,
STANDARD DAYS METHOD she skips over any remaining brown
- This method is 95% effective for beads, puts the rings on the red bead,
women who have menstrual cycles and begins a new cycle.
between 26 and 32 days long. (For
every 100 women who use
CycleBeads correctly during one
year, fewer than 5 will get pregnant)
Cycle Beads Method
- a visual tool that helps women use by keeping
track their cycle days
- identify whether or not they are fertile on that
day, monitor cycle length.

3. To monitor her cycle length

● The woman knows that if her period
starts before moving the ring to the
darker brown bead her cycle is shorter
than 26 days.
● If she doesnt start her period by the
day after moving the ring to the last
brown bead, her cycle is longer than
32 days.
2. To monitor her cycle length
● If she has a cycle shorter than 26 or
Indications for Using Cycle Beads longer than 32 days more than once in
a year, the method will not be
1. To track her fertile days effective for her, and she should be
2. To monitor her cycle length encouraged to use another method.
Cycle Beads Method
1. To track her fertile days ● Natural with no side effects
● The woman moves a rubber ring one ● Does not involve a medical procedure and
bead every day. nothing must be taken daily
 ● Does not require frequent visits to your - only pills
healthcare provider or pharmacy - contain only progestins with no estrogen
● Reversible and does not delay your return to derivatives
fertility 1. Monophasic pills
● Can help your partner become more involved - contains synthetic estrogens and
in family planning progesterones in each pill and must be
taken every day for 21 days or 28
Warnings:
days.
You should not use Cycle Beads if:
Combined pills:
● You have cycles that are shorter than 26 days
2. Biphasic pills
or longer than 32 days.
- contain a certain level of estrogens
● You and your partner would have difficulty
throughout the cycle. To mimic body
either using a condom or abstaining during
patterns in the 21-day pack, there is a
the 12 white bead days when you can get
small dose of progestins (synthetic
pregnant.
progesterones) for 10 days and then a
Coitus Interruptus slightly higher dose for 11 days.
3. Triphasic pills
- An ancient method that requires the male to - Alters the level of estrogens and
withdraw his penis from the vagina progesterones continuously
immediately before ejaculation throughout the cycle. More closely
- Coitus interruptus as a contraceptive method mimic a natural cycle, thereby
is better than no method at all. reducing breakthrough bleeding
- The withdrawal method is cheap. b. Injections (Depo-Provera)
- It has relatively few medical complications, c. Subcutaneous Implants
except - d. Transdermal Patch
- Coitus interruptus requires no preparation or
supplies. Non-contraceptive Benefits: Decrease incidence
- Coitus interruptus is not effective as a of the following conditions:
contraceptive technique.
1. Dysmenorrhea
- Coitus interruptus relies on the male
2. Premenstrual dysphoric syndrome
removing his penis from the vagina at a point
3. IDA
prior to orgasm and often when he is in a high
4. Acute PID
state of arousal.
5. Endometrial and ovarian cancer
- Coitus interruptus provides no protection
6. Fibrocystic breast disease
against sexually transmitted disease such as
7. Possibly osteoporosis and uterine myoma
HIV/AIDS, genital herpes or gonorrhea.
8. Colon cancer
- Over the long-term many couples find the
withdrawal method frustrating and 1. Oral Contraceptives (Birth Control Pills)
unsatisfactory.
Disadvantages:
ARTIFICIAL METHOD
1. No protection against HIV
A. Hormonal Contraceptive 2. Possible side effects
a. Oral Contraceptives (Birth Control a. Breast tenderness
Pill) b. Nausea
c. Increase in headaches
Types of Pills:
d. Moodiness
- contains both estrogen and progestin e. Weight gain
 f. Spotting ● S - Swelling or severe leg pain
3. Occurrence of circulatory complications 2. INJECTABLES
particularly for women who smoke
- Commonly known as Depo-Provera
4. Expensive and difficult to use for some
- DMPA is a 3 month injectable that contain a
women
synthetic progestic
- Administered deep into the deltoid or gluteal
muscle
Precaution: This method should not be used under
- A very safe contraceptive
the following conditions:
- This can be used even by breast feeding
1. Thromboembolism women or those who are contraindicated for
2. CVA estrogen-containing combined oral
3. Hypertension contraceptive
4. Breast carcinoma - 99.7% effective preventing pregnancy
5. Diabetics
Depo Medroxyprogesterone Acetate (DMPA)
Client Instructions for Oral Contraceptives
Mechanism of Action
1. Explain how to take a pill
1. Stops ovulation
- Take one pill every day, always start
2. Stops menstrual cycles
your pill on day one of your
3. Thickens cervical mucus
menstruation.
4. Thins the endometrial lining
- Those taking 21-day pill have a 7-day
pill free period then start taking the Advantages:
first pill from the next pack.
1. Safe to use
- For the 28-day pill start the next pack
2. Can be used by breastfeeding mothers
the next day after all 28 pills have
3. Does not interfere with intercourse
been taken. There is no pill free
4. Easily administered by non-physician
period.
5. Rapidly effective (24 hrs after injection)
- Take each at the same time every day.
2. Instructions about missed pill Disadvantages:
- Take two pills the following day.
Take the missed pill as soon as you 1. Menstrual irregularities -
remember and the other pill at its 2. Delay in return of fertility after discontinuing
regular schedule. DMPA -
- Take two pills as soon as you 3. Weight gain
remember and the other 2 pills the 4. Cannot be easily discontinued since its effect
next day. last for 3 months
- Stop taking the pill from the pocket 5. Provides no protection against STD
and use a condom as a back-up Indications for Use:
method until the next menstrual
period. 1. Breastfeeding her baby
3. Five warning signs: 2. Wants no more children but does not want or
● A - Abdominal pain cannot be sterilized
● C - Chest pain or shortness of breath 3. Cannot be given combined oral contraceptive
● H - Headaches that are severe and Precaution:
throbbing or only one side of the head
● E - Eye problems (blurred or double 1. Pregnant women
vision, blindness) 2. Breast cancer
 3. Active thromboembolic Disorders - It uses estrogen and progesterone to suppress
4. DM ovulation
5. Hypertension - Thicken cervical mucus
- Possibly thin the uterine lining

When/Where:
3. SUBCUTANEOUS IMPLANTS
Remember: On the same day every week (three
- Consists of six nonbiodegradable Silastic
consecutive weeks).
implants, about the width of a pencil lead,
that a filled with levonorgestrel (a synthetic - buttocks
progesterone). - abdomen
- upper torso
4. Norplant
- or the upper outer arm
- this device can remain in place for up to 5
Advantages:
years and then must be removed surgically.
- Many women find the Patch more convenient
Method of Insertion:
to use than the Pill.
- With the use of a local anesthetic, six - Can help to regulate a woman’s periods and
cylindrical capsules are inserted under the may even cause a woman’s periods to be
skin on the inside upper portion of the lighter, shorter and with fewer menstrual
woman’s arm. cramps.
- Other reported benefits of the Patch are
Advantages: similar to the birth control pill and include:
1. A viable method for woman older than 35 ● Decreased PMS symptoms
years old. ● Decrease in the appearance of acne
2. Woman who cannot use estrogens ● Some protection against pelvic
3. Woman who have difficulty with other inflammatory disease and ectopic
methods pregnancy
● Decreased risk of endometrial and
Disadvantages ovarian cancers
1. Slight risk for infection and pain during the Disadvantages:
insertion and removal procedures
2. Initially more expensive than pills - sexually transmitted diseases
3. May be visible on some thin or highly ● Breast tenderness
muscular women ● Headaches
4. The woman cannot discontinue using the ● Nausea
implant on her own ● Mood Swings
● Weight gain (sometimes weight loss)
5. TRANSDERMAL PATCH - Spotting and breakthrough bleeding
Contraceptive Patch - Irritation at the site of application
- Although rare, more serious side effects of
- The patch is worn at all times, even when you the Path include:
are exercising, bathing or in hot, humid ● Blood clots
conditions. ● Stroke
Ortho Evra - Brand Name ● Heart attacks
● Increased risk of cervical cancer
Purposes:
The risk of these serious health complications is - a small, flexible plastic frame, often has
increased for smokers and especially smokers over copper wire or copper sleeves, which is
the age of 35. inserted into a woman’s uterus through her
vagina.
Things to Remember:
Mechanism of Action
- The use of certain medications, including
some antibiotics, oral yeast infection 1. Inactivates the sperm due to the action of the
medications, seizure and HIV drugs, can copper
decrease the efficiency of the Patch. 2. Interferes with the transport of sperm in the
- The Patch may not be effective for women genital tract due to the production of
who weigh more than 198 lbs. prostaglandins and enzymes
- If the Patch falls off for less than 24 hours, re-
3. Causing inflammatory reactions in the
apply it or place a new patch on. If the Patch
endometrium thereby increasing WBC which
is off the skin for more than 24 hours, it will
phagocytize the sperm
be necessary to start a new patch cycle and
use a back-up method of birth control for the 4. The sperm are immobilized as they pass
first seven days. through the uterine cavity
B. Mechanical Barriers Precaution:
a. Intrauterine Device 1. The IUD should not be given the following
b. Male and Female Condom conditions:
c. Cervical Cap and Diaphragm a. Pregnancy
b. Active, recent, or recurrent pelvic infection
Intrauterine Device
c. Acute purulent endocervicitis
Pregnancy

Pelvic Infection

- Mirena
- Copper T
- Multiload
Endocervicitis 5. Working slowly and gently, the provider
inserts the IUD, following the manufacture's
instructions.
6. After insertion, the provider asks the client
how she feels and if she feels dizzy when
sitting

Precaution
Post Insertion and Follow-up Care
1. The IUD is not the best method for woman
with any of the following conditions 1. The client needs to know what kind of IUD
- Risk factors for PID she has and when it needs to be replaced.
- history of ectopic pregnancy 2. Tell the client when to come back for check-
- repeated IUD expulsion up.
- Repeated cesarean section 3. She should come to the clinic immediately
when one of these warning signs occurs:
Advantages ● P - period late (pregnancy)
● A - abdominal pain or pain with
1. It has no systemic side effects
intercourse
2. Very low pregnancy rate
● I - infection
3. Easy to remove if couple wants another
● N - not feeling well, fever and chills
children
● S - string missing, shorter and longer
4. Once IUD is removed, wife can be pregnant
immediately Indications for IUD Removal
5. Does not interfere with sex
6. Inexpensive 1. Patient’s desire to have it removed
2. Pregnancy, whether suspected or confirmed
Disadvantages 3. Bleeding associated with endometritis
4. Hematocrit fall of 5 gm% and Hematocrit
1. Client may feel slight pain during the first
level of 27 gm% or below
few days after an IUD insertion
5. Partial expulsion of IUD
2. She may have spotting and cramps between
6. PID
menstrual periods
3. The IUD may be expelled CONDOM
4. Client is not protected from STD and HIV
Female:
IUD Insertion
- Latex sheath made of polyurethane and
1. Proper infection-prevention procedures are prelubricated with a spermicide.
followed - The inner ring (closed end) covers the cervix,
2. The woman is asked to tell the provider of she and the outer ring (open end) rest against the
feels discomfort or pain at any time during vaginal opening
the procedure.
3. The health provider conducts a careful pelvic Characteristics of Female Condoms
examination (speculum and bimanual) and a. Less likely to constrict the penis and decrease
checks the position of the uterus sensation for the man than latex male
4. The provider carefully cleanses the cervix condoms
and vagina several times with an antiseptic b. Do not interrupt sexual activity (can be
solution. inserted up to 8 hours before intercourse)
 c. can make a noise during sexual intercourse Instructions for Male Condom Users
Male: 1. Do not try to fill them with a liquid or air to
test them for holes since condoms tears
- Latex rubber sheath or synthetic sheath worn
easily.
over an erect penis during sexual intercourse.
2. Leave ½ inch of empty space at the tip of the
- It acts as a barrier that blocks the man’s sperm
condom. Be sure not to leave any air at the tip
from entering the vagina in order to prevent
of the condom as this might contribute to a
pregnancy.
tear in the condom.
3. Wait until the vagina is well lubricated,
because a condom can tear if the vagina is
dry.
4. After the ejaculation while the penis is till
erect, hold on the rim of the condom and
withdraw the penis immediately
Instructions for female Condom Users
1. A new condom every time
2. Make sure the condom is in place
3. No male condom with a female condom
Health Benefits 4. Inserted for up to 8 hours
5. Wash your hands carefully with soap and
1. Men who have difficulty maintaining an water before inserting or removing the female
erection may find that the rim of the condom condom.
have a slight tourniquet effect helping to
maintain an erection. Inserting a Female Condom
2. Protects the couple against STDs and AID
3. Protects the woman from cervical cancer
4. Prevent allergic reactions in few women who
are hypersensitive to their partner’s semen
Advantages:
1. No method related health risks, no serious
side effects
2. No prescription and medical attention needed
3. Good interim method when a method cannot
be started
Disadvantages
1. Decreased sensation
2. New condom should be used for each act of
coitus
3. Sexual activity is interrupted
4. May cause allergic reaction to latex
5. The male partner may not accept
contraceptive responsibility
6. condoms can be weakened if stored too long
or in too much heat
Removing a Female Condom

Storage of Condom
VAGINAL METHOD
1. A cool, dry place.
2. Keep it away from heat since this may cause - Both cervical cap and diaphragm are used
the rubber to weaken with spermicide.
Vaginal Method Characteristic Diaphragm Cervical Cap
Description A curved Soft rubber
- are contraceptives that a woman places in her
rubber dome which is
vagina shortly before sex. enclosed by a smaller,
These are vaginal methods: flexible metal thicker, and
ring less flexible
Diaphragm than the
diaphragm
- a circular rubber disc enclosed by a flexible
Usage 2 hours prior May be left in
metal ring that is placed over the cervix to sexual place as long
before intercourse. intercourse as 24 hours
Cervical cap and in place
for 6 hours
- like the diaphragm but smaller after but no
longer than 24
hours
Spermicide No need to add For additional
spermicides intercourse, an
for additional applicator will
act of add spermicide
intercourse
that occur
within 48
hours after
 insertion as
long as the cap
is in place C. CHEMICAL BARRIERS
Advantages Spermicidal
1. Protection against STDs and conditions cause - chemical agents must be used immediately
STDs before intercourse.
2. Offer contraception just when needed - disable sperm and come in several forms,
3. Spermicides can be inserted 1 hour before s including creams, jellies, tablets,
avoid interrupting sex. suppositories, foams, and film
Inserting the Diaphragm and Cervical Cap - failure rate: 160-32 per 1000 women per year

1. The woman hold the diaphragm/cap with some

down Mechanism of Action:
- contain an ingredient that disables sperm
- Should be used together with another form of
contraception
Instruction:
1. Repeated intercourse requires reapplication.
2. The woman should not douche for 6 hours
after intercourse -
2. She squeezes about a tablespoon of spermicidal
cream or jelly into the cup of the diaphragm/cap and D. Permanent Method
around the rim.

Bilateral Tubal Ligation

- involves the cutting and tying of the fallopian
3. Press opposite sides of the rim together and with tube to prevent the sperm and egg from
dome side toward palm of hand, pushes the uniting
diaphragm/cap into the vagina as far as it goes.
Techniques 5. Does not protect against STIs
1. Minilaparotomy (minilap) Pre-operative
- involves a 2-3 cm abdominal incision at the
1. Not eat or drink anything for 8 hours before
suprapubic area just above the pubic hairline
the surgery
2. not take any medication for 24 hours before
the procedure
3. bathe thoroughly the night before the
procedure, especially the belly, genital area
and upper legs
4. not wear any nail polish or jewelry to the
health facility
5. make sure to move bowels before coming for
2. Laparoscopy procedure
Post-operative
1. Rest for at least 2-3 days and avoid lifting
heavy objects for a week
2. Keep the incision site clean and dry for 2-3
days
3. Be careful not to rube or irritate the incision
for 1 week
- involves the use of laparoscope instrument 4. Take analgesic to relieve pain
inserted into the abdominal cavity to 5. Avoid sex for 1 week or until the pain
visualize the pelvic organs specially the tube, subsides
rings, clips or electrocoagulation may be used Bilateral Tubal Ligation (BTL)
to disrupt continuity of the tubes
1. Return after 1 week for removal of suture
- Rings, clips or electrocoagulation may be 2. return after a month to make sure that the
used to disrupt continuity of the tubes. healing process is going well
Advantages: Vasectomy
1. No daily contraceptive routine required; - interruption of the vas deferens, the tube
nothing to remember through which the sperm passes from the
2. Private testis to the urethra
3. Does not interfere with intercourse
4. No significant long-term side effects
Disadvantages:
1. Usually permanent and difficult to have
reversed
2. Possible post-sterilization regret
3. Possible short-term surgery-related
complications: abdominal discomfort;
bruising, bleeding, or infection at the incision
site; reaction to anesthesia
The Vasectomy Procedure
4. If pregnancy occurs, there is a higher chance
that it will be an ectopic pregnancy
 Mechanism of Action:
• Vas deferens are closed by:
✓ electric current (cauterization)
✓ a mechanical method, such as a clip
✓ removal of a small segment of each
tube
• Another form of contraception is required
until a semen analysis shows no sperm
Disadvantages
1. Difficult to have reversed
2. possible post-sterilization regret
3. Possible short-term surgery-related
complications: pain and swelling vasovagal
reaction; infection at the incision site
4. does not protect against STIs
5. Not effective immediately. Must do a follow-
up sperm analysis that shows no sperm are
Mechanism of Action:
present in the semen
- the vas deferens are closed so that no sperm
Client instruction
is released to fertilize the egg
- Common techniques include: Pre-operative
● Conventional vasectomy- one or
1. you and your partner must be certain that you
two incision are made in the scrotum
understand the permanency of the procedure
to reach the vas deferens
2. Wash the penis and the scrotum thoroughly
3. Have someone accompany you when you
have the procedure
Post-operative
1. Risk for at least 2 days
2. Place an ice cap on the scrotum for at least 4
hours to reduce swelling, bleeding and
discomfort
3. Resume normal activities after 2-3 days
● No-scalpel vasectomy- a puncture 4. Avoid strenuous activities for one week
opening is made in the scrotum
Follow-up
1. Return after 1 week for removal of sutures
2. Remember, you are not sterile immediately.
Submit for sperm count examination after 20
ejaculations for baseline data.
3. Return to check if the healing process is
proceeding normally.
October 5, 2021 (Doc Tinagan) • To make identification and transfer.
Nursing Care of a Family with a Newborn CARE AT BIRTH
OBJECTIVES 1. Wipe mouth and nose of secretion after
delivery of the head with clean sterile gauze
• Describe the normal characteristics of the
pad.
newborn
2. Position-
• Assess a newborn for normal growth and
development Trendelenburg- Head lower than the body. Side
• Formulate nursing diagnoses related to a
Lying position- to permit drainage of mucus from
newborn or the family of a newborn
the mouth. Place a small pillow or rolled towel at
• Implement nursing care for a normal
the back to prevent newborn from rolling back to
newborn, such as instructing parents on the
supine position.
care of their newborn
• Evaluate outcome criteria for the 3. Gently suctioning with bulb syringe and
achievement and effectiveness of care. short catheter from mouth first then nose to
• Integrate knowledge of newborn growth and prevent aspiration of fluid into the lungs.
development with the interplay of nursing 4. Deliver the baby onto a warm. clean and dry
process. towel or cloth and keep on mother's
abdomen or chest (between the breasts).
Initial Physical Examination and Care of the
5. Wipe both the eyes separately with sterile
Newborn
swab.
Neonatal period 6. Clamp and cut the umbilical cord after 1
minute, if baby breathing
• The period from birth through the first 28
7. well.
days of life (Ruiz et al., 2009).
8. Immediately dry the baby with a warm clean
• Neonate or newborn baby.
towel or piece of cloth.
Newborn care 9. Assess the baby's breathing while drying.
10. Leave the baby between the mother's breasts
• Care given during neonatal period to start skin-to-skin care for at least an hour.
- Immediate care of the newborn 11. Cover the baby's head with a cap. Cover the
Element of Newborn Care mother and baby with a warm cloth.
12. Place an identity label/band on the baby.
A. Basic preventive care including clean 13. Encourage mother to initiate breastfeeding
delivery practices and exclusive breast (within half an hour of birth in normal
feeding. delivery) & (after 2 hrs. in LSCS)
B. Early detection of danger signs.
C. Treatment of problems such as sepsis and ASSESSMENT
birth asphyxia.
• Keep newborn warm during the
Objectives examination.
• Begin with general observations; then
• To establish and maintain respiration.
perform assessments.
• To ensure warmth.
• Initiate nursing interventions for abnormal
• To prevent infection.
findings.
• To provide care to the eyes.
• Document all abnormal findings
• To provide care to the umbilical cord.
• To provide care to the skin. • Observe or assist with initiation of
• To make observation and documentation. respirations.
IMPLEMENTATIONS
• Dry newborn and stimulate crying by
rubbing.

Important Consideration
If the amniotic fluid above evidence of meconium
staining, the physician is to suction the
nasopharnyx immediately after the head is
delivered and before the chest is delivered. Keep newborn with mother ro facilitate bonding.

Maintain temperature stability

Bonding
• Encourage parent to talk to, hold and sing to
infant
• Promotes skin-to skin contact between
parents and infant.
• Feedings are opportunities for parent-infant
bonding.
• Notify physician for digns of infection.
IMPLEMENTATIONS
IMPLEMENTATIONS
• Place newborn at mother’s breat if
• Administer eye care on lower conjunctival breaatfeeding is planned, or place on
sac mother’s abdomen.
✓ Silver Nitrate • Place newborn in warmer.
✓ Erythromycin • Ensure newborn’s proper identification.
• Administer Vitamin K injection • Place matching identification bracelets on
✓ (Phytomenadione) IM mother and newborn.
 TIME BAND: FROM 90 MINUTES TO 6
HOURS
Care prior to discahrge after 90 minutes
1. Support unrestricted, per demand
breastfeeding day and night (Rooming-In)
2. Ensure warmth of the baby (>25 degree
celcius, skin-to-skin contact, dress and
wrap)
3. Washing and bathing
4. Provide sleeping comfort
5. Look for danger signs
6. Look for signs of jaundice and local
infection (skin and eyes – gonococcal
infection)
Care after discahrge to 7 days
1. Support unrestricted, per demand. Exclusive
breastfeeding day and night.
✓ Signs of breast discomfort and
infection: Engorgement and mastitis
2. Ensures warmth form your baby. 3. Look for
danger signs (very severe disease)
3. Lookfor danger signs (very severe disease)
✓ Yellow skin to the soles
✓ Difficulty feeding
✓ Convulsions
✓ movement when stimulated
Newborn care until the First Week of life ✓ RR >60; chest indrawing
✓ temp >38.0 C and < 35.5 C
I. Immediate Newborn Care (the first 90
minute) Disvharge Planning
II. Essential Newborn Care (from 90 minute to 1. Breastfeeding well and gaining weight
6 hours) adequately for 3 consecutive days.
III. Care prior to discharge (But after the first 90 2. Body temperature between 36.5 and 37.5
minutes) degree Celsius for 3 consecutive days.
IV. Care after Discharge to 7 days 3. Mother is able and confident in caring for
Essential Newborn Care baby.

1. Give Vitamin K prophylaxis (1 mg IM-0.1 NURSING DIAGNOSES

mL) 1. Ineffective airway clearance rit mucus in the
2. Inject hepatitis B and BCG airway.
3. Examine the baby (weigh and record) 2. Ineffective thermoregulation r/t heat loss
4. Check for birth injuries, malformations or from exposure in the birthing room.
defects 3. Imbalanced nutrition, less than body
5. Cord care requirements, related to poor sucking reflex
4. Readiness for enhanced family coping
related to birth of infant
 5. Health seeking behaviors related to newborn d. Evaporation
needs • Body stabilizes temperature in 8-10 hours if
unstressed
Outcome evaluation
• Cold stress increases oxygen consumption
1. Infant establishes respirations of 30 to 60
SAMPLE QUESTION
breaths/min.
2. Infant maintains temperature at 97.8 degree Beth Ruiz, like all newborns, is in danger of losing
F to 98.6 degree F (36.5 degree C to 37 body heat by conduction. The nurse is taking action
degree C) to ensure that Beth's body temperature is maintained
3. Mother demonstrates competence in caring to protect her health and comfort. Under which
for newborn. condition is heat loss by conduction most likely to
4. Infant breastfeeds well with a strong sucking occur?
reflex.
a. A fan is operating in the room.
Newborn Assessment b. Beth is wet from amniotic fluid at
birth.
General Examination
c. She pulls off the cap the nurse put on
Note: The best time to examine the baby is her head.
midway between feedings. d. The nurse place her on a scale that
has not been prewarmed.
Body Measurements
- Answer: D
• Length: 46-54 cm - Intervention: C
• Weight: 2,500-4000g, 2.5-3.4 kg (5.5-
Integumentary System
7.5lbss)
• Head circumference: 34-35cm • Ruddy complexion
• Chest circumference: 32-33cm • General mottling is common

Vital Signs:
Temperature: 36.1-36.5 degree centigrade
RR: 30 to 60 breaths per minute (bpm)
BP: 65 to 90/45 to 65 millimeters of mercury (mm
Hg)
Apical pulse: 100–170 beats per minutes (bpm)
Temperature - Acroyanosis -Centralcyanosis
• Heat Production in newborn accomplished
by the metabolism of "Brown Fat"(8 mo
AOG)
• Newborn can 't shiver
• Newborns are unable to maintain a stable
body temperature
• NB's body temperature drops quickly after
birth
a. Convection
b. Conduction
c. Radiation
- Pallor
- Gray color(Nenotal sepsis)
- Harlequin sign

- Erythema Toxicum -Forceps Marks

Head
• Anterior fontanel (dimond shape) – closes
12-18 months
• Posteriror Fontanel (triangle shape) –
Closes 2-3 months
• Head circumference – 34-35cm (2-3 cm,
greater than chest circumference)

- Birthmarks -Nevus Flammeus

- Hemangiomas
- Strawberry Angiomas
- Cavernous Hemangioma

- Caput Succedaneum
- Lanugo - Cephalomatoma
- Milia -Desquation
Eyes
Blue or gray d/t scleral thiness
• Permanent color established within 3-12 - Subconjunctival hemorrhage
mos.
Lacrimal glands immature at birth
• Tearless cry up to 2 mos.

- Sun-setting sign
- Doll’s Eye Reflex - Congenital Glaucoma
- Red Eye Reflex

- Congenital Cataract
- Esotropia
- Exotopia
 - Choanal atresia
- Opthalmic Neonatorum Mouth
- Herpes Simplex Opthalmic Neonatorum
• Scant saliva with pink lips
Ears • Tongue may appears large
• Level of top part of external ear should be in • Palate should be intact; no breaks in the lips
line with outer canthus of the eye

- Observe for startle reflex - Natal Teeth

- Rooting and Sucking Reflex

- Trisomy 18 and 13
Nose
• Nose breathers for first few months of life
• No septal deviation
 - Congenital Toticollis
- Nuchal Rigidity
Respiratory System
• Adequate levels of surfactants (Lecithin
and spingomyelin)
• Characterized by cylindrical thorax and
flexible ribs
• Respirations appear diaphragmatic Nipples
prominent and often edematous
• Milky secretion (witch’s milk) common

- Oral Thrush

Abnormalities

- Esophageal fistula and atresia a. Retractions

b. Rates
Neck c. Grunting
• Short and wak with deep fold of skin d. Apnea for more than 15 seconds
e. Unequal breath sounds
• Head lags normally for the first new months
Silverman – Anderson
Index – Respiratory Distress
 • They regurgitate easily
Meconium
• Assess for transitional stool

Circulatory System
• Umbilical Vein and Ductus Venosus
constrict after cord id clamped
1. Drying or clamping of umbilical cord and
Assess colored Stool
stimulation of cold receptors
2. Increased PCO2, decreased PO2, and • Bright green stool
increasing acidosis
• Clay-colored stool
3. First breath
4. Decresed pulmonary artery pressure • Blood-flecked stool
✓ Increased PO2
• Black-tarry stool
✓ Closure of Ductus Arteeiosus
✓ Closure of foramen ovale (pressure • Watery stool
in left side of heart greater than in
right side)
5. Closure of ductus venosus and umbilical
arteries and vein due to decreased flow
Blood Values
• Hematocrit - 45% to 50%
• Hemoglobin -17 to 18 g/100 mL
• RBC - 4 to 6 M/mm3
• WBC - 15,0000 to 30, 000 million/mm3
Blood Coagulation
• They have prolonged coagulation or
prothrombin time
• Vitamin K, synthesized through the action of
intestinal flora, necessary for the formation
of factor II, factor VII, factor IX, and factor
X
Gastrointestinal System
• Newborn's stomach holds about 60 to 90 ml
• Limited ability to digest fat and starch
Normally dome – shaped/slightly protuberant Umbilical Cord Infection
Abdomen
• Scaphold appearance indicates
diaphragmatic hernia
• Liver, spleen and kidneys are palpable at
birth.
• Liver normally about 1-2 cm below the right
costal margin
Immature Cardiac Sphincter
• May allow reflux of food, burped,
regurgitate
• Placed NB right side after feeding
• The infection of th eumbilical shamp is
Abdomen known as Omphalitis whuch results in
inflammation of the affected area
• Omphalitis is generally caused by bacteria
which is common in newborns with weak
immunity.

• Umbilical cord is white and gelatinous

• With two arteries and one vein and begins to
dry within 1-2 hours after delivery
- Umbilical clamp can be removed after 24
hours
Urinary System

- Assess for intact cord, and ensure that damp

is cured Newborn should void within 24 hours
Later pattern is 6 to 10 voiding/day
Assess for urethral stenosis, or absent kidneys or
ureters.
Renal System

- Anal Fissure
- Imperforate anus
Anogenital Area
• Urine is and straw colored
• Infant unable to concentrate urine for the
1st 3 months
• 15 ml/urine/ voiding
• 30 to 60 ml/1st to 2days
• SG – 1.008 to 1.010
Immune System
• They have difficulty forming antibodies Male: includes rugae on the scrotum and testes
against invading antigens until about 2 mo descended into the scrotum
of age (passive antibodies-IgG) - may be edematous foreskin should be
• NB develops own antibodies during first 3 retracted to test
months but at risk for infection during the
first 6 weeks Genitalia
• Ability to develop antibodies develops • Testes should be present (descends at 36
sequentially weeks), each should be smooth, 1 cm in
diameter and freely movable)
• Testes descended but may retract with cold
Anogenital Area • Circumcision be done prior to discharge or
preferably by the end of the first week

• Anus should be patent and no fissures

- Assess for hernia or hydrocele
- Cryptorchidism (undescended testes)

Female: labia majora covers labia minora and

clitoris

- Note for urinary meatus: meatus at tip of

the penis
- First voiding should occur within 24 hours

Genitalia
• Pseudomenstruation (blood-tinged mucus)
effect of estrogen
• First voiding should occur within 24 hours
Neuromuscular System
• Mature newborns demonstrate
neuromuscular function by moving their
extremities, attempting to control head
movement, exhibiting a strong cry, and
demonstrating newborn reflexes.
All neonates have bowlegged and flat feet.
Normal Features:
• -Major gluteal folds even
• -Creases on soles of feet
• Assess for fractures (esp. clavicle) or
dislocations of the hip – dysplasia - Normal palm creases
- Simian crease
- Talipes “clubfoot”
- (erb Duchenne paralysis)

- Syndactyly
- Polydactyly • Assess for hip dysplasia
✓ when thighs are rotated outward, no
clicks should be heard
Assessment

- Some neonates may have abnormal

extremities
• increased number of folds on the posterior
thigh
• shorter limb on the affected side
• restricted abduction of the hips
• barlow's sign
• ortolani's click
• positive trendelenburg's test
 Hip Dysplasia Neutral Tube Defects
Types:
1. Anencephaly – absence of cranial
vault with crebral hemispheres.

- Ortolani's sign
- Alli’s sign
- Barlow’s sign 2. Encephalocele - protrusion of the
brain and meninges into a fluid-filled
Treatment
sac through a skull defect.

Spine

3. Spina bifkia cvstica - defect in the

closure of the posterior vertebral arch
Types of anomalies

- Should be straight and flat

- Dimpling at the base is associated with

spina bifida
Spine 4. Swallowing Reflex
- Food reaching the posterior tongue is
swallowed
5. Extrusion Reflex
- Extrusion of subs. placed in the anterior
tongue, disappears at 3-4 months

• Hypotonia (decresead muscle tone)

• A degree of hypotonicity is indicative of
central nervous system (CNS) damage. 6. Palmar Grasp Reflex
- Disappear at 6 weeks to 3 months
Newborn reflexes
1. Blink reflex
- Mature NB moves extremities, attempt to
control head movement, strong cry and have
NB reflexes.

7. Palmar Grasp Reflex

- Disappears at 8-9 months in preparation for
walking

2. Rooting reflex
- disappears at 3 to 6 months or when able to
focus eyes steadily to look for food.

8. Step (Walk)-in-Place Reflex

- NB held up w/ surfaces touching the feet
makes a few, quick alternating steps
- Disappears at 3 months

3. Sucking Reflex
- Diminished at 10-12 months
9. Placing Reflex 12. Babinski reflex
- stimulated by touching the anterior leg and - NB fans the toes when sole of the foot is
NB makes a few steps stroked in a J — curve
- Remains positive until 3 months
- in adults flexion of toes is expected
- disappears in one year

10. Tonic Neck Reflex - Fencing Reflex

- Hand and leg where the direction of head is
turned extends while the opposite arm and 13. Crossed extension reflex
leg contracts - NB's leg tries to push the hand irritating the
- beyond 6 months cerebral palsy other foot disappears at 2 months
- disappears in 2 -3 months of age. - Spinal cord lesion causes absent response
- Peripheral nerve damage causes absent
response

11. Moro (startle) Reflex

- a loud noise can cause the NB to abduct &
extend the extremities followed by an
14. Trunk Incurvation reflex
embracing posture
- NB flexes trunk and swing its pelvis toward
- strong for the 1St 8 weeks and fades by the
the area stimulated (paravertebral area)
end of the 4th or 5th month
- Disappears in few days to 4 weeks
- beyond 6 months indicate neurological
- Absence indicates neurological or spinal
problem
cord problems
 15. Landau reflex Assessment of Well-being
- Seen in horizontal suspension with the head,
APGAR Scoring System
legs & spine extended
- If the head is flexed, hip knees & elbows Indicator 0 Points 1 Point 2 Points
also flex A- Blue;pale Pink;Blue Pink;No
- Appears at approximately 3 months, Appearance extremities cyanosis
disappears at 12-24 months (Acrocyano
sis)
Clinical significance - Absence of reflex occurs in P- <60bpm; 60-100 >100bpm
hypotonia, hypertonia or mental abnormality Pulse Rate absent bpm
G- Floppy;No Grimace or Cries or
Grimace response feeble cry pulling
(reflex when away during
irritability) stimulated stimulation
A- No Flexed Active and
Activty movement arms and resists
(muscle legs extension
tone)
R- No Weak,slow Strong cry
16. Deep Tendon reflex Respiration breathing and
irregulat
breathing

Senses
1. Hearing
- Can hear even in the uterus
- Hearing becomes acute after birth but unable
to locate source
2. Vision
- Can see as soon as they are born
- Focuses bast on colors rather than colored
objects at a distance of 19 cm (8 —10
inches)
- Pupillary reflex Is present at birth
3. Touch
- Sense of touch is well developed at birth,
reacts to painful stimuli
4. Taste
NB has the ability to discriminate taste since
taste buds are well developed
5. Smell
- Present as soon as the nose is clear of lung
and amniotic fluid
Notes:
• Record the Apgar score at 1 minute and at
5 minutes
• If the score is less than 7 at 5 minutes the
Apgar score should be performed at 10
minutes
• Assess each of five items to be scored, and
assign value of 0 (very poor ) to 2
(excellent ) for each item
Interpretation of Result
a. 7 to 10 - the baby is in his best possible
health
b. 4 to 6 - means that the condition is guarded Gestational Assessment
and a baby may need clearing of the airway
Dubowitz Maturity Scale
and supplementary oxygen
c. 0 to 3 - serious danger and needs 0-36 37-38 39 and over
resuscitation (CPR), oxygen Sole Anterior Occasional Sole
creases transverse creases in covered
GRADING OF NEONATAL RESPIRATORY crease only anterior two with creases
DISTRESS thirds
Breast 2mm 4mm 7mm
nodule
diameter
(mm)
Scalp hair Fine and Fine and Coarse and
fuzzy fuzzy silky
Ear lobe Pliable;no Some Stiffened by
cartilage cartilage thick
cartilage
Testes and Testes in Intermediate Testes
scrotum lower pendolous,
canal; scrotum
scrotum full;
0 INDICATES NO RD small; few extensive
rugae rugae
1-3 MILD RD Ballard’s Assessment
4-6 INDICATE MODERATE RD
7-10 INDICATE SEVERE RD
Laboratory Studies
Heel-stick Tests
- Heamtocrit
- Hemoglobin
- Hypoglycemia
Physical Maturity

- Cord care

Neuromuscular Maturity

- Umbilical cord healing

Assessment for Behavioral Capacity

Important Consideration
• Breastfeeding usually begin immediately
after birth
• An infant with gastrostomy tube should
receive a pacifier during feeding
• At age 4-6 months, an infant should begin to
receive solid food, foods one at a time and 1
week apart - Sleeping position

- Diaper area care

- Burping
 Nutritional requirements
• Calories - 100 - 200 kcal/kg for term infant
• Fluid - 150 - 180 ml/kg.
• Protein- 2.2g/kg for the 1st to 6mos.; 1.6 g/kg for
the 2nd 6mos.
• Fat - 30% to 60% of daily calories

- Metabolic screening • Vitamin requirements vary

• Vit. A - 375 mcg for the 1st yr.
• Vit. D- 7.5 mcg for the 1st 6mos.
• 10mcg for the 2nd 6mos.

- Bathing

- Hep B vaccine/Vitamin K administration

Circumcision care

- Observe for bleeding, first urination

- Apply diaper loosely to prevent irritation
- Notify physician for signs of infection
October 12, 2021 (Miss Awayan) D. Middle Childhood Stage - School age (6 -
12yrs old)
Growth and Development
E. Later Childhood Stage - Prepubertal (10 - 13
Learning Objectives: years); Adolescent 13 - 21 years); Young
adulthood (21 - 30 years old)
1. Acquire full knowledge of the importance of
understanding the process of normal growth
and development.
2. Identify and describe the different factors
that may affect the normal process of growth
and development in every person.
3. Identify and discuss the general principles of
growth and development.
4. Identify and describe the different stages of
human development.
5. Identify and discuss the physical, behavioral, Each child displays a predictable patterns growth
cognitive, emotional, and social and development"
development in each stage. Directional Trends
6. Recognize and describe the different
important characteristics of each stage of • Cephalaocaudal development
human development and nursing implication • Proximodistal Development
on each specified characteristic. • Differentiation

Development, Growth and Maturation

• Development refers to the progressions and
regressions that occur throughout the
lifespan.
• Growth refers to the structural aspects of
development.
• Maturation refers to the functional changes
of development.
Development includes both growth and
maturation.
"Patterns of growth and development are universal and
basic to all human beings"
“Rates of growth vary and individual variation exists in
the age at developmental milestone"
“Each child is unique"
“Learning will come quickly and effortless if the child
STAGES is ready”
A. Prenatal Stage -conception to birth "Play is the universal language; children"
B. Infancy Stage - neonatal (birth to 28 days);
“Behavior is the most sensitive indicator of
Infancy (1 months - 12 months) development”
C. Early Childhood Stage - Toddler (1-3yrs);
Preschool (3-5yrs) "Development is interrelated"
 - Child learns to control urination
and defecation
• Phallic Stage (Preschooler) – site of
Factors Influencing Growth & Development pleasure: genitals
• Genetics - Aware of self as sexual being
• Nutrition - Child learns sexual identity
• Prenatal and Environment through awareness of genital
• Family and Community area.
• Cultural Factors • Latency Stage (School-age Child) – Child
involved with learning, developing cognitive
Nurse’s Role
skills, and actively participating in sport
1. Family Advocate activities.
2. Health promoter - Peers with same sex
3. Health Teacher - Child’s personality development
4. Counselor appears to be nonactive or
dormant
Concept of fixation
• Genital Stage (Adolescent) – Puberty
• Fixation is a failure of development in which - Attaining a mature sexual
the individual seeks a particular kind of relationship
gratification even after he or she has passed - Adolescent develops sexual
through the stage in which that kind of maturity and learns to establish
pleasure Is normally sought. satisfactory relationships with the
• If the need for pleasure at any stage is either opposite sex.
under-gratifies or over-gratified, an
Erik Erikson – Psychosocial Theory
individual may come fixated in that stage of
development. • Trust vs. Mistrust
- Child learns to love and be loved
- Recognizing mother as distinct
from other and self.
• Autonomy vs. Shame and Doubt
- Child learns to be independent
and make decisions for self
- Trying out own powers of
speech.
• Initiative vs. Guilt
- Child learns how to do things and
that doing things is desirable
- Exploration own body and
Theories of Growth and Development environment
- Differentiation of sexes
Sigmund Freud – Psychosexual Theory • Industry vs. Inferiority
- Child learns how to do things
• Oral Stage (Infant) – Mouth gratification
well
- Child explores the word by using
- Learning to win recognition by
mouth, especially the tongue.
producing things
• Anal Stage (Toddler) – Site of pleasure:
• Identity vs. Role Confusion
anus
- Adolescents learn who they are
and what kind of person they will
 be by adjusting to a new body - It is good to do to people but only
image, seeking emancipation because one day they may return the
from parents, choosing a favor to you.
vocation and determining value - Takes to satisfy one's need
system. • Conventional
- Accept changed body image
Good interpersonal relationship7-10yo
Jean Piaget – Cognitive Development
- Good boy- nice girl Orientation -
• Sensorimotor Behavior (1m-24m) child follows rules because of a need
- Concerned by sensations and to be a "good" person in own eyes and
actions that affect directly eyes of others
- Rules are created for the benefit of
all
• Preoperational Phase (2-7 years old)
maintenance of social order, fixed rules, and
- Comprehends simple abstractions
authority - 10-12 yo
but thinking is basically concrete
and literal - Law and Order Orientation - Right
- Symbolic thought and egocentric behavior means doing one's duty,
thinking respecting authority and maintaining
- NO sense of time, concept of the given social order for its own sake
distance is only as far as they can - Child finds following rules
see, lack of conservation or satisfying
reversible • Post-conventional
• Concrete Operation (7-12 years old)
Social contract utilitarian law-making perspectives
- Reasoning is logical but limited to
older than 12 yo
own experience, learn broad
concepts. Concrete Thinkers - Follow standards of society for the
- Classifications involving sorting good of all people
objects according to attributes such
as color, weight, multiplication Children’s Play and Games
• Formal Operations (12 years old & above) Play and toys
- Understand causality and can deal
with the past, present, and future INFANCY
- Adult or mature thought • Solitary play
- Abstract concepts, can solve - Infant engages in repetitive activities
hypothetical problem with scientific involving voices sounds, music, and a
reasoning variety of toys, which enhance language
and sensorimotor skills
Lawrence Kohlberg - Moral Development
Ex. Black-and-white pattern toys, soft,
• Preconventional cuddle toys, rattles, music boxes, squeaky
toys, teething rings,
Obedience and Punishment Orientation - 2-3yo
- Strong black and white patterns also help
- Rules are absolute
babies to develop their ability to focus
- Good/bad – right and wrong their attention and levels of
Individualism and Exchange Orientation -4-7yo concentration.
TODDLER PRESCHOOL - Fear = Dark, castration/mutilation and
abandonment
• Parallel Play
✓ First day of school
Ex. Pull toys, picture books, book of
rhymes, dress-up kits, nurse/doctor kits, SCHOOL AGE - Fear = displacement, disease and
dolls, stuffed animals, block set, balls, finger death
paints, drums, modeling clay, jungle gym,
teeter-totter ADOLESCENCE - Fear = losing identity, Rejected,
Loss of independence and Body Image Disturbance
- Stimulates gross motor skill and strength,
language development, creativity, fosters
social development
Children’s Concept of Death
PRESCHOOL
INFANCY - TODDLER
• Associative or Cooperative Play
• Death - does not understand the concept of death
Ex. Tricycle, pounding bench, big blocks, musical.
PRESCHOOL
/Rhythm toys, puzzles, dolls, memory games, fantasy
play, puppets, dress-up, books, art activities • Death - Not a permanent condition death is
- They engage in dramatic, initiative, and reversible, view death as punishment
imaginative play • Death = Reversible
• Believe that dead person will come back
SCHOOL AGE
EARLY SCHOOL AGE
• Board Games
- Enjoys video games, watching television, • Death - understand death as permanent, universal,
playing board games, starting and inevitable
collections, participating in, listening to, • Feel they might die but only in the distant future
or playing music.
ADOLESCENCE
• Competitive Play
- Games with rules are appropriate because • Death - is viewed individuals life perspective,
the child is able to think, more views death in religious and philosophical terms,
objectively, thus making group activities accepts own mortality
a possibility
- Understands the concept of cooperation
and reflect thus in their play as they work Biological Growth and Development
together for the good of the team
A. Neonatal (birth to 1 month)
ADOLESCENCE • Weight:6 to 8 lb; gains 5 to 7 oz weekly for 6
months
• Leisure activities
• Height:48-54cm
• Head Circumference:33-35cm
B. Infancy 1-12 months
FEARS OF CHILDREN • Weight: doubles in 6 mo, triples in 1 year
INFANCY - Fear = Stranger Anxiety • Height: increases 50% by 1 year
• Head Circumference: exceeds chest
TODDLER - Fear = Separation Anxiety circumference
✓ Phases of Separation Head
1. Protest
2. Despair Anterior fontanel (diamond shape) = closes 12 -18 months
3. Denial Posterior Fontanel (triangle shape) = closes 2 -3 months
 • Holds cup and spoon well; helps to dress by 12
months (pushes arm to sleeve)
Reflexes at birth and infancy
Language Development
Present at Birth
• 2 mo – cooing stage
✓ Moro reflex
• 3-6 mo - reciprocal babbling
✓ Tonic neck reflex
• 4 mo – attentive to voices, smiles and laughs
✓ Grasp reflex
• 9 mo – understands simple commands and may
✓ Rooting
imitate sounds: “mama”
✓ Babinski Reflex
• 12 mo – can say few words, imitates variety of
✓ Sucking Reflex
vocalization: waves “bye-bye”
Appears during Infancy
Sensory Development
✓ Parachute
Hearing and Touch well developed
✓ Landau Reflex
✓ Stepping Reflex • VISION
• HEARING
Gross Motor Development
• TOUCH
B. Infancy 1-12 months • TASTE
a. Largely reflex 0 -1 • SMELL
b. Holds head up when prone 2 months
Vision
c. Holds head and chest up when prone 3 months
d. Gains head control by 4 months • differentiates light and dark at birth; prefers
e. Rolls from back to side by 4 months human face
f. Rolls from abdomen to back by 5 months • smile at 2 months
g. Rolls from back to abdomen by 6 months • Follow object in the midline – 18 inches (46 cm)
h. Sits with support by 6 months at 1 month
• Can sit momentarily without support • 2 months old – focus well and follow objects with
i. Sits with hands on the floor by 7 months the eyes
j. Sits alone without support by 8 months • 3 months old – can follow an object across their
k. Creeps or crawls (abdomen off floor) by 9 midline
months; stand holding onto a coffee table if they • 4-month-old – recognize familiar objects, such as
are placed in that position frequently seen bottle, rattle, or toy animal.
l. Pull self to standing by 10 months • Sight not fully developed until 6 years.
• By holding unto the side of a playpen or a • 7-month-old children - pat their image in a mirror
low table but they cannot sit down. • 10 months – beginning of object permanence
m. “Cruises” (walks with support) by 11 months
Hearing
n. Walks well with one handheld by 12 months
• Can stand alone at least momentarily • 2 months – infants will stop an activity at the
o. Walks without help by 15 months sound of spoken words
• 3 months – infants turn their heads to attempt to
locate a sound
Fine Motor Development • 4 months – when infants hear a distinctive sound
they turn and look in that direction
• Fisted; able to follow object to midline • 10 months – infants can recognize their name and
• Desires to grasp at 3 mo listen acutely when spoken to
• Two-handed, voluntary grasp at 5 mo • 12 months – infants can easily locate sound in any
• Uses palmar grasp at 6 mo direction and turn toward it
• Holds bottle, grasps feet at 6 mo
• Transfer objects hand at 7 months
• Pincer grasp established by 10 mo
Touch, Taste, Smell • Knows 2100 words
• Increased strength and refinement of fine and
• Touch
gross motor abilities
- An infant need to be touched to experience
skin-to-skin contact. Significant Behaviors
• Taste
• Imitate adults
- Infants demonstrate that they have an acute
• Magical thinking and make-believe thoughts
sense of taste by turning away from or
• Love to tell lies
spitting out a taste they do not enjoy. - Has
• Fond of offensive language
taste preferences by 6 months
• The age of sibling rivalry
• Smell
• Masturbation (exploration) may be observed
- Infants can smell accurately within 1 or 2
• Questions about sex should be answered honestly
hours after birth
• The age of oedipal / electra complex
- They respond to an irritating smell by
drawing back from it. E. School Age (6-12 years)
- Teach parents to be alert to substances that
causes sneezing when sprayed into the air. • Weight: 5 lb/year
• Height: incr 1-2 inch/year
• Steady, slow growth, gains approximately 5 lb/yr
• Boys and girls differ little at first, but by end of
this period girls will gain more wt and ht
C. Toddler 1-3 years) compared to boys
• Walks without help – 15m Motor Development
• Jumps in place – 18 m
• Movements become more limber, graceful, and
• Goes up stairs with two feet each step – 24m
coordinated, likes to be alone watching TV, very
• Runs fairly well by 24m
modest, “bestfriends”
Fine Motor Development
F. Adolescence
• Uses cup well – 15m
• Weight:
• Builds a tower of 2 cubes
• Height: Girls 3 inch/year, stops at 16 Boys 3
• Holds crayon with fingers - 24-30m
inch/year, growth spurt at 13 but it slows in late
• Good hand-finger coordination – 30m
teens
• Copies a circle – 3y
• Who I Am?
Significant Behavior • Sebaceous glands become fully functional
• Tend to rebel against authority
• Object Permanence Rigid, 10 m-18m
• Ritualistic behavior, headstrong and negativistic,
temper tantrums
NUTRITION
• Start with Toilet Training
Infancy
D. Preschool (3-6 years)
• Infant Feeding
• Growth is slow and steady
• 5 – 6 months – cereals
• Height: inc 2-3 inch/yr
• 7 months – vegetables
• Weight: gains 4-5 lb/y
• 8 months – fruits
Motor Development • 9 months – Meat
• 10 months – egg yolk
• Rides tricycle
• Breastfeeding
• 900 words, favorite word is “why”
• Gradual weaning from breast to bottle to cup
• Skips and hops on one foot – 4y
during 6 months No more than 32 oz formula per
• Throws and catches ball well; dresses and
24 hours
underdress without help; tie shoelaces; balances
on alternate feet-5y
GUIDE FOR INTRODUCTION OF SOLID FOODS

Earliest time to introduce foods is 4 months

Toddler
• Picky and
• Ritualistic Eaters
• Dawdling at meals
• Fetish with foods
• More capricious
• Allow the child to feed himself and encourage a
bite-sized food snack
• Offer a small amount of food on a plate and ask
for more rather than serve a large meal
Preschool
• Strong taste preference (like and dislikes)
• Exhibit food fads and strong taste preferences Illness and Hospitalization

School Age Infancy - Toddler

• Boys require more calories than girls, needs app a. Experience separation anxiety
2400 cal/day b. Responses to pain: crying, facial grimace, “no”,
• Risk of obesity “ouch”, “hurts”, clings to family member
c. Regression
Adolescent
Preschoolers
• Food choices influenced by peers, increase
appetite, require calcium and protein a. View illness as punishment
b. Uncooperative, withdrawn, and aggressive
c. Responses to pain: restlessness, irritability,
kicks
d. Intrusive procedures are anxiety producing
School-age
a. Have more realistic understanding of their
disease
b. Ask relevant questions about procedures c
c. Become distressed over separation from family
and peers
 d. Response to pain: biting, kicking, bargaining Pediatric Assessment
Adolescents Principles: develop children's understanding of the
world's religions.
a. Physical appearance has major importance
b. Separation from peers is a source of anxiety 1. History Taking: Information obtained from /
c. Reluctant to ask questions through others and observation.
2. Explain reason for interview, what will happen
3. Postpone interview if client is in pain or agitated
SAFETY 4. Assure that information will be kept confidential
5. Establish rapport with child
INFANCY – accidents 6. Examiner is opportunistic. No fast rule for
• Rear-facing Car Seat / automobile accidents sequence
• Falling off beds and downstairs 7. Keen observations is significant. Be attentive and
• Aspiration of small object, suffocation avoid interruptions
• Poisoning and burns 8. Play and let the child touch the instruments to be
used.
TODDLER – accidents 9. Position: younger infant – lap of mother,
• Drowning preschooler and school age – mother at side, older
• Electrical burns children – examining table, adolescent –
• Lead poisoning determine whether prefers parent’s presence
10. minimal clothing but older child’s privacy and
PRESCHOOLER – injury modesty should be respected
11. Unpleasant and painful procedures are done last
• Safety Habits and control of the environment
12. Use terms understandable to and appropriate for
• Safety: matches, medicines, gun shots, busy
child and parents
streets, pools
13. Allow child to become familiar with examiner
SCHOOLAGE – accidents prior to beginning examination.
14. Save distressful or intrusive parts of the
• Discourage risk taking behaviors examination for last
• Common activities: 15. Encourage participation of the child or parents as
o Bicycling possible.
o Hiking 16. Examine child in a comfortable and secure
o Swimming position.
o Boating 17. Praise cooperation
o Skateboards
• MVA, drowning, fires and firearms, fractures and AGE APPROACH
dislocations INFANT • Child lying flat or held in
parent’s arm
ADOLESCENTS • Assess heart, pulse, lungs,
1. Suicide respirations while quite,
2. Homicide then head to toe
3. Motor Vehicular Accidents • Eyes, ears, mouth near end
4. Obesity • Moro reflex last
5. Pelvic inflame and kissing disease TODDLER • Minimal contact initially
• Allow to inspect equipment
Common Factors: • Assess heart and lungs while
quiet, then head to toe
1. Economic deprivation
• Eyes, ears, mouth near end
2. Family breakup
PRESCHOOL • Allow to handle equipment
3. Availability of firearms
• Head to toe if cooperative
• Same as toddler if
uncooperative
SCHOOL AGE • Respect privacy
• Explain procedures
• Head to toe
• Genitalia last
ADOLESCENT • Explain procedure
• Proceed as for school age