MCN FINALS Merged

ANGELES UNIVERSITY FOUNDATION
Angeles City
College of Nursing
CARE OF MOTHER, CHILD, ADOLESCENT (WELL CLIENTS) – NCM 0107

Second Semester, A.Y. 2020 – 2021
Module 1: A Framework for Maternal and Child Health Nursing
The area of childbearing and childrearing families is a major focus of nursing

practice in promoting health for the next generation. Comprehensive preoccupation and
prenatal care is essential in ensuring a healthy outcome for mother and child. Although
childbearing and childrearing are often viewed as two separate entities, they are
interrelated, and a deeper understanding is achieved when they are viewed as a
continuum (Burkhard, 2013).
Module Learning Outcomes:
Upon completion of this module, the student should be able to:
1. Integrate concepts, theories, and principles of sciences and humanities in the

formation of appropriate nursing care during childbearing and childrearing
years.
Learning Hours: 4 hours

Topics Learning Strategies Allotted Time
Pre-discussion activity 10 minutes
Goals and philosophies of Synchronous Discussion 40 minutes
Maternal and Child Health
Nursing
Maternal and Child Helath

Goals and Standards
WHO’s 17 Sustainable Video Presentation 10 minutes
Development Goals
Nursing Theories Asynchronous Discussion 60 minutes
Roles and Responsibilities Self-Directed Learning 50 minutes
of a Maternal and Child
Nurse
Legal Considerations of Synchronous Discussion 40 minutes
Maternal-Child Practice
Assessment Activity 30 minutes
A Framework for Maternal and Child Health Nursing Care
Maternal and child health nursing care can be visualized within a framework in
which nurses use nursing process, nursing theory, and Quality & Safety Education for
Nurses (QSEN) competencies to care for families during childbearing and childrearing
years and through the four phases of health care:
Term Definition
Health Promotion Educating parents and the children to follow sound
health practices through teaching and role modeling.
Health Maintenance Intervening to maintain health when risk of illness is
present.
Health Restoration Using conscientious assessment to be certain that
symptoms of illness are identified and interventions
are begun to return patient to wellness most rapidly.
Health Rehabilitation Helping prevent complications from illness; helping a
patient with residual effects achieve an optimal state
of wellness and independence; helping a patient to
accept inviable death.
Goals and Philosophies of Maternal and Child Health Nursing
The area of childbearing and childrearing families is a major focus of nursing

practice in promoting health for the next generation. The primary goal of both maternal
and child health nursing is the promotion and maintenance of optimal family health.
A Philosophy of Maternal and Child Health Nursing

Maternal and child health nursing is:
Family centered; assessment should always include the family as well as an
individual.
Community centered; the health of families is both affected by and influences the
health of communities
Evidence-based, that is the means whereby critical knowledge increases
A challenging role for nurses and a major factor in keeping families well and
optimally functioning.
Maternal and Child Health Goals and Standards

Access to health care and social determinants of health impact the role of the
nurse and the health of the patient. These factors have expanded the roles of nurses in
maternal and child health and, at the same time, have made the delivery of quality
maternal and child health nursing care a challenge.
2020 National Health Goals

The importance a society assigns to human life can best be measured by the
concern a nation places on its most vulnerable member – its elderly, its
disadvantaged, and its youngest citizens. The 2020 National health Goals are
intended to help citizens to easily understand the importance of health promotion
and disease prevention and to encourage wide participation in improving health in
the next decade. It is important for maternal and child health nurses to be familiar
with these goals because nurses play such a vital role in helping the nation achieve
these objectives through both practice and research.
The two main overarching national health goals are:

1. To increase quality and years of healthy life.
2. To eliminate health disparities.
Global Health Goals
The United Nations and the World Health Organization established
millennium health goals in 2000 in an effort to improve health worldwide. As with
2020 National Health Goals, these concentrate on improving the health of
women and children because increasing the health in these two populations can
have such long-ranging effects on general health.
These Global Health Goals are:
1. To end poverty and hunger.
2. To achieve universal primary education.
3. To promote gender equality and empower women.
4. To reduce child mortality.
5. To improve maternal health.
6. To combat HIV/AIDS, malaria, and other diseases.
7. To ensure environmental sustainability.
8. To develop a global partnership for development
WHO’s 17 Sustainable Development Goals

To compare the Global Health Goals with the WHO’s 17 Sustainable
Development Goals watch this video: https://www.youtube.com/watch?v=9-
xdy1Jr2eg
Nursing Theories
They are designed to offer helpful ways to view patients so nursing activities can
be created to best meet patient’s needs.
Callista Roy’s therapy stresses that an important role of the nurse is to help
patients adapt to change caused by illness or other stressor.
Dorothea Orem’s theory concentrates on examining patients’ ability to perform
self-care.
Patricia Benner’s theory describes the way nurses move from novice to expert as
they become more experienced and prepared to give interprofessional care.
QSEN: Quality & Safety Education for Nurses

There are five competencies of QSEN to address the challenge on nursing
leaders to improve the quality of nursing care and to build the knowledge, skills, and
attitudes necessary to help achieve that level of care into pre-licensure and graduate
programs (Disch, 2012). The six competencies are as follows:
1. Patient-centered care
2. Teamwork and collaboration
3. Quality improvement
4. Safety
5. Informatics
6. Evidence-based practice – is the conscientious, explicit, and judicious use of
current best evidence to make decisions about the care of patients (Falk,
Wongsa, Dang, et.al., 2012).
Nursing Research
The systematic investigation of problems that have implications for nursing
practice usually carried out by nurses plays an important role in evidence-based
practice as bodies of professional knowledge.
Roles and Responsibilities of a Maternal and Child Nurse

1. Considers the family as a whole and as a partner in care when planning or
implementing or evaluating the effectiveness of care.
2. Serves as an advocate to protect the rights of all family members, including the
fetus.
3. Demonstrates a high degree of independent nursing functions because teaching
and counseling are major interventions.
4. Promotes health and disease prevention because these protect the health of the
next generation.
5. Serves as an important resource for families during childbearing and childrearing
as these can be extremely stressful times in a life cycle.
6. Respects personal, cultural, and spiritual attitudes and beliefs as these so
strongly influence the meaning and impact of childbearing and childrearing.
7. Encourages developmental stimulation during both health and illness so children
can reach their ultimate capacity in adult life.
8. Assesses families for strengths as well as specific capacity in adult life.
9. Encourages family bonding through rooming-in and family visiting in maternal
and child healthcare settings.
10. Encourages early hospital discharge options to reunite families as soon as
possible in order to create a seamless, helpful transition process.
11. Encourages families to reach out to their community so the family can develop a
wealth of support people they can call on in a time of family crisis.
Legal Considerations of Maternal-Child Practice

Legal concerns arise in all areas of health care. Maternal and child health nursing
carries some legal concerns above and beyond other areas of nursing because care is
often given to patients who are not of legal age for giving consent.
Nurses are legally responsible for protecting the rights of their patients, including
confidentiality, and are accountable for the quality of their individual nursing care and
that of other healthcare team members.
Understanding the scope of practice (the range of services and care that may
be provided by a nurse based on state requirements) and standards of care can help
nurses practice within appropriate legal parameters. Documentation is essential for
justifying actions. Nurses need to be conscientious about obtaining informed consent.
The term “wrongful birth” is the birth of a disabled child whose pregnancy the
parents would have chosen to end if they had been informed about the disability of
pregnancy.
“Wrongful life” is a claim that negligent prenatal testing on the part of the
healthcare provider resulted in the birth of a disabled child.
“Wrongful conception” denotes that a contraceptive measure failed, allowing an
unwanted child to be conceived and born.
If a nurse knows the care provided by another practitioner was inappropriate or
insufficient, he or she is legally responsible for reporting the incident. Failure to do so
can lead to a charge of negligence or breach of duty.
Prepared by:
NCM 0107 Instructors
Reviewed by:
Jennie C. Junio, RN, MAN

Level 2 Academic Coordinator
Angeles City
College of Nursing

Module 2: Reproductive and Sexual Health
Whether or not someone is planning on childbearing, everyone is wiser for being

familiar with reproductive anatomy and physiology and his or her own body’s
reproductive and sexual health. Patients and their partners who are planning on
childbearing may become curious about reproductive physiology and the changes they
will undergo during pregnancy. Patients who are pregnant are also often interested
about physiologic changes, so nurses are frequently asked by both patients and their
partners about reproductive and gynecologic health (Callegari, Ma, & Schwartz, 2015)
Module Learning Outcome:
1. Integrate concepts, theories, and principles of sciences and humanities in the

formation and application of appropriate nursing care during childbearing and
childrearing years.
2. Apply maternal and child nursing concepts and principles holistically and
comprehensively.
CONCEPT OF UNITIVE AND PROCREATIVE HEALTH
The unitive meaning is ordered toward the marital meaning. In fact, this union is
necessary for the consummation of the marriage. And the unitive meaning is ordered
toward the procreative meaning.
Procreation – to produce other of its kind; create; reproduce; to multiply
§ It is a mechanism by which two living beings create a third living being that is
different from both the mother and the father.
Theories about Procreation

1. Theory of EVOLUTION – asserts that all life forms are the result of procreation.
§ It is based on the idea that all species are related and gradually change over
time.
§ All life is related and has descended from a common ancestor.
§ The theory is defended on common features and ascending complexity.
2. Story of Creation in the Book of Genesis – making of all thing from nothing by an
act of God.
§ Single pair of ancestors (Adam and Eve)

§ Man and woman are to be “two-in-one flesh”
§ “increase and multiply”
§ Stewards of creation
HUMAN SEXUALITY
§ It is how people experience the erotic and express themselves as sexual being.
§ A person’s sexuality encompasses complex emotions, attitudes, preferences,
and behaviors related to expression of the sexual self and eroticism.
Terminologies of Human Sexuality:
§ Sex – biological male or female status; specific sexual behavior

§ Sexuality – reflects human character and not solely genital nature
Aspects of Human Sexuality
1. Biologic Sex/Biologic Gender

§ Term used to denote chromosomal sexual development i.e. male XY; female XX
2. Gender/Sexual Identity
§ The inner sense a person has of being a male or a female
§ Sense of masculinity or femininity
§ Influencing gender/sexual identity: Biologic focus and psychosocial focus
3. Gender-role Behavior
§ The way a person acts as male or female including the expression of what is
perceived as gender appropriate behavior
§ Causes: children who suspect that their parents wanted a child of the opposite
sex are more likely to adopt roles of the opposite sex
§ Peers
Types of Sexual Identity
1. Heterosexual – one who is sexually attracted to persons of the opposite sex

§ “straight”
Nursing Responsibilities:
1. Provision of information on safe sex practice at 10 – 12 years old (beginning of

puberty)
2. Homosexual – one who is sexually attracted to persons of the same sex

§ “gay, lesbian” “LGBTQ”
§ Men with men; women with women
Causes:
1. Unusual level of estrogen and progesterone in the utero

§ Before puberty they feel “different”
§ Not interested in opposite sex
§ Adolescent – seek why they are “different”; homosexuals
§ Young adulthood – afraid of stigma; secret commitment or “come out”
1. Be sensitive to their needs because they experience identify confusion especially

during adolescence.
2. Provision of additional counseling to avoid sexually transmitted infections (STIs)
3. Obtain sexual history, provide information on prevention of STIs and signs and
symptoms.
3. Bisexual – one who is sexually attracted to persons of both sexes.
1. Prevention of STIs
4. Transsexual/Transgender – one’s belief that one is not the sex of one’s

physical body but of the opposite sex.
§ Trapped in the wrong body
§ Individual who, although of one’s biologic gender, feels as if he/she, be of
opposite gender
Sex-change Surgery
§ Appear cosmetically as the gender they feel that they are
§ Creation synthetic vagina or penis
§ Not capable of reproduction
§ No change in chromosomal structure
Sexual Health
§ Integration of somatic/physical, emotional, intellectual and social aspects of
sexual well-being in ways that are positively enriching and that enhance
personality, communication, and love (World Health Organization)
Three Basic Elements of Sexual Health:

a. Capacity to enjoy and control sexual and reproductive behavior in accordance
with a social and personal ethics.
b. Freedom from fear, shame, guilt, false beliefs and other psychological factors
inhibiting sexual response and impairing sexual relationship
c. Freedom from organic disorders, diseases, and deficiencies that may
interfere sexual and reproductive function.
Sexual Maturity
§ Capacity to form a stable relationship with the opposite sex which is physically
and emotionally satisfying, and in which sexual intercourse forms the main,
though not only the mode of expression of love.
Factors Influencing Sexuality:

a. Developmental Level – development of sexuality begins with conception and
changes throughout the life span.
b. Culture
- All cultural groups have their own practices and values relating to sexuality
- Diverse attitudes about husband/wife roles, childhood sexuality, nudity,
and appropriate sexual behavior
c. Religious values – it provides guidelines for sexual behavior and acceptable
circumstances for the behavior, prohibited sexual behavior, consequences of
breaking the sexual rules.
d. Personal Ethics/Beliefs – what a person views as bizarre/wrong may be
completely natural and right to another.
e. Health Status
- Some conditions or illnesses may interfere person’s expression of
sexuality such as: heart disease, diabetes mellitus, spinal cord injury,
surgical procedures, joint disease, chronic pain, sexually transmitted
infection, mental disorders, medications, and even pregnancy.
Human Sexual Responses (Masters and Johnson, 1966)
§ 600 men and women

§ 10,000 sexual activity
§ The sexual experience is unique to each individual; how body responds to sexual
arousal has common features
1. Excitement Phase – begins with the onset of erotic feeling and sensation which
occurs with physical and psychological stimulation (sight, sound, emotion, or
thought) that causes parasympathetic nerve stimulation.
Two primary physiologic changes:

a. Vasocongestion – increased blood supply (arterial dilation and venous
constriction in genital area and other different body parts)
b. Myotonia – an increased muscular tension (contraction)
Excitement Phase
Male Female
Erection of the penis and nipples of Erection of the clitoris and nipples of
the breast (parasympathetic nerve breast (increased size =
stimulation vasocongestion); sensitive to touch
and temperature; center of sexual
Scrotal thickening and elevation of arousal and orgasm in female;
the testes (muscle contraction) increased arterial blood supply
Presence of clear lubricating Presence of mucoid fluid or

droplets at the urethral meatus lubrication of the vaginal walls
(bulbourethral gland) (Bartholin’s gland)
Increased in temperature, Vagina widens in diameter and

perspiration, RR, HR, and BP) increases in length
Increased muscle tension in both Increase in size and change in the

smooth and skeletal muscle color of the labia, uterus, and
breasts.
Flushing of the skin
Increased in temperature,
perspiration, RR, HR, and BP
Increased muscle tension in both

smooth and skeletal muscle
2. Plateau Phase – period during which sexual tension increases to levels nearing
orgasm, which may last from 30 seconds to 3 minutes.
Plateau Phase
Male Female
Vasocongestion leads to full distention The clitoris is drawn forward and
of the penis retracts under the clitoral prepuce
HR (100 – 175 bpm) and RR (40 cpm) The lower part of the vagina becomes
extremely congested (formation of
“orgasmic platform”
HR (100 – 175 bpm) and RR (40 cpm)
3. Orgasmic Phase/Orgasm – is the involuntary climax of sexual tension,

accompanied by physiologic and psychologic release. It lasts for 3 – 10 seconds;
shortest stage in the sexual response cycle; intense pleasure affecting the whole
body.
Orgasmic Phase/Orgasm
Male Female
Muscle contractions surrounding the A vigorous contraction of muscles in
seminal vessels and prostate project the pelvic area – expels blood and
semen into the proximal urethra fluid from area of congestion
Contractions are followed immediately An average of 8 – 15 contractions at

by 3 – 7 propulsive “ejaculatory intervals of one every 0.8 seconds
contractions”, occurring at the same
time interval as in women which According to Freud:
forces semen from the penis Clitoral – masturbation/non coital acts
represent sexual immaturity
Vaginal – authentic, mature form of
sexual behavior
Neurotic – does not achieve orgasm
through intercourse
4. Resolution Phase – is the 30-minute period during which the external and
internal genital organs return to unaroused state or pre-coital stage
Resolution Phase
Male Female
REFRACTORY PERIOD occurs Women do not go through this period
during which further orgasm is so it is possible for women to have
impossible from a few hours or days, additional orgasms immediately after
depending on age and other factors the first if properly stimulated
SEX DIFFERENCES
Male Female
More easily aroused Require more physical and
More satisfactory coitus, more rapidly psychological stimulation
than women
Depend less upon ideal Proper mood or setting for intercourse

circumstances for intercourse
Does not achieve second orgasm Can achieve several consecutive

orgasms
Concepts of Sexuality in the Philippines
1. Objections to foreplay before coitus. Reasons vary as some women feel that
prolonged foreplay, they are not treated like women anymore, not respected as
wives.
2. Sexual relations generally take at night.
3. Filipinos during act as being naked makes them feel “embarrassed” before their
husbands.
4. Arousal of body sensations is done through embracing, caressing, and
sometimes biting.
5. Females are expected to repress or restrict their interests in heterosexual
relations. A wife is not supposed to ask for sexual intercourse from her husband.
Thus, non-verbal behavior is resorted to imply their needs.
Assessing Sexual Health
§ Assessment/History taking may include:

1. History, regularity, amount of menstrual flow.
2. Obstetrical/gynecological history
- Reports of discharges, pain, presence of lump, or change in color, size
and shape of genital organ; erectile dysfunction; failure to achieve orgasm;
pain during intercourse
3. Changes in urinary function
4. Birth control/medication taken
5. Sexual practices (sexually active; sexual partner – same/different gender;
number of sexual partners)
Possible Nursing Diagnosis
1. Altered Sexuality Patterns (includes sexual identity, sexuality, sexual function)

- The state in which one expresses concern regarding one’s sexuality.
§ Possible related factors:

- Impaired relationship with partner
- Fear of pregnancy
- Of acquiring an STI
- Of coitus following heart attack
- Lack of significant other
- Lack of privacy
- Body image disturbance
- Self-esteem disturbance
- Knowledge/skill deficit
- Altered body function, illness/medical therapy
2. Sexual Dysfunction – the state in which an individual experiences an

unsatisfactory, unrewarding, or inadequate change in sexual function.
§ Possible related factors:

- Altered body structure or function secondary to disease process, trauma,
medical therapy (e.g. surgery, radiation)
- Pregnancy
- Recent childbirth
- Drugs
Safe sex practice
1. Be selective in choosing sexual partner; increased partners = increased risk of

STI
2. Do not use drugs and prostitutes
3. Inspect partner for any lesions (presence of abnormal draining = no sex)
4. Use of condom
5. Void immediately (aid in washing away contaminants on vulva and urinary tract)
6. Do not use sexual aids
7. Alert sexual partner; presence of STI = no sex
Activity 1: Question and answer on the discussion board:

a. Are unitive and procreative health related?
b. Is a person’s sexuality related to sexual self and eroticism?
RESPONSIBLE PARENTHOOD
§ Refer and read the textbook pp. 103 – 109
Activity 2: Critical Thinking Question: Patient-centered care
A 17-year-old girl tells the nurse she wants to use a fertility awareness
method of contraception. How should the nurse best meet the girl’s learning
needs? Select the BEST answer and provide your rationale for choosing you
answer.
A. The nurse should teach her to record if she feels hot and
whether she is perspiring heavily.
B. The nurse should teach her to assess whether her cervical
mucus is thin and watery.
C. The nurse should teach her to monitor her emotions for sudden
anger or crying.
D. The nurse should teach her to assess whether her breasts feel
sensitive to cool air.
MENSTRUAL CYCLE
Refer to the narrated powerpoint presentation and read the textbook pp. 92 – 95
Activity 3: Practice Test.

A 10-item multiple choice quiz will be given through the poll results of
myCLASS Bigbluebutton about the concept of menstrual cycle.
FERTILIZATION
The students will watch a video on fertilization, implantation,

identical twins and fraternal twins
https://www.youtube.com/watch?v=_5OvgQW6FG4
https://www.youtube.com/watch?v=qjiG8agWdhI
DEFINITION: It is the union of the sperm and the mature ovum in the outer third or outer
half of the fallopian tube.
General Considerations:
1. Mature ovum is capable of being fertilized for 12-24 hours after ovulation. Sperms are
capable of fertilizing even for 3-4 days after ejaculation.
2. Sperms once deposited in the vagina, will generally reach the cervix within 90 seconds
after deposition.
3. Reproductive cells, during gametogenesis divide by meiosis; therefore, they contain

only 23 chromosomes, the rest of the body cells have 46 chromosomes. Sperms
have 22 autosomes and IX sex chromosomes or IY sex chromosome; ova contain
22 autosomes and IX sex chromosome. The union of an X - carrying sperm and
a mature ovum results is a baby girl (XX); the union of a Y – carrying sperm and a
mature ovum results in a baby boy (XY). Remember: Only fathers determine the
sex of their children.
IMPLANTATION
Immediately after fertilization, a fertilized ovum or zygote stays in the

fallopian tube for 3 days during which time rapid cell division – “mitosis“ is taking
place. The developing cells are now called “blastomere“ and when there are
already 16 blastomeres, it is now termed a morula. In this morula form, it will start
to travel to the uterus where it will stay for another 3-4 days. When there is already
a cavity formed in the morula, it is now called a blastocyst. Fingerlike projections,
called trophoblasts are the ones, which will implant high on the anterior or
posterior surface of the uterus. Thus, implantation, also called nidation, takes
place about 8-10 days after fertilization. Once implantation has taken place, the
uterine endothelium is now termed decidua. It is divided into three portions:
1. decidua basalis - the part that lies directly under the embedded ovum.
2. decidua capsularis - the portion that is pushed out by the embedded and
growing ovum.
3. decidua vera - the remaining portion which is not in immediate contact with the
ovum.
The three fetal membrane are the following:
1. Chorion - the outermost membrane of the growing embryo, or fertilized ovum which
serves as a protective and nutritive covering. Also known as the chorionic
membrane.
2. Amnion or Amniotic membrane - a smooth slippery, glistening membrane that forms

beneath the chorion and lines the cavity. Also known as the amniotic
membrane. It is also called the bag of water because it is filled with fluid
known as the amniotic fluid.
Functions of amniotic fluid

a. keep the fetus at an even temperature.
b. cushions the fetus against possible injury.
c. provide a medium in which the fetus can easily move.
3. Placenta - it is formed by the union of the chorionic villi and the decidua basalis. It is
a fleshy disk- like organ that measures 15-20 cm. in diameter and 2- 3 cm. in
thickness late in pregnancy and weighs 500 g. at term.
Functions of Placenta
a. serves as the fetal lungs, kidney and GIT.
b. serves as a separate endocrine organ throughout pregnancy.
c. offers some protection to the fetus against invading microorganisms and
chemical substance.
Activity 4: Exit tickets using a padlet

At the end of the discussion, the learner will answer a quick question about
fertilization.
EMBRYONIC AND FETAL STRUCTURES
§ Germ layers
- Blastocyst
- Rubella infection
- All organ systems developed at 8 weeks (organogenesis)
1. Endoderm
- Lining of pericardial, pleural, and peritoneal cavities, lining of GIT and
respiratory tract
- Tonsils, parathyroid, thyroid, thymus gland, and urinary system
2. Mesoderm
- Supporting structures of the body, dentin of teeth, upper portion of the
urinary system, reproductive system, heart, circulatory system, blood cells,
and lymph vessels.
3. Ectoderm
- CNS, peripheral nervous system, skin, hair, nails, sebaceous glands,
sense organs, mucous membranes of anus, mouth, nose, tooth enamel,
and mammary glands
Cardiovascular System:
o 16th day: single heart tube forms

o 24th day: heart starts to beat
o 6th or 7th week: development of septum
o 7th week: development of valves
o 11th week: ECG (20th week or more accurate)
o 10th – 12th week: Doppler ultrasound (UTZ)
o 20th week: fetal heart audible through stethoscope
Fetal Circulation
o 3rd week: fetal blood exchanges nutrients with maternal circulation

o Special structures”
- Ductus venosus – carry oxygenated blood = umbilical vein → inferior vena
cava
- Foramen ovale – connects the left and right atria bypassing fetal lungs
- Ductus arteriosus – carry oxygenated blood = pulmonary artery → aorta,
bypassing fetal lungs
- Umbilical vein – carry oxygenated blood (from placenta)
- Umbilical artery – carry less oxygenated blood (to placenta)
Respiratory System
o 3rd week – respiratory and digestive tracts exist as a single tube

o 4th week – septum begins to divide the esophagus from trachea (lung buds
appear on the trachea)
o 7th week – diaphragm divides the thoracic cavity from the abdomen completely
o If the diaphragm fails to close: stomach, spleen, liver, or intestines may herniate
(diaphragmatic hernia)
Nervous System
o 3rd to 4th week: active formation of nervous system

o All parts of the brain form intrauterine but matures at 5 – 6 y/o (cerebrum,
cerebellum, pons, and medulla oblongata)
o 24th week: ear is capable of responding to sound, eyes exhibit pupillary reaction
indicating sight
Endocrine System
o Fetal adrenal glands supply a precursor of estrogen synthesis by placenta

o Pancreas produces insulin needed by the fetus (insulin does not cross placenta)
o Thyroid and parathyroid glands has vital roles in metabolic function and calcium
balance
Digestive System
o 4th week: digestive tract separates from the respiratory tract

o 6th week: intestines
o 16th week: meconium formed
- Meconium consists of cellular wastes, bile, fats, mucoproteins,
mucopolysaccharides, and portions of vernix caseosa
- Dark green/black and sticky in texture
o GIT is sterile before birth (low in vitamin K)
o 36th week: GIT secretes enzymes essential in carbohydrate and protein
digestion
o Liver: active throughout gestation; filter between incoming blood and fetal
circulation; deposit site for fetal iron and glycogen
Musculoskeletal System
o 2nd week: cartilage prototypes provide position and support

o 11th week: fetus can be seen moving through the UTZ
o 12th week: cartilage → bones
o 20th week: mother usually feels fetal movement
o QUICKENING
Reproductive System
o Child’s sex is determined at the moment of conception

o 6th week: gonads form (testes or ovaries)
o Testes = (+) testosterone – male organs
= (-) testosterone – female organs
o Testes forms in the abdominal cavity but descends into scrotal sac at 34th – 38th
week
o 8th week: chromosomal analysis
Urinary System
o Forms intrauterine but not essential until birth (placenta)

o 4th week: rudimentary kidneys are present
o 12th week: urine is formed
o 16th week: urine is excreted in the amniotic fluid
o At term: urine rate is at 500 ml/day
Integumentary System
o Skin appears thin and translucent until adipose tissue forms at 36 weeks
o Lanugo – serves as insulation to preserve warmth in utero
o Vernix caseosa – serves as lubrication; prevents skin from macerating
Immune System
o 20th week: IgG class of immunoglobulin cross the placenta

o Temporary passive immunity against diseases (polio, rubella, rubeola, diphtheria,
pertussis, tetanus, infectious parotitis, hepatitis B) until 8th moth of life
o Little or no immunity = herpes virus (chicken pox, cold sores, genital herpes)
o IgA – found in colostrum and milk provides additional protection to the newborn
MILESTONES OF FETAL GROWTH AND DEVELOPMENT
1st Lunar Month (4 Gestation Weeks)
The fetus is 0.75 cm to 1 cm in length and weighs 400 mg.

Trophoblasts embed in decidua.
Chorionic villi form.
Foundations for nervous sytem,
genitourinary system, skin, bones, and lungs are formed.
Rudimentary heart appears as a bulge on the anterior surface
Back is bent so the head almost touches the tip of the tail
Buds of arms and legs begin to form.
Rudiments of eyes, ears, and nose appear.
2nd Lunar Month (8 Gestation Weeks)
The fetus is 2.5 cm (1inch) in length and weighs 20 g.

Fetus is markedly bent. Primitive tail is regressing.
Head is disproportionately large, owing to brain development.
Organogenesis is complete.
Abdomen appears large due to rapid growth of fetal intestine
Sex differentiation begins.
Centers of bone begin to ossify.
3rd Lunar Month (12 Gestation Weeks)
The fetus is 7 cm to 8 cm in length and weighs 45 g.

Bone ossification centers are forming
Fingers and toes are distinct.
Placenta is complete
Fetal circulation is complete.
Heart is audible by Doppler
Kidneys secretes urine.
4th Lunar Month (16 Gestation Weeks)
The fetus is 10 to 17 cm in length and weighs 55 g to 120 g.

Sex can be determined by ultrasound
Lanugo is well formed
Nasal septum and palate close.
Fetus actively swallows amniotic fluid
Urine is present in amniotic fluid
Liver and pancreas are functioning.
The fetus is 25 cm in length and weighs 223 g.

Lanugo covers entire body.
Fetal movements are felt by mother.
Heart sounds are perceptible by auscultation
Vernix caseosa appears

Skin appears wrinkled.
Meconium is present as far as the rectum.
Eyebrows and fingernails develop.
Active production of lung surfactant begins

Skin is red.
Pupillary membrane disappears from eyes and the eyelids open.
Lung alveoli begins to mature and surfactant present in amniotic fluid.
The fetus has an excellent chance of survival.

Fetus is viable.
Fingerprints are set.
Vigorous fetal movement occurs.
Subcutaneous fat begins to be deposited.
The fetus is 42 cm to 48 cm in length and weighs 1800 g to 2700 g. (5-6lbs.)

Additional amount of subcutaneous fat are deposited.
Lanugo disappears
Amniotic fluid decreases
Sole of foot has only 1 or 2 crisscross creases
The fetus is 48 cm to 52 cm in length and weighs 3000 g. (7-7.5 lbs)

Skin is smooth.
Fingernails extend over the fingertips
Creases on soles of feet cover at least 2/3 of the surface.
Vernix caseosa fully formed
Activity 5: Question and answer using the Discussion Board about embryonic
and fetal structures and milestones of fetal growth and development.
Physiologic and Psychologic Changes during Pregnancy
Physiologic changes that occur in the woman can be categorized as local

or systemic. Both the signs and symptoms of the physiologic changes of
pregnancy are used to diagnose and mark the progress of pregnancy. The
physiological changes during pregnancy are temporary so that as soon as
pregnancy is terminated, the woman eventually returns to the pre-pregnant state.
1. Local changes:
1.1. Uterus - the most obvious alteration in the woman's body during pregnancy is
the increase in the size of the uterus that occurs to accommodate the
growing fetus. Over the 10 lunar months of pregnancy, the uterus increases
in length from approximately 6.5 to 32 cm; in depth from 2.5 to 22 cm; and
in width, from 4 to 24 cm. Its weight increases from 50 to 1000 gm. At the
beginning of pregnancy, the uterine wall is about 1 cm. thick and its cavity
is barely enough to hold a 2 ml. bulk. By term, the increase in size has
become so extensive that the uterus can hold a 7 lb. (3175 gm.) fetus plus
1000 ml. of amniotic fluid, or a total of about 4000 gm. The uterine growth
results from:
1) increased vascularity and dilation of blood vessels;

2) production of new muscle fibers and fibroelastic tissues (hyperplasia) and
enlargement of pre-existing muscle fibers and fibroelastic tissues
(hyperthrophy).
3) Development of the decidua.
Not only is there an increase in size and shape but there also occurs
a change in the consistency of the uterus. At about the 6th week of
pregnancy, the lower uterine segment just above the cervix becomes so soft
that when it is compressed between the examining fingers by bimanual
examination, the wall cannot be felt or feels as thin as tissue paper. This
extreme softening of the lower uterine segment is known as Hegar's sign.
1.2. Cervix - In response to the increased level of circulating estrogen, the cervix
of the uterus becomes more vascular and edematous in pregnancy;
increased fluid between cells causes the cervix to soften in
consistency, and vascularity causes it to darken from a pale pink to a
violet hue. The glands of the endocervix undergo both hyperthrophy
and hyperplasia as they increase in number and distend with mucus.
A tenacious coating of mucus fills the cervical canal. This mucus plug
called the operculum seals out bacteria during pregnancy and helps
prevent infection in the fetus and membranes. Softening of the cervix
in pregnancy is so extensive that whereas the consistency of a non-
pregnant cervix may be compared with that of the nose, the
consistency of a pregnant cervix more closely resembles that of an
earlobe. This softening of the cervix is called the Goodell's sign. Just
before the onset of labor, when the cervix takes on the consistency of
butter, it is considered "ripe" for delivery.
1.3. Vagina - The vascularity of the vagina increases beginning early in

pregnancy. The resulting increase in circulation changes the color of
the vagina from its normal light pink to a deep violet which is known as
the Chadwick's sign. Under the influence of estrogen, the vaginal
epithelium and underlying tissues become hypertrophic and enriched
with glycogen; they loosen from their connective tissue attachment in
preparation for great distention at birth. This increase in the activity of
the epithelial cells results in a white vaginal discharge throughout
pregnancy. The vaginal secretions during pregnancy fall from a ph of
over 7 to 4 or 5 (due to an increased lactic acid content caused by the
lactobacillus acidophilus, which grows freely in the increased glycogen
environment) and therefore is resistant to bacterial invasion. This
change in ph unfortunately favors the growth of Candida Albicans, a
species of yeast like fungi. A candidal infection is manifested by itching
and burning sensation in addition to a cream cheese like discharge,
which if transmitted, manifest itself as thrush in the infant's mouth.
1.4. Ovaries - Ovulation stops with pregnancy because of lack of activity of the
follicle stimulating hormone and the production of the human chorionic-
gonadotropin hormone.
1.5. Breast changes - A pregnant woman may experience a feeling of fullness,

tingling or tenderness because of the increased stimulation of breast
tissue by the high estrogen level in the body. As pregnancy progresses,
the breast size increases because of hyperplasia of the mammary alveoli
and fat deposits. The areola of the nipple darkens in color and its diameter
increases from 3.5 to 5 or 7.5 cm. The sebaceous glands of the areola
(Montgomery's tubercles) enlarge and become protruberant. By the 16th
week, a thin watery, high-protein fluid and the precursor of breastmilk
known as colostrum, may be expelled from the nipples.
2. Systemic Changes
2.1 Integumentary changes - As the uterus increases in size, the abdominal

wall must stretch to accommodate it. This stretching (plus possible
increased adrenal cortex activity) causes rupture and atrophy of small
segments of the connective tissue layer of the skin. This leads to pinkish
or reddish streaks appearing on the sides of the abdominal wall and
sometimes on the thighs. These streaks are called striae gravidarum.
In the weeks following delivery, the striae gravidarum lighten to a silvery
white color called striae albicantes or atrophicae and although
permanent, become barely noticeable.
Extra pigmentation generally appears on the abdominal wall. A

brown line running from the umbilicus to the symphysis pubis and
separating the abdomen into a right and left hemisphere, this brown line
is known as the linea nigra. Darkened brown areas may appear in the
face particularly on the cheeks and across the nose. This is known as
melasma or chloasma or the mask of pregnancy. The increases in
pigmentation are due to melanocyte stimulating hormone secreted by the
pituitary. With the decrease in the level of the hormone after pregnancy,
these areas lighten and disappear.
Vascular spiders (small fiery red branching spots) are sometimes

seen on the skin of pregnant women particularly on the thighs. These
probably results from the increased level of estrogen in the body, these
may fade out but not disappear completely after pregnancy.
The activity of sweat glands increases throughout the body and is

manifested by an increase on perspiration which can become annoying
by the end of pregnancy. Palmar erythema (redness and itching) may
occur on the hands from the increase in estrogen level.
2.2. Respiratory system - As the uterus enlarges during pregnancy, a great deal
of pressure is put on the diaphragm and, ultimately, on the lungs.This
crowding of the chest cavity causes an acute sensation of shortness of
breath late in pregnancy, until ligthening relieves the pressure.
A local change also that often occurs in the respiratory system, is

marked congestion or "stuffiness" of the nasopharynx, a response to
increased estrogen level.
2.3. Circulatory system - Changes in the vascular system are extremely

significant to the health of the fetus as they are important for adequate
placental and fetal circulation. To provide an adequate exchange of
nutrients in the placenta and for blood to compensate for blood loss at
delivery, the circulatory blood volume of the woman's body increases at
least 30 to 50 percent during pregnancy. As the plasma volume first
increases, the concentration of hemoglobin and erythrocytes may
decline, giving the woman a pseudoanemia.
To handle the increase in blood volume in the circulating system,

a woman's cardiac output increases significantly by 25 to 50 percent;
the heart rate increases by ten beats per minute.
During the third trimester, blood flow to the lower extremities is

impaired by the pressure of the expanding uterus on veins and arteries,
which slows circulation. This decrease in blood flow in the venous
system leads to edema and varicosities of the vulva, rectum and legs.
Palpitations in the early months of pregnancy are probably

caused by sympathetic nervous system stimulation; in later months,
they may result from increased thoracic pressure of the uterus against
the diaphragm. The level of circulatory fibrogen, a constituent of the
blood necessary for clotting as well as other clotting factors such as VII,
VIII, IX, X and the platelet count increases as much as 50 percent during
pregnancy, probably because of the increased level of estrogen. This
increase is a safeguard against major bleeding should the placenta be
dislodged and the uterine arteries or veins open up. In most pregnant
women, blood pressure actually decrease slightly during the second
trimester because of the lowered peripheral resistance to circulation as
the placenta expands rapidly.
2.4. Gastro-intestinal system - As the uterus increases in size, it tends to

displace the stomach and intestines towards the back and sides of the
abdomen. At about the midpoint of pregnancy, the pressure may be
sufficient to slow intestinal peristalsis and the emptying time of the
stomach, leading to heartburn, constipation and flatulence. This is also
about the same time the ovaries produce a hormone called relaxin, which
contributes to decreased gastric motility. Progesterone has also an effect
on smooth muscles such as that in the intestine making it less active.
Nausea and vomiting early in pregnancy known as morning sickness is
probably a systemic reaction to decreased glucose levels, glucose being
utilized in great quantities by the growing fetus, and increased estrogen
levels.
2.5. Urinary system - During pregnancy, the kidney must excrete not only the
waste products of the woman's body but those of the growing fetus as
well. Thus, urinary output gradually increases (about 60 to 80 percent)
and specific gravity of urine decreases during pregnancy. The pregnant
woman may notice an increase in urinary frequency during the first three
months until the uterus rises out of the pelvis and somewhat relieves
pressure on the bladder. Frequency of urination may return at the end of
pregnancy as lightening occurs and the fetal head exerts renewed
pressure on the bladder.
2.6. Skeletal system - As pregnancy advances, there is a gradual softening of the

pelvic ligaments and joints to allow for pliability and to facilitate passage
of the baby through the pelvis at the time of delivery. This is due to
influence of the ovarian hormone, relaxin. The attempt of a pregnant
woman to change her center of gravity and make ambulation easier, she
tends to stand straighter and taller than usual. This stance is referred to
as the "pride of pregnancy."
2.6. Endocrine changes - The most striking change in the endocrine system
during pregnancy is the addition of the placenta as an endocrine organ,
producing large amounts of both estrogen and progesterone leading to
the suppression of follicle stimulating hormone and leutenizing hormone.
The thyroid glands is altered significantly. The gland enlarges in

pregnancy to compensate for the increased basal body metabolic rate by
about 20 percent. These thyroid changes along with emotion lability,
tachycardia, heart palpitations, and increased perspiration may lead to a
mistaken diagnosis of hyperthyroidism if pregnancy has not been
determined.
2.7. Temperature changes - Early in pregnancy, temperature increases slightly

because of the activity of the corpus luteum (the temperature elevation
that marked ovulation remains this way). As the placenta takes over the
function of the corpus luteum at about the 16th week, the temperature
generally decreases to normal at about this time.
2.8 Weight - A weight increase of about 25 to 40 lbs. is spread throughout

pregnancy. It may be distributed as follows:
Fetus .......................…………….. 7.5 lbs

Placenta ...................... …………. 1.5 lbs.
Amniotic fluid ................ ………… 2 lbs
Increased weight of uterus ………2.5 lbs
Increased blood volume ......……. 4 lbs.
Increased weight of breasts ... …. 1 1/2 to 3 lbs
Weight of additional fluid .... ……. 4 lbs
Fat and fluid accumulation ..……. 7 lbs
Psychological Tasks of Pregnancy
1. First Trimester: Accepting the Pregnancy

2. Second Trimester: Accepting the Baby
3. Third Trimester: Preparing for Parenthood
Confirmation of Pregnancy
Pregnancy is diagnosed on the basis of the symptoms reported by the woman

and signs elicited by a health care provider. These signs and symptoms are
traditionally divided into three classifications:
1. Presumptive Signs - These are least indications of pregnancy; taken as single

entities, they could easily indicate other conditions. These findings are largely
subjective in that they are experienced by the woman but cannot be documented
by the examiner.
1.1. Amenorrhea - absence of menstruation. May also result from sudden

changes in environment, emotional stress, malnutrition, fatigue and
menopause.
1.2. Nausea and vomiting - May be due to gastro-intestinal tract irritation or

an emotional symptom.
1.3. Breast changes - May just signal another menstrual cycle.
1.4. Frequent urination - Could be the result of increased fluid intake,

excitement, cold climate or urinary tract infection.
1.5. Quickening - The first time life or fetal movement is felt by the mother.
It can sometimes be imitated by peristalsis or flatulence.
1.6. Fatigue - General feeling of tiredness which is a common complaint

even among those who are not pregnant.
1.7. Changes in abdominal shape - Tumors and as cited may also change
the shape of abdomen. Cushing's disease may even manifest
striae like marks on an enlarged abdomen.
2. Probable Signs - In contrast to presumptive signs of pregnancy, probable signs

can be documented by the examiner. Although they are more reliable than
the presumptive signs, they are still not positive or true diagnostic findings.
2.1. Changes in reproductive organs - Due to the possibility of tumors or

inflammation, this symptom is considered as a probable sign of
pregnancy.
2.2. Basal body temperature elevation - Although this is considered as

having 97 percent accuracy as a diagnostic observation, it is
possible that the patient might have employed the wrong tech-
nique.
2.3. Positive biological and immunochemical pregnancy tests - A form

of diagnosis of pregnancy which can usually be made after the 8th
week. However, a hydatidiform mole can give a positive result also.
2.3.1. Progesterone withdrawal test - An oral hormone containing

progesterone and estrogen is given to the woman for 2 or 3 days.
The effect of the medication takes place within 15 days following
the administration of the last dose. Physiologically, the increase in
these hormones will develop the endometrium and upon
withdrawal of the drug, menstruation will occur. But if the woman
is pregnant, the corpus luteum and the placenta will produce
sufficient hormones to keep the baby implanted, and there will be
no bleeding following withdrawal. Therefore, bleeding would
indicate that pregnancy has not occurred and the absence of
bleeding would indicate pregnancy.
2.3.2 Ultrasound determination - High frequency sound waves projected

toward a woman's abdomen are useful in diagnosing pregnancy. If
pregnancy is present, a characteristic ring indicating the gestational
sac will be revealed on the oscilloscope as early as the 6th week
of amenorrhea. Incidentally, ultrasound is also useful in
demonstrating fetal maturity and indicating site of implantation.
2.3.3. HCG test - For pregnancy testing HCG is measured in international

units. In the non-pregnant woman, no units will be detectable
because there are no trophoblast cells producing HCG. In the
pregnant woman, trace amounts of HCG will appear in the serum
as early as 24 to 48 hours following implantation.
Because all laboratory tests for pregnancy are inaccurate to

some degree, positive results from these tests are considered
probable rather than positive signs.
3. POSITIVE SIGNS OF PREGNANCY. There are only three positive signs of

pregnancy: fetal heart sound, fetal movements felt by the examiner and
visualization of the fetal outline by sonogram.
3.1. Auscultation of fetal heart sounds - although the fetal heart has been
beating since the 24th day after conception, it is audible by auscultation
of the abdomen with an ordinary stethoscope only at about 18 to 20 weeks
of pregnancy. Fetal heart sounds are difficult to hear when abdomen have
a great deal of subcutaneous fat or there is greater than normal amount
of amniotic fluid (hydramnios). They are heard best when the position of
the fetus is determined by palpation and the stethoscope is placed over
the area of the fetus' back. A fetal heart rate usually ranges between 120
and 160 beats per minute.
3.2. Fetal movements felt by the examiner - Movements of the fetus perceived
by the woman may be misleading. Those felt by an objective examiner
are much more reliable and constitute a positive sign of pregnancy. Such
movements may be felt by the 20th - 24th week of pregnancy unless the
woman is extremely obese.
3.3. Visualization of fetus by ultrasound.
Activity 5: Practice test

A 20-item multiple choice quiz will be given through myCLASS Bigbluebutton.
Prepared by:
NCM 0107 First Cycle Instructors
Reviewed by:

Angeles City
College of Nursing

Module 3: Care of the Mother and the Fetus during the Perinatal Period
(Prenatal Care)
Prenatal care, essential for ensuring the overall health of newborns and their
mothers, is a major strategy for helping to reduce complications of pregnancy such as
the number of preterm or low-birth-weight babies born each year (Mehta & Sokol,
2013).
Ideally, preparation for a healthy pregnancy begins during a woman’s childhood
as good preparation includes a lifetime of an adequate intake of calcium and vitamin D
to prevent rickets (which can distort pelvic size), adequate immunization against
contagious diseases so a woman has protection against viral diseases such as rubella
and varicella during pregnancy, and maintenance of an overall healthy lifestyle to
ensure the best state of health possible for woman and her partner when entering
pregnancy. Preconception care and risk assessment should be provided at every
healthcare visit throughout the childbearing years for both men and women.
Other phases of an overall healthy lifestyle are a positive attitude about sexuality,
womanhood, and childbearing. Once a woman becomes sexually active, preparation for
a successful pregnancy includes practicing safer sex, regular pelvic examinations, and
prompt treatment of any sexually transmitted infection to prevent complications that
could lead to subfertility (Price, Ades, Soldan, et al., 2016). It also includes not smoking,
drinking alcohol, or using recreational drugs. Acquisition and use of reproductive life
planning information can help ensure each pregnancy is intended and wanted.
The initial prenatal visit is the first time many women have been to a healthcare
facility since their routine health maintenance visits of childhood and adolescence.
Urging her to continue prenatal care is important because of lack of prenatal care is
associated with pregnancy complications such as preterm birth (Dermont-Heinrich,
Hawkes, Ghosh, et al., 2014).
Module Learning Outcomes:
1. Assess mother, child, adolescent’s health status with the use of specific methods
and tools to address existing health needs.
2. Formulate nursing diagnosis/es focusing on health promotion and disease
prevention related to mother, child, and adolescent’s health.
3. Implement safe and quality nursing interventions addressing health needs
affecting women from pregnancy to postpartum and children from perinatal to
adolescent stage.
4. Conduct individual/group health education activities based on the priority learning
needs of the mother, child, adolescent.
5. Evaluate with the client the health outcomes of nurse-client working relationship.
6. Institute appropriate corrective actions to prevent or minimize harm arising from
adverse effects.
The Preconception Visit

- Choosing a healthcare provider for pregnancy and childbirth
The following are components of the initial prenatal visit:
A. Vital signs taking with special emphasis on blood pressure and weight taking to
establish a baseline for future comparison; laboratory screening such as urinalysis
and blood examinations.
B. Initial interview/History-taking. This has several purposes: to gain information

about the woman's physical and psychosocial health, to establish rapport, and to
obtain a basis for anticipatory guidance at the conclusion of the visit.
1. Information regarding this pregnancy, including date and character of last

menstrual period, and normal frequency of menstruation and early signs of
pregnancy such as nausea, vomiting, heartburn and fatigue.
2. Previous obstetric history, including weight, condition, spacing and type of

previous deliveries. Any previous miscarriages or abortion, and complications if any.
3. Medical history (past and present). Diseases which are threats to pregnancy
especially diabetes, hypertension, cardiovascular disease, tuberculosis, venereal
disease, mumps, rubella, poliomyelitis, allergies, kidney diseases, and
gynecological interventions.
4. Surgical history especially abdominal or uterine surgery.

5. Medications used before and during this pregnancy including alcohol, tobacco,
and marijuana.
6. Any problem encountered during this or previous pregnancy. Has she

experienced any of the danger signals of pregnancy such as bleeding, continuous
headache, blurring of vision, or swelling of the hands or face.
C. Information about a woman's nutrition, elimination, sleep, recreation, lifestyle

and inter-personal interactions.
D. Review of systems. This method causes her to recall diseases she forgot to mention
earlier, diseases that are important to your history taking.
a. Head: headache; head injury; dizziness, seizures, syncope

b. Eyes: vision, infection, cataract, eyeglass user
c. Ears: Infection, discharge, hearing loss, vertigo
d. Nose: Epistaxis, sinusitis, discharge
e. Mouth and Pharynx: Conditions of teeth and gums, hoarseness, difficulty in
swallowing
f. Neck: Stiffness, masses
g. Breast: Mass, lumps, secretions, pain and tenderness
h. Respiratory System: Cough, wheezing, asthma, shortness of breath
i. Cardiovascular System: Any heart disease, hypertension
j. Gastrointestinal System: Vomiting, diarrhea, constipation, hemorrhoids, ulcer
k. Genitourinary System: Infection, frequency of urination, hematuria

l. Extremities: Varicose veins, edema, pain, or stiffness of joints
E. Pelvic Examination – reveals information on the health of both internal and external
reproductive organs. This examination has the reputation of being painful and causing
loss of modesty.
- Equipment required for pelvic examination:

1. Speculum
2. Spatula
3. Clean examining gloves
4. Lubricant
5. A glass, slide or liquid collection device
6. Culture tube
7. Sterile cotton tipped applicator
8. Good examining light
9. A stool at correct sitting height
1. Allow woman the opportunity to talk with the person performing the examination.
Pelvic examination begins with the inspection of external genitalia then the internal
genitalia. To view the cervix, the vagina must be opened with a speculum.
Internal examination or Vaginal examination
Patient preparation:
a. Provide explanation
b. Let woman empty her bladder first
c. Provide good lightning
d. Place the woman in a lithotomy position with buttocks extended slightly beyond
examining table
e. Drape properly
f. fLet support person stay at the head of the bed
g. Instruct woman not to:
- hold or squeeze your hands and that of her husband
- hold her breath
- close eyes tightly
- clench fist
- contract perineal muscles
h. After procedure, provide tissue to wipe perineum of lubricant.
Speculum examination and Papanicolau smear
- the purpose of speculum examination is to examine the internal genitalia and to

obtain for cytological examination known as Papanicolau or pap smear
1. Instruct the woman to avoid coitus, douches, tampons, vaginal medications or
vaginal sprays or powder at least 24 hours before having pap smear
2. Schedule the test not on the time of menstruation. Schedule the test during the
early part of the menstrual cycle, 8 to 12 days from the start of the last menstrual
period
3. Make the patient empty her bladder
4. Inform patient that during the insertion of the speculum, she may feel some
pressure or pulling. Discomforts is often experienced if the vaginal canal is
irritated during the examination. Instruct patient
Speculum examination and Papanicolau smear
- the purpose of speculum examination is to examine the internal genitalia and to

obtain for cytological examination known as Papanicolau or pap smear
1. Instruct the woman to avoid coitus, douches, tampons, vaginal medications or
vaginal sprays or powder at least 24 hours before having pap smear
2. Schedule the test not on the time of menstruation. Schedule the test during the
early part of the menstrual cycle, 8 to 12 days from the start of the last menstrual
period
3. Make the patient empty her bladder
4. Inform patient that during the insertion of the speculum, she may feel some
pressure or pulling. Discomforts is often experienced if the vaginal canal is
irritated during the examination. Instruct patient to breathe deeply and avoid
tensing her perineal muscles during the insertion of the speculum
5. A small amount of vaginal bleeding is expected after this test. The woman may
use a sanitary napkin or panty liner to protect her clothes from any spotting.
Classification of Pap Smear results using Bethesda System:
FINDINGS INTERPRETATION
Negative No precancerous or cancerous cells are found
Squamous cells
Atypical squamous cells (ASC) Some cells appear different than normal but cannot be
classified as precancerous
Low-grade squamous intraepithelial Mild precancerous changes may have been found in some
lesion (LSIL) cells
FINDINGS INTERPRETATION
High-grade squamous intraepithelial lesion Moderate to severe precancerous changes may have
(HSIL) been found in some cells
Squamous cell carcinoma Cancerous cells are present
Glandular cells
Atypical glandular cells There is an increased risk of precancer or cancerous

cells
Adenocarcinoma Cancerous cells are present
Vaginal Inspection is also used for culture for trichomoniasis or group B streptococcus
(35 to 37 weeks of gestation), chlamydia, gonorrhea, HPV
Bimanual examination is used to demonstrate:
a. Chadwick’s sign
b. Goodel’s sign
c. Hegar’s sign
d. Ballotment
F. Rectovaginal Examination – done after bimanual pelvic examination
G. Pelvic measurements - to determine with the use of the pelvimeter, whether or not
the vaginal route of delivery will be safe for both infant and mother. The types of pelves
found in women can be categorized into four groups:
a. Gynecoid pelvis. This is the "normal" female pelvis. The inlet of this type is
well rounded forward and backward, and the pubic arch is wide. This pelvic
type is ideal for childbirth.
b. Anthropoid pelvis - In this pelvis, the transverse diameter is narrow and the
anteroposterior diameter of the inlet is larger than normal. This does not
accommodate a fetal head as well as the gynecoid pelvis does.
c. Platypelloid pelvis. In this pelvis, the inlet is an oval smoothly curved, but
the anteroposterior diameter is shallow. A fetal head would not be able to
rotate to match the curves of the pelvic cavity in this type of pelvis.
d. Android pelvis, or "male" pelvis. The pubic arch in this type of pelvis forms
an acute angle, making the lower dimensions of the pelvis extremely narrow.
A fetus has difficulty exiting from this type of pelvis.
The internal pelvic measurements give the actual diameter of the inlet and outlet
through which the fetus must pass. The following measurements are done most
commonly:
a. Diagonal conjugate. This is the distance between the anterior surface of the
sacral prominence and the anterior surface of the inferior margin of the
symphysis pubis. It is the most useful measurement for estimation of pelvic
size. The pelvic inlet is rated as adequate for childbirth if the diameter is
more than 12.5 cm.
b. True conjugate or conjugate vera. This is the measurement between the

anterior surface of the sacral prominence and the posterior surface of the
inferior margin of the symphysis pubis.
c. Ischial tuberosity. This is the distance between the ischial tuberosities. The
external pelvic measurements are:
c.1 Intercrestal diameter. The distance bet. the middle points of the iliac
crests.
c.2 Interspinous diameter. The distance between the superior iliac spines.
c.3 Intertrochanteric (Baudelocque's) diameter. The distance between the

trochanters of the femur.
H. Diagnostic Procedures and Laboratory Exams
1. Complete blood count (CBC) – to detect presence of anemia

- hematocrit count
- hemoglobin
- leukocyte count
- platelet count
2. Genetic Screen – to detect common ethnically inherited disease

3. VDRL or RPR – serologic test for syphilis
4. MSAFP – detects presence of neural or abdominal defect and chromosomal
anomaly
5. Indirect Coombs test – determines whether Rh antibodies are present in a Rh
negative woman
6. HIV screening
7. Antibody titers for rubella and hepatitis B
8. Diabetes mellitus universal screening
9. Blood typing including Rh factor
10. Urinalysis
11. Tuberculosis screening (Mantoux test)
12. Interferon-gamma release assay – uses blood serum
13. Ultrasonography
I. Computation of the Expected Date of Delivery (EDD)
Pregnant women generally want to know when the baby is coming or the
"due date." The ability to detect the date of delivery is an essential nursing
competency needed by anyone dealing with maternity clients.
The Nagele's Rule is the standard method used to predict the length of a
pregnancy. To calculate the EDD by this rule, count backward three (3) calendar
months from the first day of the last menstrual period (LMP) and add 7 days.
Consider the month in numerical term. (For the first 3 months of the year, add 12
to the numerical value e.g. January: 1 + 12 = 13).
Example A. LMP is January 5
Numerical value of January is 13: so,
13 5
-3
------------
5
+7
-------------
10 12 EDD is October 12
Example B.
LMP is September 12
Numerical value of September is 9, so:
9 12
-3
-------------
12
+7
-------------
6 19 EDD is June 19
HEALTH MAINTENANCE DURING PREGNANCY
Ideally a pregnant mother should follow the schedule of clinic visits:
First 7 months – once a month

7th and 8th month – every other week
9th month until delivery – every week
A. Measurement of Fundal Height

Place the zero line of the tape measure on the anterior border of the symphysis
pubis and stretch tape over midline of abdomen to top of fundus.
The tape should be brought over the curve of the fundus.
Purposes:
a. Check pregnancy is progressing at the expected rate
b. Estimate AOG (McDonald’s Rule)
Formula: Height of fundus (cm) x 2/7 = gestation in lunar month

Height in fundus (cm) x 8/7 = gestation in weeks
B. Estimation of Fetal Weight
- using the fundic height (Johnson’s Rule)
Formula:
FH (cm) – n x K = fetal weight in gms
Where:
n = 12 if the fetal head is below the level of the ischial spine (engaged)
= 11 if the presenting fetal part is above the level of the ischial spine
= 1 is added to n for patients over 200 lbs
k = 155 (constant)
C. Estimation of Fetal Length
- use of Haase’s rule

- expressed in centimeter
Rule:
1. first 5 months of pregnancy, square the number of the month of pregnancy

2. from 6 months on multiply the number of the month by 5
D. Bartolomew’s Rule – estimates the growth of the fundic height
12 weeks – level of symphysis pubis

16 weeks – halfway between symphysis and pubis and umbilicus
20 weeks – level of umbilicus
24 weeks – two fingers above umbilicus
28-30 weeks – midway between umbilicus and xiphoid process
36 weeks – at the level of xiphoid process
40 weeks – two fingerbreadths below xiphoid, drops at 34 weeks level because
of LIGHTENING
E. Leopold’s Maneuver
This is a systematic abdominal palpation to determine position and

presentation of the fetus. It is done by about 32 weeks and over.
Nursing Care in Leopold's Maneuver
a. Explain the procedure.

b. Instruct client to empty the bladder. To make her more comfortable and fetal
contours are not obscured by a distended anterior urinary bladder.
c. Position in dorsal recumbent with knees flexed slightly to relax the abdominal
muscles from contracting.
d. Drape client to provide privacy.
e. Warm two hands by rubbing one against the other briskly before placing them
on the abdomen.
f. Palpate firmly but gently.
g. Inform the woman of results.
Maneuver 1:
Face head part of patient. Palpate upper abdomen to detect what lies in the fundus of
uterus.
a. Normally buttocks: soft, globular, non- ballotable
b. If head: hard, round, ballotable.
Maneuver 2:
Face head part of patient. Palpate the sides of the abdomen to detect the location of the
fetal back and fetal small parts.
a. Back: hard, smooth, resistant plane.
* The area of the fetal back is the best site for FHT auscultation
b. Small parts: Irregular, nodular with bony prominences
Maneuver 3:
Face head part of patient. Palpate the lower abdomen just above the symphysis pubis to
detect what occupies the pelvic inlet.
a. Normally if the head: hard, round and ballotable
b. Buttocks if breech presentation: soft, globular, non-ballotable
Maneuver 4:
Face the foot part of patient. Palpate the lower abdomen along the Poupart's ligaments
to detect degree of flexion, position, station.
a. If one of your hands met an obstruction above the ligament it is the fetal brow
b. If the fetus is in poor attitude, it will meet an obstruction on the same side as
the fetal back.
The learner will watch a video on performing Leopold’s maneuver

and outline the steps correctly after watching the video
https://www.youtube.com/watch?v=G-6x6Po5orc
F. Check Fetal Heart Rate
Funic souffle - refers to a soft blowing murmur caused by blood rushing through
the umbilical cord. 140 bpm
Uterine souffle – refers to a soft blowing by blood rushing through the large
vessels of the uterus. 80 bpm
Activity 1: Question and answer on the discussion board:
What benefits should a nurse cite when responding a patient’s

question “Why do I need to bother coming for prenatal care?”?
Activity 2:
The learner will be provided relevant data to compute for

the: expected date of delivery; age of gestation; estimated
fetal length and weight; estimated fundic height
G. Danger Signs of Pregnancy - It is important to instruct the pregnant woman about

the danger signs of pregnancy. Assure her you have no reason to think she is
going to experience any of these things, that you have every reason to believe she
is going to have a normal, uncomplicated pregnancy; but that if any of these things
should occur, she should inform or consult a doctor immediately.
1. Vaginal bleeding no matter how slight. This may mean abortion.
2. Persistent vomiting. This may lead to severe dehydration and fetal distress.
3. Chills and fever. This maybe an evidence of an intrauterine infection.

4. Sudden escape of fluid from the vagina. It is evident that the membrane
have ruptured and so mother and fetus are now both threatened.
5. Abdominal or chest pain. This may mean ectopic pregnancy: a separation

of the placenta; pre-term labor; appendicitis; ulcer or pancreatitis.
6. Danger signs of pregnancy - induced hypertension, like swelling of the face

or fingers, flashes of light or dots before the eyes, dimness or blurring of vision,
and severe continuous headache, decreased urine output, and rapid weight gain.
7. Increase or decrease fetal movement.
Activity 3. Practice Test.
A 10-item multiple choice quiz will be given through the poll results
of myCLASS Bigbluebutton.
PROMOTION OF NUTRITIONAL HEALTH DURING PREGNANCY
A woman's nutritional status at conception and during pregnancy have

direct bearing on her health as well as fetal growth and development. Ensuring
optimum nutrition for all childbearing women might not eliminate all the problems
of pregnancy, but it certainly makes an important contribution.
A fetus who is deprived of adequate nutrition early in pregnancy, then, will

be small for gestational age because of too few cells in the fetus's body; later on,
retarded growth is due to a normal number but smaller than usual size cells. To
be certain that early pregnancy deficiencies do not occur, women of childbearing
age should be especially encouraged to follow a balanced diet.
1. Take the diet history
A thorough assessment of the pregnant women's nutritional health

patterns is important before and nutritional planning can begin. Determining
not only whether the client is eating a "balanced" diet but what cultural,
environmental and social lifestyle factors affect her eating habits.
2. Provide nutritional instruction

The recommended dietary allowance for pregnant women vary with
weight, age, health activity and health status and therefore must be used
as guide.
a. Increase calorie intake for energy
A total caloric intake of 2500 cal/day is recommended to meet the

increased needs of pregnancy. This much of energy is essential for
deposition, synthesis and maintenance of new tissue. Inadequate calories
results to utilization of protein for energy instead of it being used for fetal
growth and development. Prentice and co-workers (1983, 1988) in their
investigation of the impact of calorie supplementation on birthweight of
infants of Gambian women, identified a three fold decrease in the frequency
of low-birthweight infants with calorie supplementation of pregnant women.
b. Increase protein intake
Protein is necessary for growth and repair of maternal and fetal

tissues for increased maternal blood volume and for fetal growth and
development. During pregnancy, the intake of protein should be increased
to 60 g per day.
c. Decrease fat intake
Fats is difficult to digest and can contribute to gastrointestinal

discomfort in early pregnancy. A daily quota of 90 g fat coming mainly from
animal sources would be a reasonable amount. (Myles, 1981)
d. Decrease carbohydrates intake
The human placental lactogen (HPL), the major insulin antagonist in

pregnancy spares maternal glucose for fetal use. To prevent excessive
fetal growth, the woman's carbohydrates should be decreased during the
second and third trimesters during which time there is an increase in HPL
secretion.
e. Increase major minerals and vitamins intake
1) Iron - is the most important mineral that must be taken in supplementary

amount. the total iron needed for pregnancy is about 800 to 1000 mg. Of
this total amount, 50% (500 mg) is needed for hemoglobin formation, the
result of increased maternal blood volume in pregnancy; 30% (300 mg) is
transferred to the placenta and the fetus to provide for iron store in the liver
to last for 3 to 6 months; and 20% (200 mg) is to replace natural loses in
skin, sweat and hair.
Liver is an excellent source of iron. Other red meats; beef;
heart and kidneys; green leafy vegetables; cereals; whole or
enriched grain, nuts, and legumes; dried fruits and eggs are
appropriate.
To enhance iron utilization and absorption, ascorbic acid (Vit.

C) in the form of fruit juices is essential.
2) Calcium and phosphorus - To supply adequate minerals for bone

formation, the daily requirement of calcium and phosphorus is 1,200 – 1,500
mg/day. Tooth formation begins as early as 8 weeks and bones begin to
calcify at 12 weeks in utero. Milk and milk products such as cheese are the
best sources of calcium and phosphorus.
Almost all of the calcium requirement in pregnancy is utilized

by the fetus. The expectant mother retains about 30 g of calcium
during pregnancy and most of which is deposited in the fetus late in
pregnancy (Pitkin, 1985).
3) Iodione. This is essential for the formation of thyrozine and therefore

for the proper functioning of the thyroid gland. The daily need for iodine
is 175 ug. Pharaoh and associates (1971,in their study of New Guinean
pregnant women demonstrated that intramuscular injection of iodized oil
early in pregnancy could prevent cretinism is infants.
4) Vitamin C - The recommended Vit. C per day is 80-100 mg. A

reasonable diet rich in citrus fruits, tomatoes, green leafy vegetables and
green peppers may be enough to provide this amount.
Excess Vitamin C supplementation (1 g/day) may prove harmful

in pregnancy as shown by Cochrane (1965) who identified withdrawal
scurvy in normally fed infants whose mothers received large doses of
Vit. C during pregnancy. Likewise, excess Citamin C can result to a
functional deficiency in Vitamin B12 by interfering with its absorption and
metabolism and which cannot be overcome by Vitamin B12
supplementation (Herbert and Jacob,1974).
5) Vitamin B12. To help in red blood cell formation and to provide a

coenzymes in protein metabolism, 4 ug Vitamin B12 daily is recom-
mended.
2. Plans for improving nutrition patterns of the pregnant woman must be

discussed with the entire family as well and should be within the woman's
lifestyle, preferences, financial resources customs and cultural desires, while
those foods that provide the essential nutrients must be encouraged.
4. Encourage pregnant women to increase fluid intake for good kidney function
and eat foods rich in fiber to prevent constipation. Fiber also has the
advantage of lowering cholesterol levels and may remove carcinogenic
contaminants from the intestine.
5. Educate the pregnant woman regarding foods to be avoided during

pregnancy, such as:
a. Foods with caffeine. Caffeine is a central nervous system stimulant

capable of increasing heart rate, urine production in the kidney, and
secretion of acid in the stomach. A daily intake of caffeine of more than
300 mg has been associated with low birth weight (Caan et. al., 1989).
For this reason, the Food and Drug Administration has issued a formal
warning to women to limit their caffeine intake during pregnancy.
b. Alcoholic beverages should not be ingested by the pregnant woman

because of their potentially teratogenic effects on the fetus.
c. Foods with artificial sweeteners. The use of saccharine is not

recommended during pregnancy because it is eliminated slowly from
the fetus (London, 1988).
d. Weight loss diets
6. Advise the pregnant woman not to smoke. Smoking results to small-for-

gestational age (SGA) infants which is the effect of:
a. vasoconstricting nicotine
b. decreased plasma volume
c. increased carbon monoxide level in the blood functionally
inactivates oxygen
d. decrease caloric intake
1. Activity 4. Critical Thinking Care Study – Written Activity
A 25-year-old woman is 5 months pregnant. She tells the

nurse “she did not intentionally want” to get pregnant. She
began feeling nauseated early in pregnancy and has
continued to feel this way into her 5th month. She vomits
three or four times a day. Her 24-hour recall: breakfast:
none, lunch: 1 cup of coffee, a few dry crackers, dinner: 1
slice of pizza, 1 glass of milk, snack: 1 orange
She knows, she is eating very little but insist on the nurse that is the amount she
usually eats and is all right for her.
1. Is her food intake adequate for pregnancy?
2. What common steps would you want to try to decrease her feeling of
nausea?
3. What are some nursing diagnoses applicable for the patient?
HEALTH PROMOTION DURING PREGNANCY
1. General hygiene. Daily bathing is recommended not only because of leukorrhea

but also because of increased sweating during pregnancy.
2. Exercise. Women need exercise during pregnancy to prevent circulatory stasis,

to promote comfort, to facilitate labor and delivery and to strengthen muscles.
3. Sexual Activity. Women who have a history of repeated abortion may be advised
to avoid coitus during the time of the pregnancy when the previous abortions
occurred. Women whose membranes have ruptured or who have vaginal spotting
should be advised against coitus until they are examined in order to prevent
infection. Otherwise, there are no sexual restrictions during pregnancy.
4. Travel. Early in pregnancy, there are literally no restrictions except those who are
susceptible to motion sickness. Late in pregnancy, travel plans should take into
consideration the possibility of early labor.
5. Work. Unless the woman's job involves exposure to toxic substance, lifting heavy
objects, other kinds of excessive physical strain, or long periods of standing or
having to maintain body balance, the pregnant woman may continue to work.
6. Importance of a well-balanced diet as previously discussed.
7. Dental care. It is important that women continue good toothbrushing habits

throughout pregnancy. Gingival tissue tends to hypertrophy during pregnancy.
8. Breast care. All women should observe a few precautions during pregnancy to
prevent loss of breast tone which can result in pendulous breasts later in life that
can be painful.
Activity 5. Exit tickets using a padlet

At the end of the discussion, the learner will answer a quick
question about health promotion during pregnancy.
Provision of Health Teachings
Minor discomforts of pregnancy like:
1. Nausea and vomiting

- Take dry carbohydrates (e.g. crackers, toast) 30 minutes before getting up
in the morning.
- Refrain from taking fatty foods
- Take small frequent meals
- Increase fluids, but best tolerated between meals
* Excessive vomiting (hyperemesis gravidarum) is hazardous to health of fetus

and mother. Consult physician.
2. Heartburn / Pyrosis
- Take small frequent meals
- Refrain from taking indigestible gas forming fatty and spicy foods
- Maintain an upright position to prevent regurgitation of gastric contents in
the esophagus.
3. Constipation
- Increase fluid intake at least 6-8 glasses a day
- Increase roughage or bulk in the diet. Take 3-4 servings of fruits and
vegetables a day
- Have regular exercise like walking
- Encourage regular bowel movement
4. Easy Fatigability
- Have enough rest and sleep in modified Sim's position
- Wear comfortable dress and shoes
5. Leg Varicosities
- Wear support or elastic stockings
- Elevate legs and hips at intervals for 15-20 mins. twice a day
- Avoid prolonged sitting and standing
- Avoid wearing round garters
6. Muscle Cramps
- Avoid fatigue of muscles, change position frequently
- Don't wear constricting garters
- Hyperextension of involved muscles
- Soaking in warm water or using heating pads.
7. Hemorrhoids
- Avoid straining at stools. Prevent constipation
- Avoid spicy foods
- Ice packs or warm water sitz bath to promote comfort
- Prolapsed hemorrhoids are lubricated and may be replaced gently
8. Palpitations
- Refrain from making sudden, rapid movements at anytime
- Enough rest
9. Leukorrhea
- Daily bath and good perenial hygiene every after voiding
- Wear perenial pad for more comfort
10. Frequency of Urination

- Increase fluids to replace losses except before bedtime
- Use perenial pad to absorb leakage
- Flush perineum every after voiding
- Explain that voiding frequently is a normal phenomenon.
11. Pedal Edema

- Avoid prolonged sitting and standing. Elevate legs at intervals
- Wear comfortable shoes
- Avoid round garters
12. Backache
- Maintain good posture
- Wear flat or low-heeled shoes for better balance
- Wear firm supportive maternity girdle
- Use a firm and comfortable bed
Activity 6. Question and answer on the discussion board.
Prepared by:
NCM 0107 First Cycle Instructors
Reviewed by:

Module 4: Care of the Mother and the Fetus during the Perinatal Period
(Intrapartal Care – Part 1) page 326
Intrapartal Care- medical supervision given to clients undergoing true labor.
Labor and delivery is the culmination of the childbearing cycle and is an intense period during
which the products of conception are expelled from the uterus. It calls for all the psychologic and
physical coping methods that a woman has available to her. No matter how much childbirth
preparation she has had, nor how many times she has already gone through the experience, the
woman will require nursing care that is efficient and family focused, because childbirth marks the
beginning of a new family structure.
Nursing interventions to make labor safe, comfortable, and effective are vital. Any support
person should be treated with respect and should be included in all phases of the process, whenever
possible. Labor and delivery are enormous emotional and physiologic accomplishments for a woman
and her support person, and interventions that make the experience more positive and memorable for
them will mean a lot to future family interactions.
Module Learning Outcomes

1. Assess mother, child, adolescent with the use of specific methods and tools to address existing
health needs.
2. Formulate nursing diagnosis/es focusing on health promotion and disease prevention related to
mother, child, and adolescent’s health.
3. Implement safe and quality interventions addressing health needs affecting women from
pregnancy to postpartum and children from perinatal to adolescent stage.
4. Conduct individual/group health education activities based on the priority learning needs of mother,
child, adolescent.
5. Evaluate with the client the health outcomes of nurse-client working relationship.
6. Institute appropriate corrective actions to prevent or minimize harm arising from adverse effects.
Pain Pathway:
Ending of the small peripheral nerve fibers detect a stimulus > Transmit to the cells in the dorsal horm
of the spinal cord > Impulses pass through a dense, interfacing network of cells in the spinal cord
(substantia gelatinosa) > A synapse occurs that returns the transmission to the peripheral site through
motor nerve > Impulse then continues in the spinal cord to reach the hypothalamus and cortex of the
brain > …
Principles:
(Non pharmacologic methods are anchored according to these 3 principles:)
A woman needs to come into labor informed about what causes labor pain and prepared with
breathing exercises to use to minimize pain during contractions.
A woman experiences less pain if her abdomen is relaxed and the uterus is allowed to rise freely
against the abdominal wall with contractions.
Using the gating control theory of pain perception- distraction techniques
Methods to Manage Pain in Childbirth
A. Gate Control Mechanisms – involves halting the impulse at the level of the spinal cord so the
impulse is never perceived at the brain level as a pain- a process similar to closing a gate
occurs.
3 Techniques:
a. Cutaneous stimulation - ability of the small nerve fibers at the injury site to transmit pain
impulses appears to decrease if the large peripheral nerves next to the injury site are
stimulated
Example: Rubbing an injured part; applying TENS; heat/cold; effleurage
b. Distraction- if the cells of the brain stem that register an impulse as pain are pre-occupied
with other stimuli, a pain impulse will not register.
Example: Breathing techniques- increases oxygenation-decreasing pain
c. Reduction of anxiety- pain are perceived more quickly if anxiety is also present
d. Effleurage- french for “light abdominal massage”
- apply a little pressure
e. Focusing/ Imagery- sensate focus like photograph of her husband/ children, a graphic
design, or something that appeals to them
B. Bradley Method (Partner-coached) Method

- Pregnancy is a joyful natural process and stresses importance of the husband
- Pain is reduced by: abdominal breathing, walking during labor
C. Psychosexual Method (Sheila Kitzinger)

- Stresses that pregnancy, labor and birth and the early newborn period are important points
in woman’s life cycle
- The program involved conscious relaxation and levels of progressive breathing encourages
the woman “to flow with” rather than struggle against contractions of labor.
D. Grantly Dick-Read Method

- Fear leads to tension and tension leads to pain
- Achieves relaxation and reduced pain in labor by using abdominal breathing during
contractions
E. Lamaze Method (Ferdinand Lamaze)

- Based on stimulus-response conditioning, To be effective, full concentration on breathing
exercises during labor should be observed.
- Psychoprophylactic method: preventing pain during labor (prophylaxis) by the use of mind
(psyche)
6 Major Concepts of Lamaze:
1. Labor should begin on its own, not induced.
2. Woman should walk, move around, and change position.
3. Woman should bring loved one, friend for continuous support.
4. Interventions that are not medically necessary should be avoided.
5. Women should be allowed to give birth in other positions.
6. Mother and baby should be kept together after birth.
Best time for couples to prepare: DURING PRENATAL CARE
Relaxation Techniques
1. Conscious relaxation- relax the body so woman does not remain tense and unnecessary muscle
strain and fatigue during labor
2. Cleansing breath- woman breaths deeply and then exhales deeply
3. Consciously controlled breathing- used in the progress of labor
LEVEL 1: slow chest breathing (comfortable but full respiration 6-12 bpm)
LEVEL 2: breathing lighter than level 1, rib cage expands lightly the diaphragm barely moves, RR up
to 40/min
: good for contractions when cervical dilation is 4 & 6 cms. (through internal examination)
LEVEL 3: Breathing is shallow mostly at the sternum, rate 50-70 bpm. Keep the tip of the tongue
against the roof of her mouth (prevents the dryness of the oral mucosa). Cervical dilation of 7 & 10
cms.
LEVEL 4: uses “pant-blow-pattern”= 3-4 quick breaths then a forceful exhalation. “choo-choo” “hee-
hee-hee-hoo”, done during crowning (labas ulo na baby) (may prevent vaginal lacerations)
LEVEL 5: chest panting is continuous, very shallow, 60 bpm. Prevents pushing before dilation (done
as crowning progresses) (do not let the mother push or bear down without uterine contractions= may
cause fatigue)
Types of Birth Setting
Besides how to prepare for labor, choosing a birth setting is another important decision that a couple
needs to make during pregnancy (Alliman & Phillippi, 2016).
1. Hospital Birth (labor-birth-recovery postpartum rooms or labor-birth-recovery)

- Bed- will become a birthing chair when delivery starts (Philippines)
- Dorsal lithotomy/ Dorsal recumbent
2. Alternative Birthing Center – wellness-oriented childbirth facilities designed to remove
childbirth from the acute care hospital setting while providing enough medical resources for
emergency care should complication of labor and birth arises.
- woman is encouraged to express her own needs and wishes during labor, she can choose a
birth position, bring her own music or distraction object and partner can perform such tasks
such as cutting the cord, woman remains 4 to 24 hours after birth
3. Home Birth – it allows for family integrity, puts responsibility on the woman to prepare the
house and take care of her infant after birth.
4. Children attending birth
Alternative Methods of Birth
1. Leboyer – from a warm, fluid-filled intrauterine environment to a noisy, air-filled brightly lit birth
room creates a major shock.
- The birthing room is darkened so there is no sudden contrast in light, keep room pleasantly
warm, soft music is played, infant handled gently, cord is cut late, place in a warm-water
bath.
- Imitate intrauterine environment
2. Hydrotherapy and Water Birth
- Reclining or sitting in warm water labor can be soothing, feeling of weightless and
relaxation can reduce discomforts (ex. Labor in shower, spa tubs)
- Disadvantages: water contaminated with mother’s fecal material, aspiration, maternal
chilling
3. Unassisted Birthing- freebirthing or couple birth = woman giving birth without healthcare
provider supervision
- it differs from home birth.. no accompaniment
- it needs no medical supervision
THE LABOR PHENOMENON
- is a series of events by which the uterine contractions and abdominal pressure expel a fetus and
placenta from a woman’s body
- a series of continuous, progressive contractions of the uterus which help the cervix to open (dilate)
and to thin (efface), allowing the fetus to move through the birth canal
THEORIES OF LABOR ONSET
Labor normally begins when a fetus is sufficiently mature to cope with extrauterine life yet not
too large to cause mechanical difficulties in delivery. However, the trigger that converts the random,
painless Braxton Hicks contractions into strong, coordinated, productive labor contractions is
unknown. A number of theories have been proposed to explain why labor begins. These include:
1. Uterine Stretch Theory. Any hollow body organ when stretched to capacity will necessarily
contract and empty because of pressure on nerve endings and increased irritability of the uterine
musculature.
2. Oxytocin Theory. Oxytocin is an effective stimulant of uterine contractions in late pregnancy

and is commonly used to induce or augment labor.
Nipples are stimulated
Nerve impulses travel from nipple to the hypothalamus
Stimulates posterior pituitary gland to produce oxytocin
Causing uterine contraction
3. Progesterone Deprivation Theory. Progesterone is believed to inhibit uterine

motility/contraction. The onset of labor in humans might result from withdrawal of progesterone
at a time of relative estrogen dominance. (Pregnancy= high progesterone < prevents premature
labor)
Progesterone- inhibits uterine contraction
Progesterone deprivation
Onset of labor
Withdrawal of progesterone
At a time = estrogen predominance (uterine contraction)
4. Prostaglandin Theory. The relative progesterone deprivation and estrogen predominance set
off production of cortical steroids which act on lipid precursors to release arachidonic acid, and in
turn, increase the synthesis of prostaglandins. Prostaglandins, like oxytocin are known to
stimulate uterine contractions.
Progesterone Deprivation and Estrogen Predominances
Set-off production of cortical steroids
Act on lipid precursors

Releases arachidonic acid
Increases synthesis of prostaglandins (causes pain and inflammation and uterine contraction)
5. Theory of Aging Placenta. The decrease of nutrients and blood supply in the aging placenta
causes uterine contractions.
Theory of aging placenta
Decrease nutrients
Decrease blood supply
Uterine contractions bc of the irritation of the patients due to lack of nutrients
COMPONENTS OF LABOR
A successful labor depends on three integrated concepts:
1. Passageway. This refers to the route the fetus must travel from the uterus through the cervix and
vagina to the external perineum; because these organs are contained inside the pelvis, the
fetus must also pass between the pelvic ring.
- Type of maternal pelvis
- Ability of the cervix to dilate and efface
- Route of the fetus to travel (intauterine-extrauterine)
- Size of the maternal pelvis- diagonal conjugate (AP diameter of the inlet) and transverse diameter
outlet
*11.5-12 cm - size of diagonal conjugate dapat minemeasure parin kahit gynecoid
* If gynecoid tas 8 cm lang = Cannot deliver = Cephalopelvic disproportion= fetal head bigger than
maternal pelvis= Cesarean section
2. Passenger. If the fetus is of appropriate size and in an advantageous position and presentation.
- fetus, fetal position, presentation
I. Fetal head- the body part that has widest diameter
II. Fetal skull-
A. Cranium- uppermost portion of the skull
- Frontal The four superior bones
- Two parietal
- Occipital
- Sphenoid
- Ethmoid
- Two temporal bones
III. Sutures - are membranous spaces between the cranial bones
- allow for molding (overlapping of the bones)
A. Sagittal suture line- joins the two parietal bones of the skull
B. Coronal suture- joins the frontal bone and the two parietal bones
C. Lamboid suture- joins the occipital bone and the two parietal bones
D. Frontal (mitotic) suture- joins the two frontal bones, becomes the anterior
continuation of the sagittal suture
Molding- changes in shape of the fetal skull produced by the force of the uterine contractions
pressing the vertex against the not-yet dilated cervix
*Skull sutures are closed at this point
IV. Fontanelles- intersections of the cranial sutures (2 fontanelles)
Anterior Fontanelle
Diamond Shape
It permits growth of the brain by remaining unossified for 12-18 months
Posterior Fontanelle
Lies in the junction of the lamboidal and sagittal sutures
Triangular shaped and closes within 8-12 weeks/ 3-4 months

V. Other important landmarks of the fetal skull:
A. Mentum- fetal chin
B. Sinciput- anterior area know as the brow
C. Vertex- the area between the anterior and posterior fontanelles
D. Occiput- the area of the fetal skull occupied by the occipital bone, beneath the posterior
fontanelle
Diameter of the fetal skull
- The shpae of the skull causes it to be wider in anteroposterior diameter than in its transverse
diameter to fit the birth canal
- Measurement: AP diameter of the skull is wider than the transverse diameter.
1. Transverse diameter - Bi-parietal : 9.25 cm
- Bitemporal : 8 cm
2. Anteroposterior diameter- Suboccipitobregmatic : narrowest diameter is from the inferior
aspect of the occiput to the center of the anterior fontanelle (approximately
9.5 cm)
- Occipitofrontal : measured from the bridge of the nose to the occipital
prominence (approximately 12 cm)
-Occipitomental : widest AP diameter measured from the chin to the
posterior fontanelle (approximately 13.5 cm)
FETAL PRESENTATION AND POSITIONS

(Attitude) Fetal Attitude- describes the degree of flexion a fetus assumes during labor or the relation
of the fetal parts to each other
A. Good Attitude= complete flexion
Spinal column is bowed forward

The head is flexed forward so much that the chin touches the sternum
The arms are flexed and folded on the chest
The thighs are flexed onto the abdomen
The calves are pressed against the posterior aspect of the thighs
* normal fetal position that is advantageous for birth because it helps a fetus present the smallest
anteroposterior diamater because it puts the whole body into an ovoid shape, occupying the smallest
space possible
B. Military position = fetus is in moderate flexion, the chin is not touching the chest but it is in an alert
= causes next-widest anteroposterior diameter, the occipital diameter, to present
to the birth canal
C. Brow= the fetus is in partial extension presemts the brow of the head in the birth canal
D. Face presentation= fetus is in poor flexion, the back is arched, the neck is extended, and in
complete extension
Engagement- refers to the setting of the presenting part of a fetus far enough to the pelvis to be at the
level of the ischial spine
Station- refers to the relationship of the presenting part of a fetus to the level of the ischial spine
0- Level of the ischial spine (synonymous w/ engagement)
-1 to -4 above the ischial spine
*-4 floating
+1 to +4 below the ischial spine
*+3 to +4 synonymous to crowning
Vacuum Extraction Delivery- Fetus at +1 Station in Occiput Anterior Presentation
Fetus at +2 Station in Occiput Posterior Presentation
Fetal lie- refers to the relationship of the cephalocaudal axis (spinal column) of the fetus to the
cephalocaudal axis of the woman
Longitudinal lie- cephalocaudal axis of the fetus is parallel to the woman’s spine
Transverse lie- cephalocaudal axis of the fetal spine is at the right angles to the woman’s spine
FETAL PRESENTATION
- determined by the fetal lie and by the body part of the fetus that enters the maternal pelvis
first.
- it may be cephalic, breech, shoulder
A. Cephalic presentation- is the most frequent presentation occuring as often as 95%
Aka Vertex Presentation - is the most common type of presentation
- the fetal head is completely flexed onto the chest
- the smallest diameter of the fetal head
(suboccipitobregmatic presents to the maternal pelvis)
- occiput is the presenting part
Caput succedaneum- during labor the area of the fetal
skull that comes in contact with the cervix and often
becomes edematous from the continued pressure against
it
Cephalhematoma- is when blood is collected between
the periosteum of the skull bone and the skull bone itself,
so it does not cross suture lines
B. Military presentation - the fetal head is neither flexed or extended
- the occipitofrontal diameter presents to the maternal pelvis
- the top of the head is the presenting part
C. Brow presentation - the fetal head is partially extended
- the occipitomental diameter, the largest anteroposterior diameter,
is presented to the maternal pelvis
- the sinciput is the presenting part
D. Face presentation - the fetal head is hyperextended (complete extension)
- the face is the presenting part
E. Breech Presentation -COMPLETE BREECH
: the fetus has thighs tightly flexed on the abdomen; both the
buttocks and the tightly flexed feet present to the cervix
: good attitude and longitudinal lie
-FRANK BREECH
: attitude is moderate because the hips are flexed but the knees are
extended to rest on the chest,
: buttocks alone present to the cervix
: lies longitudinal and moderate attitude
-FOOTLING BREECH
: neither the thighs nor lower legs are flexed. If one foot present, it
is a single-footling breech; if both present, it is a double footling
breech
- Longitudinal lie, poor attitude
F. Shoulder presentation - In transverse lie, a fetus lies horizontally in the pelvis so that the
longest fetal axis is perpendicular to that of the mother.
- The presenting part is usually one of the shoulders (acromion
process), an iliac crest, a hand or an elbow
- caused by relaxed abdominal wall from grand multiparity, allows
unsupported uterus to fall forward, pelvic contraction, the horizontal
is greater than the vertical space, placental previa (limit a fetus
ability to turn)
FETAL POSITION
- the relation of the fetal presenting part to a specific quadrant of the woman’s pelvis
3 notations to describe the fetal position:
1. Right (R) or Left (L) side of the maternal pelvis
2. The landmark of the presenting part: Occiput (O), Mentum (M), Sacrum (Sa), or Acromion process
(A)
3. Anterior (A), Posterior (P), or transverse (T), depending on whether the landmark is in front, back,
or side of the pelvis--
Positions- indicated by an abbreviation of three letters
First letter- defines whether the landmark is pointing to the mother’s R or L
Middle letter- denotes fetal landmark (O,M,Sa,A)
Last letter- whether the landmarks point A,P,T
Most common:
Left Occipitoanterior
Right Occipitoanterior
Importance of Determining Fetal Presentation and Position

Could prevent putting a fetus at risk due to proportional differences between fetus and pelvis
Membrances also are more apt to rupture early, increasing possibility of infection
Determine risk of fetal anorexia and meconium staining leading to respiratory distress at birth
4 methods determining fetal position, presentation, & lie:
Inspection and palpation (Leopold’s maneuver)
Vaginal examination
Sonography
Ausculation of fetal heart tones
3. Power. This is supplied by the fundus of the uterus and implemented by uterine contractions, a
process that causes cervical dilatation and the expulsion of the fetus from the uterus.
- uterine contraction
4. Psyche. The woman’s psyche is preserved so afterward labor can be viewed as a positive
experience.
- positive experience a woman may bring during labor process
Mechanisms of Labor
Passage of a fetus through the birth canal involves a number of different position changes to keep the
smallest diameter of the fetal head always presenting to the smallest diameter of the birth canal.
These position changes are termed as the Cardinal movements.
The learner will watch a video on the cardinal movements of labor

https://www.youtube.com/watch?v=odHEQNGph2Y – Cardinal movements
Descent>Engagement>Increased flexion>Internal rotation>Extension>Restitution>External
rotation>Delivery of posterior shoulder>Delivery of anterior shoulder>Delivery of trunk and legs
https://www.youtube.com/watch?v=ybWQCkElMiI – Cardinal movements of labor
Engagement>Descent>Flexion>Int. Rotation>Extension>Ext. Rotation>Expulsion
1. Descent/flexion
Flexion- fetal head reaches the pelvic floor, the head bends forward onto the chest, making the
smallest anteroposterior the one presented to the birth canal
2. Internal rotation
- the head enters the pelvis with fetal anteroposterior head diameter in a diagonal or
transverse position. The head flexes as it touches pelvic floor and the occiput rotates until it is
superior or just below the symphysis pubis
3. Extension begins
Extension- the occiput is born, the back of the neck stops beneath the pubic arch and acts as a
pivot for the rest of the head
4. External rotation
- immediately after the head of the infant is born, the head rotates from the AP position
assumed to enter the outlet back to the diagonal/ transverse position
5. Extension complete
6. Expulsion
- once shoulders are born, the rest of the baby is born easily and smoothly because of the
smaller size
D’FIERE- is the downward movement of the biparietal diameter of the fetal head within the pelvic inlet
POWERS OF LABOR
Fundus ---> Implements uterine contraction ---> Causing cervical dilation ---> Expulsion fetus &
placenta
* After dilatation of the cervix, the primary power is supplemented by the use of abdominal muscles.
PREMONITORY SIGNS OF LABOR
1. Lightening. This is the descent/settling of the presenting part into the pelvic inlet which happens
10-14 days before labor in primigravida and 1 day before labor in a multipara. And when the
largest diameter of the presenting part passes the pelvic inlet, the head is said to be
"engaged." However, lightening is heralded by the following signs:
a. Relief of dyspnea
b. Relief SOB/ diaphragmatic pressure
c. Relief of abdominal tightness
d. Increased frequency of voiding
e. Increased amount of vaginal discharge
f. Increased lordosis as the fetus enters the pelvis and falls further forward. Walking is more
difficult and leg cramping may increase
g. Increased varicosities
h. Shooting pains down the legs because of pressure on the sciatic nerve
2. Increased Braxton Hicks's contractions in the last week or days before labor.
These are false labor contractions, painless, irregular, abdominal and relieved by
walking, and are also known as practice contractions.
3. A sudden burst of maternal energy/activity because of hormone epinephrine. This is meant to

prepare the body for the “labor” ahead.
Increased Level of Activity – awaken full of energy because of the increase in epinephrine, release
is initiated by increase in progesterone produced by the placenta
4. Slight decrease is maternal weight. Loss of weight is about 2-3 lbs. One to two days before the
onset of labor because of the decrease in progesterone level and probably loss of appetite.
5. Softening /”ripening” of the cervix. (butter soft)
Differences between True and False Labor Contractions

FALSE CONTRACTIONS TRUE CONTRACTIONS
Begin and remain irregular Begin irregularly but become regular and
predictable
Felt first abdominally and remain confined to the Felt first in lower back and sweep around to the
abdomen and groin abdomen in a wave
Often disappear with ambulation and sleep Continue no matter what the woman’s level of
activity
Do not increase in duration, frequency, or Increase in duration, frequency, and intensity
intensity
Do not achieve cervical dilation Achieve cervical dilation
SIGNS OF TRUE LABOR

The more women know about true labor signs, the better, because they will be able to
recognize them. True labor is said to occur when the following signs are observed:
1. Uterine Contractions. The surest sign that labor has begun is the initiation of effective,
productive, involuntary uterine contractions.
There are 3 phases of uterine contractions:
a. Increment / Crescendo – intensity of the contraction increases.

b. Apex / Acme – the height or peak of the contraction.
c. Decrement / Decrescendo – intensity of the contraction decreases.
*Interval- End of one contraction to the beginning of the next contraction
Characteristics of Contractions:
1. Frequency of contraction – this is timed from the beginning of one contraction to the
beginning of the next.
2. Duration of contraction – this is time from moment the uterus first begins to tighten until
it relaxes again.
*Interval- End of one contraction to the beginning of the next contraction
*as labor progresses, interval decreases
3. Intensity of contraction – it may be mild moderate or strong at its acme.
a. Mild contraction (tip of the nose) – the uterine muscle becomes somewhat tense, but
can be indented with gentle pressure.
b. Moderate contraction (forehead) – the uterus becomes moderately firm and a firmer
pressure is needed to indent.
c. Strong contraction (wood) – the uterus becomes so firm that it has the feel of wood
like hardness, and at the height of the contraction, the uterus cannot be indented
when pressure is applied by the examiner’s finger.
2. Uterine Changes. As labor contractions progress, the uterus is gradually differentiated into two
distinct portions. These are distinguished by a ridge formed in the inner uterine surface, the
physiologic retraction ring.
Upper uterine segment – this portion becomes thicker and active, preparing it to exert the strength
necessary to expel the fetus during the expulsion phase.
Lower uterine segment – this portion becomes thin walled, supple, and passive so that the fetus
can pushed cut of the uterus easily.
Contour of the uterus changes from a round ovoid to a structure markedly elongated in a vertical
diameter than horizontally. This serves to straighten the body of the fetus and place it in better
alignment to the cervix and pelvis.
Duration of the contractions increases from 20-30 secs to 60-90 secs
Contour Changes: upper uterine portion becomes thicker and active

Preparing it to be able to exert strength necessary to expel the fetus
Expulsion phase of labor is reached
The lower uterine segment becomes thin-walled, supple, and passive to pushed out the fetus
easily in the uterus
The upper/lower segment becomes marked a ridge on the inner uterine surface (PHYSIOLOGIC
RETRACTION RING)
The contour of the overall uterus changes from a round, ovoid structure to elongated -- vertical
diameter greater than horizontal
This lengthening serves to straighten the body of the fetus
Placing better alignment with the cervix and pelvis
As the uterus contracts, round ligaments move keeping the fundus forward, assisting the fetus in
good alignment with the cervix
Elongation of the uterus exerts pressure against the diaphragm
Uterus is taking control of a woman’s body
Cervical Changes: Effacement (shortening and thinning of the cervical canal)
Dilatation: enlargement and widening of the cervical canal
Show: blood-tinged mucus discharged from the vagina due to the pressure of the descending fetal
part on the cervical capillaries
(clear-contains vernix; green-contaminated with meconium; yellow- blood incompatibility; pink-

bleeding)
1. Cervical changes. There are 2 changes that occur in the cervix.
Effacement. This is the shortening and thinning of the cervical canal to paper-thin edges to
primiparas, effacement is accomplished before dilatation begins while with multiparas,
dilatation may proceed before effacement is complete.
Dilatation. This refers to the enlargement of the cervical canal from an opening a few millimeters
wide to one large enough (approximately 10 cm.) to permit passage of the fetus.
Dilatation occurs for two reasons. First, uterine contractions gradually increase the diameter of
the cervical canal lumen by pulling the cervix up over the presenting part of the fetus. Second,
the fluid-filled membranes press against the cervix.
4. Show. This is the blood-tinged mucus discharged from the vagina because of pressure of the
descending fetal part on the cervical capillaries, causing their rupture. Capillary blood mixes
mucus when operculum is released.
Rupture of the membranes of bag of waters. This is a sudden gush or a scanty slow seeping of
amniotic fluid from the vagina. The color of the amniotic fluid should always be noted. At term,
this is clear, almost colorless and contains white specks of vernix caseosa. Green staining means
it has been contaminated with meconium, a sign of fetal distress. Yellow staining may mean
blood incompatibility while pink staining may indicate bleeding.
Once membranes have rupture, labor is inevitable, meaning to say that uterine contractions
will occur within next 24 hours. The initial nursing action is for patients with ruptured
membranes are:
1. Notify physician.
2. Lie patient to bed to ensure that the fetus is not impinging on the cord.
3. Check the fetal heart rate to determine for fetal distress.
4. If the patient claims she can feel a loop of the cord coming out of her vagina (umbilical
cord prolapse), lower the head of the bed (Trendelenberg postion) in order to release
pressure on the cord. Also apply sterile saline-saturated gauze to prevent drying of the
cord, if needed.
If labor does not occur spontaneously at the end of 24 hours after membrane
rupture, it will be induced, provided the woman is estimated to be at term.
POSITIONS DURING LABOR AND BIRTH
LENGTH OF LABOR:
Comparison :
Stage Primi Multi
First stage 12 1/2 hours 7 hrs and 20 mins
Second stage 80 mins 30 mins
Third stage 10 mins 10 mins
TOTAL 14 hours 8 hours
STAGES OF LABOR
A. STAGE OF DILATATION (1st Stage) - True labor + Full dilatation and Complete Effacement
- begins with first symptoms of true labor and ends with complete dilatation of the cervix (10cms)
- has 3 phases:
PHASE ONSET MINUTES OF MANIFESTATIONS
CONTRACTIONS
LATENT begins with onset of the Mild uterine Low backache,
(6 hours – nullipara and regular contractions contractions 10-20mins abdominal cramps,
4.5 hours for multipara) and ends with complete apart and are short excited, alert talkative
effacement (100%) and duration 20-40 secs and in control
cervical dilatation of 3
cm
ACTIVE Begins with complete Uterine contractions Begin to cause
(3 hours in nullipara effacement and cervical occur at 3-5minutes discomfort, exciting,
and 2 hours in dilatation of 4-7cms apart and last 40-60 frightening, labor is
multipara) secs. Contractions are progressing
stronger, last longer
2 Periods:
Acceleration (4-
5cm)
Maximum slope (5-
9cm)
Transition Maximum dilatation Maximum dilatation of Experience feeling of

(peak of this phase can until contractions 8-10cm occurs and loss of control, anxiety,
be identified by a slight reaches their peak of contractions reached panic, irritability
slowing rate of cervical intensity their peak of intensity
dilatation when 9cm occurring 2-3mins with
reached and 10cm duration of 60-90secs
dilatation an irresistible
urge to push begins to
occur
- Nursing Care Management (1st Stage)

a. History taking, review of the woman’s pregnancy (physical/psychological events) general health,
family medical information
b. Physical assessment – Leopolds, IE to determine:
effacement, dilatation and conditions of membranes
Lie (vertical or horizontal), presentation, presenting part
Location of FHT – Vertex (LLQ); Breech (above level of umbilicus); Face (fetal chest)
Station
Position – 4 quadrants; 4 parts – O,M,Sa,A

c.Provide privacy and reassurance – rapport
d. Bath – comfort and relaxation
e. Perineal preparation
f. NPO, start IVF and monitor I & O
g. Avoid solid foods ff. reasons:
Digestion delayed labor
Full stomach interferes with proper bearing down
Aspiration
h. Empty bladder every 2 -3 hrs. – because: retards fetal descent, urinary stasis can lead to UTI, full
bladder can be traumatized during delivery
i.Bear down only during true labor contractions – to minimize maternal exhaustion
j. Encourage to change and assume comfortable position (Sim’s position)
a. Favors anterior rotation of the head
b. Promotes relaxation between contraction
C. Prevents supine hypontensive syndrome
k. Monitor uterine contractions every hour during the latent phase and every 30 mins during active
phase: Duration, Interval, Frequency, Intensity
l. Monitor vital signs – BP and FHR taken every hour during the latent phase and every 30 mins
during the active phase. This should not be taken during contractions.
m. Administration of analgesics – analgesics (Demerol) acts to suppress the sensory portion of the
cerebral cortex.
n. Administration of anesthetics
o. Be aware of the danger signs of labor and delivery (fetal/maternal distress)
-Tachycardia, Bradycardia, Meconium, Fetal trashing, Fetal acidosis
k. Transfer of patient from the labor room to the delivery room
-Multiparas (cervical dilatation 7-9cms) Primi (full dilatation)
- Pressure on the fetal head as it progresses down the birth canal
- Begins at the onset of contraction and end as the contraction ends
- Usually seen in active labor when dilatation 4 to 7 cm
- Increased intracranial pressure stimulates vagus nerve which slows the heart rate
- Due to uteroplacental insufficiency
:Decrease blood flow impeding O2 transfer to the fetus through the intervillous space during
uterine contraction (hypoxemia)
- Umbilical cord compression
:Decreases amount of blood flow to the fetus
:Repetitive deceleration may indicate short cord or nuchal cord
:CS, forcep births or vacuum extraction is Indicated
:Repositioning the woman corrects this type of pattern
B. STAGE OF EXPULSION or Fetal Delivery (2ND Stage) - Full dilatation and complete effacement +
Delivery of the baby
- this stage begins from the time of full dilatation of the cervix and ends with the delivery of the infant.
- 2 PHASES:
a) Deceleration phase: the progress of labor does not slow down; the final degree of cervical
dilatation is achieved and the cervix retracts over the presenting part
b) Fetal descent phase: fetus descent in the pelvic ring, being pushed beyond the open cervix,
perineum begins to bulge (labia), and vaginal introitus stretched apart.
- Mechanisms of labor:
- Nursing Care Management (2nd Stage)
a. Proper positioning on the delivery table- 2 alternative positions (Sim’s and dorsal recumbent),
semi-sitting, squatting. Less tension on the perineum to have fewer perineal tears.
b. Bearing down techniques – best time to encourage strong pushing with contractions, the woman is
asked to take two short breath and bear down the peak of the contraction.
c. Care of Episiotomy Wound – Episiotomy is a surgical incision of the perineum made to prevent
tearing of the perineum and to release pressure on the fetal head during delivery. It has natural
anesthesia
The two types of episiotomy are:
a. Median- begun in the midline of the perineum and directed toward the rectum.
b. Mediolateral- begun in the midline of the perineum but directed laterally away from the
rectum
d. Breathing Techniques- as soon as the head crowns, the woman is instructed not to push any
longer because it can cause rapid expulsion of the fetus instead she should be advise to pant ( rapid
and shallow breathing).
e. Ritgen’s Manuever – the basic steps in applying this method of delivery are as follows:
1. Support the perineum during crowning by applying pressure with the palm against the
rectum.
2.The head should be pressed gently while it slowly eases out to prevent rapid expulsion of
the fetus which could result to not only to lacerations, abruptio placenta, and uterine inversion
but also shock because of sudden decrease in intraabdominal pressure.
3. As soon as the head as been delivered, the nurse should insert two fingers into the vagina
to feel for the presence of a cord looped around the neck. If it so and is loose, it should be
slipped down the shoulder, be clamped twice an inch part and cut in between.
4. As the head rotates, give a gentle, steady downward push in order to deliver the anterior
shoulder and then a gentle upward lift to deliver the posterior shoulder.
5. While supporting the body’s head and neck, the rest of the baby is delivered.
f. Time of Delivery must be noted.

g. Proper Handling of the newborn – immediately after delivery, the newborn should be held below
the level of the mother’s vulva so that blood from the placenta can enter the infant’s body on the basis
of gravity flow.
h. Cutting of the Cord – this is postponed until pulsations have stopped because 50-100 ml of
blood is flowing from the placenta to the newborn at this time
I. Initial Contact : Maternal- infant bonding is initiated as soon as the baby has been suctioned and
provided warmth
C. PLACENTAL EXPULSION (3rd Stage) - Delivery of the baby + Delivery of the placenta
PLACENTA - a freely disc like organ that is 15 – 20 cm in diameter 2.3 cm in thickness and weighs
500 gms at term. A mature placenta has 16 – 30 separate segments known as COTYLEDONS.
- The stage begins with the delivery of the infant and ends with the delivery of the placenta. It is
divided into two phases:
a. Placental Separation phase – separation of the placental results from the disproportion
between the size of the placenta and the reduced size of the site of the placental attachment after
the delivery of the baby. The sign of the placental separation are follows:
The uterus becomes more firm and round in shape and rising high at the level of the
umbilicus – CALKIN SIGN
Sudden gush of blood from the vagina.
Lengthening of the umbilical cord.
B. Placental expulsion –placenta is delivered either by natural bearing down effort of the
mother or by gentle pressure on the contracted uterine fundus by the physician or nurse (CREDE’s
MANUEVER). Two mechanisms by which placenta is expelled:
a. Schultz (shiny-fetal membrane) – placenta separates first from the center so that it
will folds itself like an umbrella and its shiny and glistening fetal surface is presented at the
vaginal opening.
b. Duncan (dirty –irregular maternal surface) – if the placenta separates first at the
edges, it slides along the uterine surface evident. It looks raw red and irregular with cotyledons
showing.
Nursing Care Management (3rd Stage)

1. Never hurry the delivery of the placenta by forcefully pulling out the cord or by vigorous fundal push
as it can lead to uterine inversion
Brandt Andrews Maneuver – wind the cord around the clamp, then deliver the placenta by
rotating it so that no placental fragments are left inside the uterus.
2. Take note the time of placental delivery should be delivered 20-30mins after the delivery of the
baby.
3. Inspect for the completeness of the cotyledons
4. Palpate the uterus to determine degree of contraction if boggy/uncontracted – massage fundus
gently and properly, apply ice or ice cap over abdomen
5. Administration of oxytoxic agents – Methergin (0.2mg/ml) and Syntocinon (10u/ml)
6. Inspect perineum for laceration
Classifications:
a. First degree – involved vaginal mucous membrane and the skin of the perineum to the
fourchette
b. Second degree – vagina, perineal skin, fascia, levator animuscle, perineal body
c. Third degree – entire perineum, external sphincter of the rectum
d. Fourth degree - entire perineum, rectal sphincter and some mucuos membrane of the
rectum
7. Assist doctor in doing episiorraphy, repair of the episiotomy or lacerations
8. Estimate amount of blood loss
9. Provide comfort and perineal care, apply clean sanitary
10. Vital signs every 15 minutes for the first hour and palpate uterine fundus for size and position.
11. Transfer back to the RR or room and position flat on bed w/o pillows. To prevent dizziness due to
intra-abdominal pressure
D. One to FOURS HOURS AFTER -DELIVERY (4th Stage)- delivery of the placenta + First 1-4 hours
after delivery
-The stage refers to the first one to four hours immediately after delivery when the VS are quite
unstable.
-Critical condition - possibility of uterine atony.
Nursing Care Management (4th Stage)
1. Assessment
a. Fundus – palpate every 15 minutes first hour; 30 mins for the next hours. Should be firm, at the
midline of the umbilicus
b. Bladder – checked every 2 hours during 1st 8 hours then every 8 hours for 3 days. Suspect full
urinary bladder if the fundus is not well contracted and is shifted to the right. A full bladder prevents
good contraction of the uterus and may cause hemorrhage.
c. Vaginal discharge – checked every 15mins and should be moderate. Saturated napkin every 30
mins – excessive bleeding.
d. Checked BP and PR every 15 mins first hour then 30 mins till stable
e. Inspect perineum every 8 hours for 3 days. Note the episiorrhaphy should be clean and intact
2. Comfort Measures:
a. Perform perineal care gently and apply napkin
b. Lower legs simultaneously from the stirrups and positionher flat on bed
c. Give mother soothing sponge bath changed linen and clothing
d. Provide additional blankets
e. Give the mother initial nourishment of coffee, tea, soup or milk
f. Provide a quiet and restful environment
g. Allow mother to take enough rest and sleep in order regain energy
Perineal Cleaning
Prepared by:
Reviewed by:

ANGELES UNIVERSITY FOUNDATION Commented [1]: (SGD) MCT
Angeles City
College of Nursing
CARE OF MOTHER, CHILD AND ADOLESCENT WELL

NCM 0107
First Semester, Academic Year 2020-2021
MODULE 5
Stages of Labor
MODULE OVERVIEW
This self-instructional module is designed and prepared for BSN II students to provide
them with adequate knowledge and skills in preparing woman for childbirth physically,
emotionally, and psychologically thus making labor safe and comfortable for both the
mother and her family. It presents a knowledge on describing the different stages of labor
and nursing care of patients during labor and delivery.
Labor and delivery is the culmination of the childbearing cycle and is an intense period
during which the products of conception are expelled from the uterus. It calls for all the
psychological and physical coping methods that a woman has available to her. No matter
how much childbirth preparation she has had, nor how many times she has already gone
through the experience, the woman will require nursing care that is efficient and family
focused, because childbirth marks the beginning of a new family structure.
Nursing interventions to make labor and delivery safe, comfortable, and effective are vital.
Any support person should be treated with respect and should be included in all phases
of the process, whenever possible. Labor and delivery are enormous emotional and
physiologic accomplishments for a woman and her support person, and interventions that
make the experience more positive and memorable for them will mean a lot to future
family interactions.
In this module you will spend 8 hours discussion and activities . Below are the details of
the content, the activities that you need to accomplish and estimated time of completion:
PART OF THE MODULE ESTIMATED TIME OF

COMPLETION
Video Conference: Stages of labor 15 minutes
Asynchronous: Knowledge Check: 10 minutes
Video Conference: Nursing Care and Management during the First 20minutes
Stage of Labor:
Asynchronous: Video Viewing Fetal Position 5 minutes
Asynchronous: Knowledge Check Fetal Position 10 minutes
Video Conference: Fetal Station 15 minutes

Asynchronous: Video Viewing Fetal Station 5 minutes
Video conference: Location of the fetal heart tone in relation to the 15 minutes
presentation.
1 | MODULE 9 STAGES OF LABOR

Video Conference: Continuation Nursing Care and Management 30 minutes
during the First Stage of Labor:
Asynchronous: Knowledge Check on 1st stage of labor 15 minutes
Video Conference: Second Stage of Labor, Mechanism of Labor 15 minutes
Asynchronous: Video Viewing Mechanism of labor 5 minutes
Asynchronous: Knowledge Check on mechanism of labor 15 minutes
Video Conference: Fetal Heart Monitor Interpretation 30 minutes
Asynchronous: Video Viewing Understanding the different changes 10 minutes
in fetal heart tone
Asynchronous: Knowledge Check Interpretation Fetal Monitor 30 minutes
Video Conference: Nursing care and Management during the second 45 minutes
stage of labor
Asynchronous: Video Viewing Normal delivery Process 3 minutes
Video Conference: Third Stage of Labor Nursing Care Management 45 minutes
Asynchronous: Video Viewing Mechanism of Separation and signs 4 minutes
of placental separation
Video Conference: Nursing Care and Management for Fourth Stage 45 minutes
of Labor
Assessment Check: REFLECTIVE WRITING 60 minutes
Summative Evaluation: 30 minutes

Quiz 30 points
TOTAL HOURS: 8 HOURS
MODULE LEARNING OUTCOME:
Pursuant to the Commission on Higher Education (CHED) Memorandum Order No. 15,
the required policies, standards and guidelines in the nursing program parallels this
module’s aim to satisfactorily meet the following learning outcomes.
LO1: Integrate concepts, theories and principles of sciences and humanities in the
formation and application of appropriate nursing care (of well mother, child, adolescent)
during childbearing and childrearing years (P01a);
LO3: Assess mother, child, adolescent’s health status with the use of specific methods
and tools to address existing health needs. (PO2a)
LO4: Formulate nursing diagnosis / es focusing on health promotion and disease
prevention related to mother, child, and adolescent’s health. (PO2b)
LO5: Implement safe and quality nursing interventions addressing health needs affecting
women from pregnancy to postpartum and children from perinatal to adolescent stage.
(PO2c)
LO6: Conduct individual/group health education activities based on the priority learning
needs of mother, child, adolescent. (PO2d)
LO7: Evaluate with the client the health outcomes of nurse-client working relationship.
(PO2e)

Learning Objectives:
Upon completion of this module, the learner should be able to:
1. Identify the different stages of Labor

2. Compare the length of labor among Primigravida and Multigravida
3. Identify and differentiate the signs under the phases of labor
4. Identify Nursing care for mother’s in the 1 st stage of labor
5. Properly identify the fetal lie, presentation, attitude and position
6. Identify the location of the fetal heart tone in relation to the presenting part
7. Identify the nursing care for mother’s in the 2 nd stage of labor
8. Enumerate in order the Mechanism of labor and describe each mechanism
9. Interpret fetal heart monitor in relation to the maternal contraction
10. Identify the nursing interventions needed for the changes in the fetal monitor
tracing
11. Identify Nursing care for mother’s during the 3 rd stage of labor
12. Enumerate the signs of placental separation
13. Identify and differentiate the mechanism of placental separation
14. Identify Nursing care for mother’s during 4 th stage of labor
Recommended Preparation
The study of Maternity and Child Health Nursing makes use of the developmental
approach. It is therefore, suggested that prior to studying this program, the student should
read the modules on Pregnancy and Prenatal care. In addition, a review of the anatomy
of the female reproductive system and study of the fetal skull will facilitate the user's
understanding of this self- instructional module.
Key Terms: Please familiarize yourself with the following terms which will guide you in
understanding as you read the module for stages of labor.
Dilatation
Effacement
Engagement
Lie
Presentation
Position
Station
Attitude
Crowning
Episiotomy
Episiorrhapy
Assessment
PRETEST
I. Multiple Choice. Choose the best answer
1. Effacement is a characteristic referable to the:

a. widening of the cervical canal.
b. shortening and thinning of the cervical canal.
c. thickening of the uterine wall.
d. formation of a ridge dividing the uterus into two segments

2. The relation of the long axis of the fetus to the long axis of the mother is termed:
a. station
b. position
c. presentation
d. attitude
3. The primary aim of doing a perineal incision or episiotomy is to:

a. prevent lacerations
b. reduce duration of second stage of labor
prevent prolonged and severe stretching of muscles supporting
the bladder
d. spare the infant's head from prolonged pressure and
pushing against the rigid perineum
4. Crowning is best defined as the:

a. accommodation of the fetal head to the pelvic shape
b. encirclement of the largest diameter of the fetal head by the
vulvar ring
c. enlargement of the fetal head
d. appearance of the fetal head at the vagina
5. Signs of placental separation include the following:
1. uterus becomes elongated

2. uterus rises to level of umbilicus
3. sudden gush of blood from vagina
4. shortening of the cord
a. 1 and 2
b. 1 and 3
c. 2 and 3
d. 3 and 4
6. Which of the following describes the Shultz mechanism of placental separation?
1. placenta separates first from its center

2. the shiny surfaces presents at vaginal opening
3. placenta separates first at its edges
4. the raw, red, irregular surface presents at the vaginal opening
a. 1 and 2
b. 2 and 3
c. 1 and 3
d. 3 and 4
7. The most common position for the fetus at birth is:

a. right sacroposterior (RSP)
b. left occipitoanterior (LOA)
c. right mentotransverse (RMT)
d. right acromiodorsoanterior (RADA)

8. In a vertex presentation and an LOA position, the fetal heart rate can usually be heard
at the:
a. right lower quadrant
b. left lower quadrant
c. right upper quadrant
d. left upper quadrant
9. Voiding every 2-3 hours is encouraged in a woman in labor to:
1. facilitate fetal descent 2. lessen the weight of her abdomen

3. avoid urinary tract infection 4. stimulate contractions
a. 1 and 2
b. 1 and 3
c. 2 and 3
d. 3 and 4
10. Which of the following is a characteristic of true labor pains?
a. lack of cervical effacement or dilatation

b. cessation of uterine contractions
c. irregular, generally confined to the abdomen
d. intensification of uterine contractions with walking
11. The beginning of the second stage of labor can be recognized by the patient's desire
to:
a. blow during contractions
b. tense up during contractions
c. push during contractions
d. pant during contractions
12. The average length of time a primipara patient will be in labor is approximately:
a. 18
b. 20
c. 24
d. 14
13. When the placenta has been delivered, the first thing the nurse should do is to:
a. palpate the uterus if it is contracted

b. administer oxytocic agents as ordered
c. inspect the placenta for completeness of the cotyledon
d. estimate the blood loss to detect any bleeding
14. It is the relation of the fetal presenting part of a specific quadrant of the woman's
pelvis.
a. station
b. position
c. presentation
d. attitude
15. It is the relation of the fetal presenting part to the level of the ischial spines.
a. lie

b. station
c. presentation
d. position
16. The stage of expulsion in labor is also known as:
a. first stage of labor

b. second stage of labor
c. third stage of labor
d. fourth stage of labor
17. The stage of dilatation in labor is also known as:
a. first stage of labor

b. second stage of labor
c. third stage of labor
d. fourth stage of labor
18. The normal amount of blood loss during labor and delivery is:
a. 100 ml.
b. 250 ml - 350 ml
c. 600 ml
d. 1000 mL
19. It is the relation of the long axis of the fetus to the long axis of the mother.
a. presentation
b. station
c. position
d. attitude
20. It is synonymous to crowning which is the encirclement of the largest diameter of the
fetal head by the vulvar ring.
a. station +1 or +2
b. station -1 or -2
c. station -3 or -4
d. station +3 or +4
After accomplishing this pretest, we will be discussing the answers using

MENTIMETER.
DISCUSSION:

I. THE LABOR PROCESS
STAGES OF LABOR:
A. STAGE OF DILATATION (1st Stage)
B. STAGE OF EXPULSION (2ND Stage)
C. PLACENTAL EXPULSION (3rd Stage)
D. One to FOURS HOURS AFTER DELIVERY (4th Stage)
Length of Labor
Comparison of length of labor in Primigravida and Multigravida.
Stage of Labor Primigravida Multigravida
First stage 12 ½ hours 7 hrs. 20 minutes

Second stage 80 minutes 30 minutes
Third stage 10 minutes 10 minutes
Total 14 hours 8 hours
A. First stage of labor/dilatation stage.
This stage begins with the first symptoms of true labor and ends with the
complete dilatation of the cervix (10 cms.) The “force” or “power” at work during
this stage is the involuntary uterine contraction which is divided into 3 phases:
1. Latent phase – the phase begins with onset of regular contractions and ends
with complete effacement (100%) and cervical dilatation of about 3 cm. Mild
uterine contractions occur regularly 10-20 minutes apart and are of short
duration (20-40 seconds). The woman usually experiences low backaches,
and abdominal cramps and is general excited, alert talkative and in control.
This phase lasts approximately 6 hours in nullipara and 4.5 hours in multipara.
Analgesia given too early in labor will prolong this phase.
2. Active phase – this begins with complete effacement and cervical dilatation of
4-7 cms. Uterine contractions occur at 3-5 minutes apart and last 40-60
seconds. The contractions are stronger, last longer and begin to cause
discomfort. It is an exciting and frightening time because she realizes that labor
is truly progressing. This phase lasts approximately 3 hours in nullipara and 2
hours in a multipara.
Two Periods of Active Phase:

a. Acceleration (4-5 cm)
b. Maximum slops (5-9 cm)
At its most rapid pace at an average rate of 3.5 cm. Per hour in nulliparas
and 5-9 cm. per hour in multiparas.
3. Transition Phase – Maximum dilatation of 8 to 10 cm. occurs, and contractions

reaches their peak of intensity, occurring every 2-3 mins with a duration of 60-
90 secs. May experience a feeling of loss of control, anxiety, panic, and
irritability. Her focus is entirely inward on the task of birthing her baby. The peak
of this phase can be identified by a slight slowing in the rate of cervical dilatation
when 9cm is reached. As the woman reaches 10 cm of dilatation, an irresistible
urge to push begins to occur.
SUMMARY OF THE 3 PHASES:
PHASE ONSET MINUTES OF Manifestation

CONTRACTIONS s
LATENT onset of the Mild uterine Low backache,

Nulli = 6 hours regular contractions abdominal cramps,
Multi = 4.5 hours contractions and Interval: 10-20 mins excited, alert talkative
ends with Duration: 20-40 and in control
complete secs NR= aromatherapy,
effacement distraction,
(100%) accupressure;X
Cervical dilation: analgesics
0-3 cm = controlled breathing;
walk
ACTIVE complete Contractions are Begin to cause

Nulli = 3 hours effacement to stronger, last discomfort, exciting,
Multi = 2 hours Cervical dilatation: longer frightening, labor is
4-7cms Interval = 3-5 mins progressing
*Show Duration = 40-60 NR= active
secs participant;
comfortable position
Transition Maximum Maximum dilatation Experience feeling of

(peak of this dilatation until of 8-10cm occurs loss of control,
phase can be contractions and contractions anxiety, panic,
identified by a reaches their peak reached their peak irritability
slight slowing rate of Intensity of intensity *intense discomfort
of cervical *full dilatation Interval = 2-3 mins (NV)
dilatation when *full effacement

9cm reached and Duration = 60-70
10cm dilatation an secs
irresistible urge to
push begins to
occur
KNOWLEDG
E CHECK
Case Scenario: Anna, 34 years old, a gravida 4 patient went to the hospital with chief
complain of labor pains. She said the pain starts from her abdomen radiating to her back,
which can be relief by walking or change of position. Upon internal examination it revealed
80% effacement and a cervical dilatation of 3 cm. She was place in an external monitor
and her contraction are lasting for 30 seconds every 15 minutes.
1. Based from the signs and symptoms of the patient, what phase in the 1 st stage of
labor is she?
2. What are the signs and symptoms manifested by the patient that will defend your
answer in no. 1 question?
3. What are the interventions that a nurse can do during this phase?
Nursing Care and Management during the First Stage of Labor:
1. Upon admission, history taking should include a review of the

woman’s pregnancy, both physical and psychological events, and a
review of pregnancies, general health, and family medical information to
aid in planning other nursing care.
2. Physical Assessment. General physical examination, Leopold’s

maneuvers and/or internal examination are done to determine the
following:
a. Effacement, dilatation, and condition of the membranes
b. Lie: Refers to the relationship of the cephalocaudal axis (spinal column)

of the fetus to the cephalocaudal axis of the woman
Lie may either be vertical or horizontal lie is very rare(1%) and may be
due to a relaxed abdominal wall because of multiparity pelvic contraction
or placenta previa.
Longitudinal lie (99%) – cephalocaudal axis of the fetus is parallel to the woman’s
spine. It can be Cephalic or Breech Lie
Transverse lie – cephalocaudal axis of the fetal spine is at the right angles to the
woman’s spine

c. Presentation may either be cephalic, breech or shoulder. Presenting
part refers to the part of the fetus that presents at the internal cervical os
and may either be the head, the buttocks, the shoulder, brow, chin, face
or feet.
c.1: CEPHALIC PRESENTATION

● Vertex presentation: the most common type
- vertex (skull bones are capable of effective molding to accommodate
the cervix )
- the smallest diameter (suboccipitobregmatic) presents to the maternal
pelvis
- the occiput is the presenting part
⮚ Military presentation
- the fetal head is neither flexed or extended
- the occipitofrontal diameter presents to the maternal pelvis
- Brow / Sinciput becomes the presenting part
⮚ Brow presentation

- the fetal head is partially extended
- the sinciput is the presenting part
⮚ Face presentation
- the fetal head is hyperextended (complete extension)
- the face is the presenting part
c.2: BREECH PRESENTATION
⮚ Complete breech
- thighs tightly flexed on the abdomen;
- Presenting part: buttocks + tightly flexed feet
⮚ Frank breech -
-hips are flexed
- knees are extended to rest on the chest.
- PP: buttocks alone
⮚ Footling Breech
- Neither the thighs nor lower legs are flexed.
- If one foot presents, (single-footling breech)
- both present (double-footling breech)

c.3: SHOULDER PRESENTATION:
- Fetus lies horizontally in the pelvis
- longest fetal axisc.3 is perpendicular to that of the mother.
- Presenting Part: Shoulders (acromion process), an iliac crest, a hand or an elbow
d. Attitude: Fetal attitude refers to the posture of a fetus during labor.

Mammalian fetuses have a tendency to assume a fully flexed posture
during development and during parturition. Flexion of the fetal head on
the chest allows for the delivery of the head by its smallest bony diameter.
A loss of this flexed posture presents a progressively larger fetal head to
the bony pelvis for labor and delivery. The fetal arms and legs also tend
to assume a fully flexed posture. The longitudinal posture of the fetus
likewise is flexed under normal circumstances.

Fig. 1. Importance of cranial flexion is emphasized by noting the increased diameters
presented to the birth canal with progressive deflection. A. Flexed head. B. Military
position. C, D. Progressive deflection.
f. Position – the relation of the fetal presenting part to a specific quadrant of the woman’s
pelvis. The woman’s pelvis is divided into 4 quadrants.
1. right anterior
2. right posterior
3. left anterior
4. left posterior
Consequently, four parts of the fetus have been chosen as points of direction.
1. occiput – in vertex presentations

2. chin (mentum) – in face presentations
3. sacrum – in breech presentations
4. scapula (acromion) – in shoulder presentations.
3 notations to describe the fetal position:

1. Right (R) or Left (L) side of the maternal pelvis
2. The landmark of the presenting part:
Vertex presentation: Occiput (O)
Face presentation: Chin (M) mentum
Breech presentation: Sacrum (Sa)
Shoulder presentation: Scapula / Acromion process (A)
3. Anterior (A), Posterior (P), or transverse (T) depending on whether the landmark
is in front, back, or side of the pelvis
Occiput of the fetus points to the left anterior quadrant in a vertex position, LOA; ROA =
born fastest
Occiput of the fetus points to the right posterior quadrant, ROP

ROP/LOP = labor is extended; more painful for a woman because the rotation of the fetal
head puts pressure on sacral nerves
YOU MAY WATCH THIS VIDEO TO FURTHER UNDERSTAND HOW TO

LOCATE FETAL POSITION:
https://www.youtube.com/watch?v=EPo4WFC1g9Y
KNOWLEDGE
CHECK…
ACTIVITY: CASE SCENARIO FOR FETAL POSITION
ACTIVITY: Based from the images of ultrasound taken from different pregnant
mothers below, identify the right position of the fetal head.
Case 1: Maria is on her 37 weeks AOG, her ultrasound revealed:
What is the position of the baby?
Case 2: Hanna, 17 years old and is on her 39th week AOG , her ultrasound revealed:
What is the position of her baby?
Case 3: Joanna, 27 years old and is on her 37th week AOG , her ultrasound revealed:
Case 4: Marites, a 38 years old gravida 4 mother is on her 37th week AOG , her
ultrasound revealed:

Case 5: Cess, a 35 years old gravida 2 mother is on her 39th week AOG , her
ultrasound revealed:
g. Station the relation of the fetal presenting part to the level of the ischial spines.
1. Station 0 – when the fetal presenting part is at the level of the ischial
spines. Synonymous to engagement.
2. Station -1 or -2 – when the fetal presenting part is above the level of
the ischial spines.
3. Station +1 or +2 – when the fetal presenting part is 1 cm. or 2 cm.
Below the level of the ischial spines.
4. Station +3 or +4 – is synonymous to crowning. It is the encirclement
of the largest diameter of the fetal head by the vulvar ring.
The ischial spines can be palpated at about a finger-length into the vagina. They are felt
as bony prominences.

Engagement – refers to the settling of the presenting part of a fetus far enough to the
pelvis to be at the level of the ischial spine.
Station - refers to the relationship of the presenting part of a fetus to
the level of the ischial spine
0 – level of the ischial spine (engagement)
-1 to -4 ( above the spines)
* -4 (floating)
+1 to +4(below the spines)
* +3 to +4 (crowning)

YOU MAY WATCH THE VIDEO ON STATION:
https://www.youtube.com/watch?v=ze53Ep-gwBQ
h. Location of the fetal heart tone in relation to the presentation.
In vertex presentation, fetal heart sound is best heard at the area of

the fetal back, usually located at the left lower quadrant (LLQ) or the
right lower quadrant (RLQ). In breech presentations fetal heart sound
are located at or above the level of the umbilicus; in face presentations
fetal heart sounds are best heard at the area of the fetal chest.
LOCATIONS OF THE FETAL HEART TONE
LOA
LOP ROA
ROP
LSA
You can locate the fetal heart tone by locating the fetal back using the Leopold’s
Maneuver. You may want to review how to perform Leopold’s maneuver. Please
READ page 369 of your Pillitteri book, Box 15.6.
The average fetal heart rate is between 110 and 160 beats per minute. It can vary
by 5 to 25 beats per minute. The fetal heart rate may change as your baby
responds to conditions in your uterus. An abnormal fetal heart rate may mean that
your baby is not getting enough oxygen or that there are other problems.
Fetal heart rate and Uterine contraction records:

• Moderate bradycardia
– 100-109 bpm; vagal response from compression of fetal head
• Marked bradycardia
– 🡫 100 bpm; hypoxia
• Moderate tachycardia
– 161-180 bpm
• Marked tachycardia
– 🡫 180 bpm; hypoxia, maternal fever, fetal arrhythmia, maternal
anemia or hypothyroidism
You can use the following in getting the fetal heart tone
Stethoscope:
Doppler :
NOTE: When using these two devices (stethoscope and Doppler) Do not take the
FHT once the uterus is contracted because it will give you unreliable result. You need to
simultaneously get the fetal heart tone and maternal pulse to determine if the sound you
are hearing comes from the baby and not from the mother’s heartbeat.
YOU MAY WATCH THIS VIDEO FOR GETTING THE FETAL

HEART TONE.
https://www.youtube.com/watch?v=voPoxY_a1_Q
Electronic Fetal Monitor

⮚ External Fetal monitor: is a test used during pregnancy. It measures
a baby's heart rate and the mother's contractions. The test uses
instruments placed on the mother's belly to make the measurements. The
results are viewed as graphs on a video screen.
⮚ The electrodes are place in the FUNDUS of the mother to record
uterine contraction
⮚ The other electrode is place on the FETAL BACK to record the FHT.

⮚ Internal Fetal monitor: involves placing a electrode directly on the fetal scalp
through the cervix. This test is performed to evaluate fetal heart rate and variability
between beats, especially in relation to the uterine contractions of labor.
Continuation Nursing Care and Management during the First Stage of Labor:
3. Provide privacy and reassurance; establish and maintain rapport with the patient and
family.
4. Bath, if contractions are tolerable to ensure cleanliness and provide comfort and
relaxation.
5. Perineal preparation. The perineum is cleansed from front to back using the no. 7 stroke
in order to disinfect the area surrounding the vagina. This helps to prevent contamination
of the birth canal and reduce possibilities of postpartum infection.
6. Advise patient not to eat anything by mouth (NPO). Start IVF regulated as ordered and
monitor intake and output hourly. Solid or liquid foods must be avoided for the following
reasons:
⮚ Digestion is delayed during labor.
⮚ A full stomach interferes with proper bearing down.
⮚ Aspiration may occur during the reflex nausea and vomiting of the transition phase
or if anesthesia will be used.
7. Encourage patient to empty her bladder every 2-3 hours because:

⮚ full bladder retards fetal descent
⮚ urinary stasis can lead to urinary tract infection
⮚ a full bladder may be traumatized during delivery
4. Instruct/Advise patient to bear down only during true labor contractions to

minimize maternal exhaustion and prevent cervical edema which may interfere
with labor progress. To minimize bearing down, the patient should be advised
to do abdominal breathing during contractions.
5. Encourage patient to change and assume comfortable position. Sim’s position

is the best because:
a. It favors anterior rotation of the head
b. It promotes relaxation between contractions
c. It prevents supine hypotensive syndrome
6. Monitor uterine contractions every hour during the latent phase and every 30
minutes during the active phase. The following aspects are to be considered:

a. Duration – from the beginning of one contraction to the end of the same
contraction. Early in labor, duration is 20-40 seconds; late in labor,
duration is 60-90 seconds because fetal well being will be compromised.
It must be remembered that there is no blood supply when uterine
muscles are contracted.
b. Interval – from the end of one contraction to the beginning of the next
contraction. Early in labor interval is 10-20 minutes; late in labor, interval
is only 2-3 minutes.
c. Frequency – from the beginning of the contraction to the beginning of the
next contraction. The nurse should time 3-4 contractions at a time to have
a good picture of the frequency of contractions.
d. Intensity – refers to the strength of contractions. It may be mild, moderate
or strong. When estimating intensity, the nurse should check the fundus
at the end of every contraction to ensure that there is a period of
relaxation between contractions. This relaxation period is important
because it is during this time that the uterine vessels refill with blood,
thereby maintaining continuous and adequate oxygen supply to the fetus.
Prolonged and sustained uterine contractions can lead not only to fetal
distress but also to rupture of the uterus.
7. Monitor vital signs. Blood pressure and fetal heart rate are taken every hour
during the latent phase and every 30 minutes during the active phase.
Definitely, BP and FHR should never be taken during contraction. During
uterine contractions, no blood goes to the placenta. The blood is pooled to the
peripheral blood vessels which results in increased blood pressure. On the
other hand, FHR tends to decrease during a contraction because of the
compression of the fetal head. When the fetal head is compressed by the
contracting uterus, the vagus nerve is stimulated, thus causing bradycardia.
Normal FHR is 120-160 per minute.
8. Administration of analgesics. Narcotics are the most commonly used

analgesics, specially Demerol (meperideine hydrochloride). Its dosage is
based on the patient’s weight, the status of labor, and the size and stage
gestation. Demerol acts to suppress the sensory portion of the cerebral cortex.
9. Administration of anesthetics. Regional anesthesia is preferred over any other

form because it does not enter maternal circulation and therefore does not
retard labor contractions nor cause respiratory depression in the newborn.
10. The nurse must be aware of the danger signals during labor and delivery. Signs
of fetal and maternal distress are as follows:
a. Signs of fetal distress:

i. Tachycardia – FHR more than 160/min.
Bradycardia – FHR less than 110/min.
ii. Meconium – stained amniotic fluid
iii. Fetal trashing or hyperactivity due to fetal struggling for more
oxygen.
iv. Fetal acidosis – blood ph below 7.2
b. Signs of maternal distress;

1. BP over 140/90,or falling BP associated with clinical signs of
shock such as pallor, restlessness, or apprehension, increase
respiratory rate and pulse rate.
2. Abnormal pulse of more than100 bpm may indicate hemorrhage.
3. Inadequate / prolonged contractions.
4. Abnormal lower abdominal contour.

5. Increasing apprehension could be a sign of O2 deprivation or
internal hemorrhage
11. Transfer of patient from the labor room to the delivery room. In general,
multiparas are transported to the delivery room when cervical dilatation is about
7-9cms. While primiparas are transferred to the delivery room at full dilatation
with perineal bulging when crowning is taking place.
Knowledge
check:
ACTIVITY: CASE SCENARIO FOR STAGE ONE OF LABOR:
Mrs. M. is a 27-y/o gravida 3, para 2, who was admitted at term at 6:30 p.m. She stated
that she had been having contractions at 7 to 10 minute intervals since 4 p.m. They
lasted 30 seconds. She also stated that she had been having "a lot of false labor" and
hoped that this was "the real thing". Her membranes were intact. Mrs. M.'s temperature,
pulse and respirations were normal and her blood pressure was 124/80. The fetal heart
tones were 134 and regular. The nurse midwife examined Mrs. M. and found that the
baby's head was at +1 station, and the cervix was 4 cm. dilated and 80 percent effaced.
She reported her findings to the doctor and he ordered Demerol 50 mg. with Phenergan
25 mg. to be given intravenously when needed.
1. What type of labor is Mrs. M experiencing? (TRUE OR FALSE LABOR)

Give reasons for your answer based on the assessment data of the patient.
2. As Mrs. M. was getting into bed, her membranes ruptured. What intervention will you
do as a student nurse caring for Mrs. M? Give the rationale for your interventions?
3. After her membranes ruptured, her contractions began coming every 4 minutes and
lasted 45 to 55 seconds. They were moderately strong. Upon internal examination it
revealed a cervical dilatation of 7 cm. Based from the assessment data of the patient,
what phase of the 1st stage of labor is the patient? Explain your answer by enumerating
the signs and symptoms that the patient presented.
4. Why is it important for Mrs. M. to relax during her contractions? How can you help
her to relax?
5. Do you think Mrs. M. should be given the medication ordered by the doctor? What
safety measures should be taken at the time the medication is given? What
observations should be made after it is given? Why?
6. A vaginal exam revealed that Mrs. M. is complete and +2. What is the interpretation
of this? What should be the nursing interventions at this time? Explain the rationale
behind your interventions
7. How would you know that Mrs. M. has entered the transition phase?
8. What are the interventions a nurse can do during the transition phase?

B. SECOND STAGE OF LABOR/STAGE OF EXPULSION
This stage begins from the time of full dilatation of the cervix and ends
with the delivery of the infant. It is often the pelvic division. This stage is
divided into two phase; deceleration and fetal descent.
1. Deceleration phase – is a misnomer for this phase in that the
progress of labor does not actually slow down; the final degree
of cervical dilatation are achieved and the cervix retracts over
the presenting part.
2. Fetal descent phase – with retracted of the cervix over the
presenting part, fetal descent and negotiation of the pelvis
occurs rapidly. As the fetus descent in the pelvic ring, being
pushed beyond the open cervix, woman’ perineum begins to
bulge, the labia part, and the vaginal introitus stretched apart.
MECHANISMS OF LABOR / FETAL POSITION CHANGES
Passage of fetus through the birth canal involve a number of different position
changes so that the smallest diameter of the fetal head will fit through the pelvic inlet and
outlet. These position changes are termed the CARDINAL MOVEMENTS OF LABOR,
they are:
1. Descent –is the downward movement of the biparietal diameter of the fetal head
to within the pelvic inlet. It occurs because of pressure on the fetus by the uterine
fundus: full descent may be aided by abdominal muscle contraction.
2. Flexion- as descent occurs, pressure from the pelvic floor causes the fetal head to
bend forward onto the chest. This brings the smallest diameter of fetal head into a
good position, which is termed. Attitude, therefore, is the degree of flexion that the
fetus assumed prior to delivery.
3. Internal Rotation- the wider anteroposterior (AP) diameter of the fetal head enters
the wider transverse diameter of the pelvic inlet and will rotate so that fetal head is
positioned at the wider AP diameter of pelvic outlet. The sequence therefore, is
from occipitoransverse (LOT) to left occipitoanterior (LOA) to occiput anterior (OA).
The occiput is now either superior to or just below the symphysis pubis.
4. Extension – as the occiput is born, the back of the neck stops beneath the pubic
arch and acts as a pivot for the head. The head thus extend and the foremost parts
of the head, the face and chin, are born.
5. External Rotation (Restitution) – after the head has been delivered, it rotates 45 to
left so that the anterior shoulder is just below pubic arch.
6. Expulsion-this consists of the delivery of the rest of the body.

For you to better understand the mechanisms of labor watch this 5
minute video. It will illustrate how the fetal head changes position as it
goes down from the pelvic inlet to the outlet up to the expulsion of the
baby. You need to take note in order the mechanism of labor because after watching
the video you will be asked to enumerate in order the mechanism and explain the
importance of each mechanism to achieve a successful delivery process.
https://www.youtube.com/watch?v=7lwgnWYzGWY
Knowledge
Check
Based from the discussion and the video provided for viewing on the mechanism of
labor, Enumerate in order the mechanism and explain the importance of each
mechanism to achieve a successful delivery process.

Electronic monitoring of FHT and Uterine contractions
a. Accelerations
● A short-term rises in the heart rate of at least 15 beats per minute,
lasting at least 15 seconds.
● Accelerations are normal and healthy. They tell the doctor that the
baby has an adequate oxygen supply
– Non-periodic; 🡫in FHR; 🡫 30 secs
– Caused by: Fetal movement, change in maternal position, analgesic
– Before 32 weeks; 10 bpm; 10 secs
– After 32 weeks; 15 bpm; 15 secs
b. Decelerations
● Decelerations are temporary drops in the fetal heart rate. There are three
basic types of decelerations: early decelerations, late decelerations, and
variable decelerations.
● Early decelerations are generally normal and not concerning. Late and
variable decelerations can sometimes be a sign the baby isn’t doing well.
– Symmetrical; periodic 🡫 in FHT

– CAUSED BY: Pressure on fetal head during contractions which stimulates
vagal nerve which caused Parasympathetic stimulation
b.1: Early Deceleration: Early decelerations begin before the peak of the
contraction and end when the contraction ends.. Early decelerations can happen
when the baby’s head is compressed. This often happens during later stages of
labor as the baby is descending through the birth canal. They may also occur
during early labor if the baby is premature or in a breech position. This causes the
uterus to squeeze the head during contractions. Early decelerations are generally
not harmful.
INVERSE OF CONTRACTION WAVES
b.2: Late Decelerations:

● Delayed 30-40 secs after the onset of contractions and continued beyond end of
contraction
● Caused by UTERO PLACENTAL INSUFFICENCY
● Late decelerations don’t begin until the peak of a contraction or after the uterine
contraction is finished. They’re smooth, shallow dips in heart rate that mirror the
shape of the contraction that’s causing them. Sometimes there is no cause for
concern with late decelerations, as long as the baby’s heart rate also shows
accelerations (this is known as variability) and quick recovery to normal heart rate
range.
Nursing Responsibility:
Position the mother in Left-lateral position
Initiate IV fluids and O2 inhalation with doctor’s order

● Late decelerations can be a sign that the baby isn’t getting enough oxygen. Late
decelerations that occur along with a fast heart rate (tachycardia) and very little
variability can mean that the contractions may be harming the baby by depriving
them of oxygen. Your doctor may opt to begin an urgent (or emergent) cesarean
section if late decelerations and other factors indicate that the baby is in danger.
Prolonged decelerations:
• 🡫 in FHT of 15 bpm or more
• Lasts longer 2-3 minutes
• CAUSED BY: Cord compression / Maternal hypotension
b.3: Variable Decelerations
• Variable decelerations are irregular, often jagged dips in the fetal heart rate that
look more dramatic than late decelerations
• Decelerations at unpredictable times in relation to contractions

• Cord compression / ROM / Oligohydramnios
• Nursing Responsibilities
• Left lateral position
• O2
• Knee-chest position
For you to better understand the different changes in fetal heart tone as
reflected on the external monitor strip, the causes of these changes and
the interventions please watch this 10 minute video. Please take note of
the difference in the strips, what causes it and the interventions
because you will be using it in answering the knowledge check activity.
https://www.youtube.com/watch?v=ac14n5uD4_0

Knowledge
Check:
Case Scenario:
CASE 1: A 24 year old G3 P2 39 weeks AOG is in active labor. Her cervix is presently 5
cm dilated.
a. What is the interpretation of the External monitor tracing?

b. What might be the possible cause for it?
c. What management can a nurse do at this time?
CASE 2: A 35 year old G3 P1 mother is on transitional stage of labor. Her contractions

are 2-3 minutes apart. There is process in her cervical dilatation.


CASE 3. Joana, a G1P0 mother is on labor. She has moderate amount of vaginal
bleeding and bag of water ruptured 15 minutes ago.

NURSING CARE AND MANAGEMENT DURING THE SECOND

STAGE OF LABOR
1. Proper positioning on the delivery table
Two alternative delivery positions are lateral Sim’s and

dorsal recumbent (on the back with knees flexed), semi sitting and
squatting, Nurse-midwives tend to favor these alternative birth
positions for their clients; with less tension on the perineum, women may have
fewer perineal tears.
2. Bearing Down Techniques
3. This is the best time to encourage strong pushing with contractions. At the
beginning of a contraction, the woman is asked to take two short breaths, then to
hold her breath and bear down at the peak of the contraction. She could also be
told to use BLOW_BLOW breathing patterns to prevent pushing between
contractions
4. Perineal Cleaning:
Rinse the perineal area with sterile water and clean the Vagina from inner to outer
part; clean compress with each stroke.

5. Care of the Episiotomy Wound
Episiotomy is a surgical incision of the perineum made to prevent tearing of

the perineum and to release pressure on the fetal head during delivery.
No anesthesia is necessary during episiotomy because the pressure of the

fetal presenting part against the perineum is so intense that the nerve endings for
pain are momentarily deadened, resulting in natural anesthesia.
The two types of episiotomy are:

a. Median – begun in the midline of the perineum and directed toward the
rectum.
b. Mediolateral – begun in the midline of the perineum but directed laterally
away from the rectum.
Mediolateral episiotomies have the advantage over midline cuts in

that, if tearing occurs beyond the incision, it will be away from the rectum
with less danger of complication from rectal muscosal tears. However,
midline episiotomies appear to heal more easily, cause less blood loss, and
result in less discomfort to a woman in the postpartal period.

6. Breathing Technique
As soon as the head crowns, the woman is instructed not to push any longer
because it can cause rapid expulsion of the fetus. Instead she should be advised
to pant (rapid and shallow breathing).
7. Ritgen’s Maneuver. The basic steps in applying this method of delivery are as
follows:
a. Support the perineum during crowning by applying pressure with the palm
against the rectum with the use of sterile towel. This will not only prevent
lacerations of the fourchette but will also bring the fetal chin down the chest
so that the smallest diameter of the fetal head is the one presented at the
birth canal.
b. The head should be pressed gently while it slowly eases out to prevent rapid
expulsion of the fetus, which could result not only lacerations, abruption
placenta, and uterine inversion but also shock because of sudden decrease
in intra abdominal pressure.

c. As soon as the head has been delivered, the nurse should insert two fingers
into the vagina to feel for the presence of a cord looped around the neck. If
it is so and is loose, it should be slipped down the shoulder, be clamped
twice, an inch apart, and cut in between.
d. As the head rotates, give a gentle, steady downward push in order to deliver
the anterior shoulder and then a gentle, upward lift to deliver the posterior
shoulder.
e. While supporting the body’s head and neck, the rest of the baby is delivered.

8. Time of delivery must be noted.
9. Proper handling of the newborn.

Immediately after delivery, the newborn should be held below the level of
the mother’s vulva so that blood from the placenta can enter the infant’s body on
the basis of gravity flow.
10. Cutting of the Cord

This is postponed until pulsations have stopped because 50-100 ml. of
blood is flowing from the placenta to the newborn at his time.
• Delayed cutting (Physiologic clamping)

– Continue to pulsate for a few minutes after birth
– Postponed the cutting until pulsations have stopped because 50-100
ml of blood is flowing from the placenta to the newborn at this time
– (+) Adequate RBCs and WBCs
– Delayed cutting can prevent Polycythemia and Hyperbilirubinemia
- Clamp the cord 8-10 inches from infant’s umbilicus with 2 hemostats
then cut in the middle of the hemostats.
- Check for 3 Vessels.
AVA: 2 arteries , 1 vein (larger diameter)

11. Initial Contact
Maternal – infant bonding is initiated as soon as the baby has been
suctioned and provided warmth. The mother is informed of the baby’s sex and
condition and allow her to hold onto her baby, maybe put to breast to suck, it can
help contract the uterus as well as the weight of the baby on her abdomen.
For you to understand and have an idea on the normal delivery

process please watch this 3 minute video. This will help you when
you will be having your actual duty in the Delivery Room
https://www.youtube.com/watch?v=ZDP_ewMDxCo

C. THE THIRD STAGE OF LABOR/PLACENTAL STAGE
This stage begins with the delivery of the infant and ends with the
delivery of the placenta. It is divided into two phases: placental separation
phase and placental expulsion phase.
1. Placental separation phase – separation of the placental results from

the disproportion between the size of the placenta and the reduced size
of the site of placental attachment after the delivery of the baby. The signs
of placental separation are the following.
a. Sudden gush of blood from the vagina
b. Lengthening of the umbilical cord
c. The uterus becomes more firm and round in shape and rising high at the
level of the umbilicus. (CALKIN’S SIGN)
d. Placenta is visible at the vaginal opening
2. Placental expulsion – the placenta is delivered either by the natural bearing down
effort of the mother or by gentle pressure on the contracted uterine fundus by the
physician or nurse (Crede’s maneuver). Pressure must never be applied to a
uterus in a non-contracted state or the uterus may evert and hemorrhage. This is
a grave complication of delivery, because the maternal blood sinuses are open
and gross hemorrhage occurs.
If the placenta does not deliver spontaneously, it can be removed manually. There
are two mechanisms by which the placenta is separated and expelled from the
uterus:
a. Schultz – if the placenta separates first from its center so that it folds on
itself like an umbrella and its shiny and glistening fetal surface is presented
at the vaginal opening.
b. Duncan – if the placenta separates first at its edges, it slides along the
uterine surface evident. It looks raw, red, and irregular with the cotyledons
showing.

A single trick of remembering the presentations is associating “shiny” with
Schultz (the fetal membrane surface) and “dirty” with Duncan (the irregular
maternal surface).
NURSING CARE AND MANAGEMENT DURING THE THRID STAGE OF LABOR:
1. The delivery of the placenta is the main focus of nursing activity during the third
stage of labor.
Never hurry the delivery of the placenta by forcefully pulling out the cord or
by vigorous fundal push as this can leads to uterine inversion.
Encourage the mother to push with contractions to aid in placental

expulsion. As soon as the signs of separation appear, tract the cord slowly and
wind it around the clamp. Then deliver the placenta by rotating it so that no
placenta fragments are left inside the uterus. This method is called the Brandt
Andrews maneuver.
2. Take note of the time of placental delivery, should be delivered within 20

minutes after the delivery of the baby. If the placenta is not delivered within
this time, the doctor should be immediately notified as it could be a sign of
uterine atony, a condition that could lead to death due to hemorrhage.
3. Inspect for completeness of cotyledons. Incomplete cotyledons means that

some placental fragments may have been retained in the uterus. This will
prevent the uterus from contracting well and, therefore, cause excessive
bleeding.
4. Palpate the uterus to determine degree of contraction. If relaxed, boggy or

non-contracted, the immediate nursing actions are:
a) massage the fundus gently and properly
b) apply an ice or ice cap over the abdomen.
5. Administration of oxytocic agents. Oxytocic agents may be administered as
ordered to ensure uterine contractions, thus preventing hemorrhage.
Methergin (0.2 mg/ml) and Syntocinon (10 u/ml) via intramuscular (IM) are two
of the more commonly given oxytocics. Never administrered ocytocics before
placental delivery, it may cause placental entrapment. Also, a common side
effect of oxytocins is hypertension. The nurse should, therefore, assess or
monitor the blood pressure of mothers who have received oxytocics.

For you to better understand the mechanism of separation, signs of
placental separation, proper delivery of the placenta and nursing
management after the delivery of the placenta, please watch this 4
minute video. https://www.youtube.com/watch?v=WvKSKTahCss
6. Inspect the perineum for lacerations. Presence of bright red vaginal bleeding
following placental delivery and if uterus if firm, lacerations should be
suspected. Lacerations are ragged edge which heal more slowly and therefore
predispose the mother to infection.
Lacerations are classified into:
a) First-degree – involved the vaginal mucous membrane and the skin of

the perineum to the fourchette.
b) Second-degree – involve the vagina, perineal skin, fascia levator
animuscle and perineal body.
c) Third-degree – involves the entire perineum and external sphincter of
the rectum.
d) Fourth-degree – involve the entire perineum, rectal sphincter and some
of the mucous membrane of therectum.
7. Assist the doctor in doing episiorrhaphy, repair of episiotomy or lacerations. A

local anesthetic, usually Xylocaine is given in order to minimize pain during the
procedure. In episiorrhaphy, vaginal packing is done to maintain pressure on
the suture line and, therefore, prevent bleeding. The nurse should be aware
that this packing is usually removed after 24-48 hours.

8. Estimate the amount of blood loss. The normal amount of blood loss during
labor and delivery is around 300-500 ml. Any amount exceeding 500 ml. is
considered hemorrhage.
9. Provide comfort and perineal care, apply clean sanitary. Soiled napkin should
be removed from front to back.
10. Take vital signs every 15 minutes for the first hour and palpate the uterine
fundus for size, and position. Pulse may become rapid 80-90 min., respiration
20-24/min. and BP slightly elevated due to the excitement of the mother and
recent Oxytocin administration.
11. Transfer back to room (recovery room if she had undergone anesthesia) and
position flat on bed without pillows to prevent dizziness due to decrease in intra-
abdominal pressure. (Start of Fourth Stage of Labor or Puerperium)
D. THE FOURTH STAGE OF LABOR
This stage refers to the first one to four hours immediately after
delivery when the vital signs of the mother are quite unstable. Just like
the first three stages of labor, the stage is important and said to be critical
because of the possibility of postpartum complications, notably uterine
atony.
NURSING CARE AND MANAGEMENT DURING THE FOURTH STAGE OF

LABOR
Nursing interventions during the fourth stage of labor are focused mainly on
assessment of the newly delivered mother’s condition and the giving of comfort
measure.
1. Assessment. The nurse should carefully monitor the following aspects:
a. Fundus – should be palpated every 15 minutes during the first hour

postpartum and then every 30 minutes for the next four hours. The
fundus should be firm, at the midline and at the level of the umbilicus.
b. Bladder – should be checked every 2 hours during the first 8 hours

postpartum and then every 8 hours for 3 days. Suspect a full urinary
bladder if the fundus is not well contracted and is shifted to the right. A
full urinary bladder prevents good contraction of the uterus and therefore,
may cause hemorrhage.
c. Vaginal discharge. The amount of blood flow should be checked every

15 minutes and should be moderate. It is said that if a newly delivered
woman saturate a sanitary napkin more often than every 30 minutes, the
flow is excessive necessitating immediate referral to the doctor.
d. Blood pressure and pulse rate – should be checked every 15 minutes

during the first four hours postpartum and then every 30 minutes until
stable. BP and pulse rate are slightly increased from excitement and the
effort of delivery but normally stabilizes within one hour.
e. Perineum – should be inspected every 8 hours for 3 days. Take note of

the condition of the episiorrhaphy: the suture should be clean and intact.

The perineum may be edematous and discolored for several days
postpartum but will spontaneously resolve in several days’ time.
3. Comfort Measures. Helping the mother feel comfortable after delivery can be
effected by the following measures:
a. Perform perineal care gently and apply a sanitary napkin snugly.
Lower the legs simultaneously from the stirrups and position her flat on bed without
pillows to prevent dizziness due to sudden release if intra-abdominal pressure.
b. Give the mother a soothing sponge bath, change her soiled gown dress and
dirty linens.
c. Provide additional blankets if the mother suddenly complaints of chilling.
This is common complain immediately after delivery because of the sudden
release in intra-abdominal pressure the temperature of the delivery room,
or even fatigue.
d. Give the mother initial nourishment of coffee, tea, milk or soup.
e. Provide a quiet and restful environment.
f. Allow mother to take enough rest and sleep in order to regain lost energy
ASSESSMENT CHECK
1. REFLECTION WRITING: Because of the pandemic we are still not allowed to go

to the hospital and handle actual cases of mothers in the labor and delivery
process. In order for you to have an idea on the entire process please watch this
Vlog of Kara and Allan a couple who shared their experience during labor and
delivery.
https://www.youtube.com/watch?v=mlB2zfTtq7M
After watching it, make a reaction paper about their experience on Labor and Delivery
process integrating the concepts you have learned from the previous discussion.
Instructions and rubric will be posted on the discussion tab of MyClass.
2. FLOW CHART: Create a flowchart that will summarize the events that happened
from stage 1 to stage 4 of the labor process. Integrate in the flow chart the
nursing responsibilities a nurse must do in each process. Instructions and Rubric
will be provided in the assignment tab of MyCLass.
Answer to the Pretest and Post test:

1. B 6. B 11.C 16.B
2. B 7.B 12.D 17.A
3. A 8. B 13.C 18.B
4. B 9. B 14.B 19.C
5. C 10. D 15.B 20.D.
Note: If your score is 12 or higher, your understanding of Stages of labor is

satisfactory
REFERENCES:
Adopted From:
The Self – Instructional Modules in Maternal and Child Health Nursing
Author: Dr. Zenaida S. Fernandez
PRESCRIBED TEXT:
Silbert-Flagg, J. and Pilliteri, A. (2018). Maternal child health nursing: Care of the
childbearing and childrearing family. Volume 1 and 2 (Philippine edition); 8th edition.
Philadelphia: Lippincott
Books:
Leap, N. (2016). Supporting women for labour and birth: a thoughtful guide. London: Routledge/Taylor and Francis Group.
Leifer, G. (2015). Introduction to maternity and pediatric nursing. Boston: Pearson. .
PREPARED BY:
BRENDA B. POLICARPIO RN, RM, MN
NCM 0107 Instructor
PEER REVIEWED BY:

Ma. Corazon Tanhueco, RN, MAN
Sarah S. Nares, RN, MN Commented [2]: (SGD) SSN
Evaluated By:
Level 2 Coordinator
APPROVED BY:
Zenaida S. Fernandez, RN, PhD

Dean, College of Nursing

ANGELES UNIVERSITY FOUNDATION Commented [1]: (SGD) MCT
Angeles City
College of Nursing
NCM0107
CARE OF MOTHER, CHILD AND ADOLESCENT (WELL CLIENTS)
First Semester, Academic Year 2020-2021
MODULE 6
POSTPARUM CARE
MODULE OVERVIEW
This self-instructional module is designed and prepared for BSN II students to

provide them with adequate knowledge and skills in preparing woman after delivery.
Postpartal period involves being certain not only that the woman and her baby are safe
but also that she knows how to maintain her health after returning home from a health
care facility. This module is all about the different aspects of care regarding involutional
changes that newly delivered woman experience and the prevention of possible
complications that may hamper normal recovery.
The postpartal period, also known as puerperium (from the Latin puer, "child," and
parere, "to bring forth"), refers to the first six to eight weeks after delivery. This is a time
of maternal changes that are retrogressive (the involution of the uterus and vagina) and
progressive (the production of milk for lactation, the restoration of the normal menstrual
cycle, and the beginning of parenting role). Protecting the woman's health as these
changes occur is important for preserving future childbearing function and for ensuring
that she is physically well enough to help incorporate her new child into the family. This
period is popularly termed the fourth trimester of pregnancy.
The physical postpartal care a woman receives can influence her health for the
rest of her life. The emotional support she receives can influence the emotional health of
her child and family and can be felt into the next generation.
In this module you will spend 8 hours discussion and activities. Below are the details of
the content, the activities that you need to accomplish and estimated time of completion:
PART OF THE MODULE ESTIMATED TIME OF

COMPLETION
Pretest: 10 minutes
Video Conference: Reproductive System Changes 40 minutes
Video Viewing: Reproductive Changes 5 minutes
Video Conference: Systemic Changes 40 minutes
Video Conference: Psychological Changes 30 minutes

Asynchronous: Knowledge Check on Discussion Tab: 40 minutes
Asynchronous: Assessment Check: Concept Map 4 hours
Summative Evaluation: Quiz 30 points 30 minutes
Total learning hours: 8 hours
1 |MODULE ON POSTPARTUM
MODULE LEARNING OUTCOME:
LO3: Assess mother, child, adolescent’s health status with the use of specific methods
and tools to address existing health needs. (PO2a)
LO5: Identify safe and quality nursing interventions addressing health needs affecting
women from pregnancy to postpartum and children from perinatal to adolescent stage.
(PO2c)
LO11: List appropriate evidence-based nursing care using participatory approach based
on mother, child, adolescent preferences. (PO3a4)
LO12: Identify appropriate evidence-based nursing care using participatory approach
based on mother, child, adolescent and staff safety. (PO3a5)
Learning Objectives:
Upon completion of this module, the learner should be able to:

⮚ Identify changes that will happen in the reproductive system post partum
⮚ Identify systemic changes that will happen postpartum
⮚ Identify nursing interventions specific for these postpartum changes
⮚ Identify nursing management for postpartum mothers
⮚ Identify psychological changes that happens postpartum
⮚ Differentiate post-partum blues, depression and psychosis
⮚ Identify Nursing interventions for these psychological changes
This program is intended primarily for nursing students who already have background
knowledge in caring for the pregnant woman and the woman in labor and delivery. It may
also be used by graduate nurses and other health workers who may find the subject
matter relevant in their work. The reader is advised to read on Anatomical changes and
clinical manifestation in the postpartum woman before reading this module
PRETEST:
1. Return of reproductive organs to prepregnant state.
A. After pains
B. Puerperium
C. Involution
D. Taking-in phase
2. Cramplike pains due to postpartum uterine contractions

A. Afterpains
B. Involution
C. Postpartum blues
D. Puerperium
3. Tension in the breasts on the third postpartum day

A. Lactation
B. Engorgement
C. Milk fever
D. Taking-in
4. Overwhelming feeling of sadness that cannot be accounted for:
A. Puerperium
B. Postpartum blues
C. Postpartum Psychosis
D. Puerperium
5. Uterine discharge on the 1st 3 days postpartum

A. Lochia rubra
B. Lochia serosa
C. Lochia alba
D. Involution
6. Brownish/ pinkish uterine discharge from the 4 th to the 9th day postpartum:
A. Lochia rubra
B. Lochia serosa
C. Lochia alba
D. Involution
7. Whitish uterine discharge from the 10 th day to the 3rd week postpartum:
A. Lochia rubra
B. Lochia serosa
C. Lochia alba
D. Involution
8. It is the 6-8 weeks after delivery:

A. Postpartum psychosis
B. Puerperium
C. Involution
D. Taking-In
9. Psychological phase during puerperium where the mother becomes concerned

with her own needs rather than the baby.
A. Taking-In
B. Taking hold
C. Letting Go
D. Involution
10. Psychological phase during puerperium when the mother begins to develop
strong interest in caring for her baby.
A. Taking-In
B. Taking hold
C. Letting Go
D. Involution
Note: If your score is 6 or higher, your understanding of postpartum is satisfactory. You
can continue with reading this module.
KEY TERMS: Please familiarize yourself with the following terms which will guide you in
understanding as you read the module for POSTPARTUM.
Puerperium
Involution
Lochia (rubra, serosa, alba)
Homan's sign
Engorgement
Taking-in phase
Taking-hold phase
Letting-go phase
DISCUSSION:
PHYSIOLOGIC CHANGES OF THE POST PARTAL PERIOD
This section deals with the care of the newly- delivered woman as her
baby goes through the various involutional changes, using the following
goals of physical postpartum care as guidelines:
1. Promotion of healing and return to normal of the perineum and pelvic

structures.
2. Providing comfort and relief of pain
3. Prevention of infection of the bladder, the breasts, the uterus, and other body parts.
4. Establishment of successful lactation if the mother so desires.
5. Provision of emotional support.
6. Changes during involution may relate to the circulatory and renal systems,
gastrointestinal adaptation, nutritional demands, genital and breast modifications,
emotional concerns, and physical tolerance.
A. Reproductive System Changes
Involution - is the process whereby the reproductive organs

return to their non-pregnant state. The most dramatic changes during the postpartum
period are observed in the genital organs:
1. UTERUS - the organ is gradually reduced to its approximate pregestational size.
2 main processes:
a. The organ is reduced to its approximate pregestational stage:

Uterine involution is measured by finger breadths. On the first day postpartum
the fundus is one finger-breadth (1 cm.) below the umbilicus; on the second day,
2 finger breadths (2 cm.) below the umbilicus; on the third day, three finger-
breadths (3 cm.) below the umbilicus and so on and so forth until on the tenth
postpartum day it can no longer be palpated because it is already behind the
symphysis pubis. A sub-involuted uterus implied the presence of blood clots,
which are good culture media for bacteria, it is, therefore, a sign of puerperal
sepsis.
Weight of the uterus:
✔ Right after delivery: 1000 gms
✔ One week after delivery: 500 gms
✔ Two weeks after delivery: 300 gms
✔ Six weeks after delivery: 50-60 gms
Fundus:
✔ Assessed frequently for firmness, position and height. It should be
checked after the bladder is emptied
✔ Palpate the fundus: Place the woman in supine position with small pillow
under her head and knees flexed to relaxed abdominal muscles. Palpate
by placing a hand at the umbilicus and pressing it downward while the
other hand is placed just above the symphysis to support the lower
uterine segment.
If boggy:
a. Massage gently in circular motion, first action
b. Place infant on the mother’s breast to stimulate uterine
contraction (released of oxytocin)
c. Administer oxytocin or increase infusion if BP is not above
140/90 mmHg
✔ Height of the fundus: Measure the position or height by using umbilicus
as landmark. Place fingers on the abdomen of the woman just below the
umbilicus and count the number of fingerbreadths that fit between the top
of the fundus and umbilicus. It descends one fingerbreadth per day.
b. The area where the placenta used to be implanted is sealed off, which is accomplished
by rapid contraction of the uterus following placental delivery. These uterine contractions
cause cramp like pains, which are called afterpains. Afterpains occur more frequently in
multiparas and in those who delivered large babies and twins because of the over
distention of the uterus. It is also common among breastfeeding women because of the
release of oxytocin when the infant sucks. It is necessary for the nurse to explain that
afterpains are normal and rarely last for more than three days.
Nursing Management for AFTERPAINS:

1. Explain the cause and purpose
2. Keep bladder empty
3. Instruct to assume prone position
4. Massage uterus gently
5. Administer analgesics
c. Immediately after delivery, the uterus casts off fragments of the decidua basalis, white
blood cells, mucus and blood and becomes fully cleaned by this sloughing process. This
uterine flow is called lochia.
Types of lochia Color Duration Composition
Lochia rubra Red 1-3 days - Blood, fragments of decidua and mucus (first
our-may contain small clots)
Lochia serosa Pink or Brown 4-9 days - Blood, mucus and invading
leukocytes
Lochia alba White 10 days- Largely mucus, high leukocytes (decreased

may last for amount of lochia) 6 weeks
Estimation of blood loss:
✔ 1 inch stain after one hour: scant amount
✔ 2-4 inch stain after one hour: light amount
✔ 4-6 inch stain after one hour: moderate amount
✔ Fully saturated after one hour: heavy amount
Smell:
Like menstrual discharges
d. If the postpartum woman is not breastfeeding, menstrual flow may return within 8
weeks after delivery. If she is breastfeeding, menstrual flow may return in 3-4 months
time or, in some women may take the entire lactation period before menstruation
resumes. The absence of menstruation, though, is not a guarantee that she is not
capable of getting pregnant because although she is not menstruating, she may be
ovulating the absence of menstruation may be her body's own way of conserving fluid for
lactation.
NURSING MANAGEMENT
a. Assess for the fundic height every 15 minutes for the first hour postpartum.
a.1. Be certain the bed is flat for uterine assessment, so the height of the uterus
is not influenced by an
elevated position.
a.2. Palpate the fundus of the uterus by placing a hand on the base of the
uterus just above the symphysis pubic and the other at the umbilicus.
a.3. Press in and downward with the hand on the umbilicus until you bump
against a firm globular mass in the abdomen - the uterus fundus.
a.4. Assess the fundic height and measure in finger breadths.
a.5. Never palpate the uterus without supporting the lower segment, as the
uterus potentially can invert if not supported this way and may lead to massive
hemorrhage.
b. Assess the fundus for consistency (firm, soft or boggy) and whether it is in the midline.
c. Palpate the fundus gently so not to cause pain.
d. If the uterus is not firm on palpating, massage it gently with the examining hand.
Massage in a gentle rotating motion of the hand. It should never be hard or forceful. This
causes it to contract and become firm immediately.
e. Evaluate the uterus for height and consistency less frequently following the first hour
after delivery such as every hour for the next 8 hours, then once each shift.
f. Assess for lochia discharge every 15 minutes for the first hour, then once every hour
for the first 8 hours then every 8 hours. Observe for the character, amount, color, smell
and presence of any clots by checking the perineal pad.
g. Upon discharge 3 days after delivery, provide the mother with teachings on how to
perform uterine assessment herself.
To further understand the local changes that happens

postpartum watch these 5 minute video:
https://www.youtube.com/watch?v=cufVFTAco8U
2. CERVIX
a. Immediately following delivery, the cervix is soft and malleable.
b. Both the internal os and external os are well open.
c. Retraction of the cervix begins at once.

d. At the end of 7 days postpartum, the external os is narrowed to the size of a pencil
opening and feels firm and non-gravid again.
e. The process of involution in the cervix involves the formation of new muscle cells.
f. The cervix does not return exactly to its virginal state.
g. The internal os will close as before, however if the mother delivers through vagina, the
external os will usually remain slightly open and appear slit like or stellate (star
shaped) where it was round before, this suggests that childbearing has taken place.
3. VAGINA
a. After childbirth, soft and swollen, with few rugae, with greater diameter than
normal, hymen is permanently torn.
b. Following vaginal delivery, the vagina is soft, few rugae are present, and its
diameter its considerably greater than normal.
c. It takes the entire postpartal period for the vagina to involute by contraction until
it gradually returns approximately to its non-pregnant state.
d. Thickening of the walls also appears due to renewed estrogen production from
the ovaries.
e. With breastfeeding wherein ovulation is delayed may continue to have thin-walled
or fragile vaginal cells causing slight bleeding during sexual intercourse until about
6 weeks time.
f. Vaginal outlet remain slightly more distended than before. If the woman
practices Kegel's exercises, the strength and tone of the vagina will increase
more rapidly.
4. PERINEUM
a. Following delivery the perineum responds by the development of edema and
generalized tenderness brought about by a great deal of pressure during
delivery
b. Ecchymosis may appear due to the rupture of surface capillaries.
c. Perineal muscles tone regained by 6 weeks
d. Labia majora and labia minora typically remain atrophic and softened in a
woman who has borne a child.
e. Lacerations or episiotomy incision may be present.
NURSING MANAGEMENT
a. Perineal care - the perineum seems to be the major focus of care during the early
postpartum period and this is because of the following reasons:
a.1. Lochia which is allowed to dry and harden on the vulva not only furnishes
a bed for bacterial growth and cause infection but also results in
discomfort and emits a foul odor.
a.2. In mothers who delivered vaginally, the perineum is the area which was
subjected to a great deal of pressure. This resulted in edema and
generalized tenderness and some portions may even show ecchymosis
because of rupture of surface capilalries.
a.3. Perineal stitches at the episiotomy site cause much discomfort since
perineal muscles are involved in many activities such as sitting,
walking, standing, squatting, bending, voiding and defecating.
Perineal care should be done after each voiding or bowel movement and
as part of the daily bath, or as the mother wishes for her own comfort. In cleaning
the perineal area, warm water is poured gently over the perineum while cleansing
the labia with clean gauze square or very soft wash cloth, always washing from
front to back (from the pubic to rectum). In doing perineal care during the
postpartum period, the labia should not be extremely separated as this can cause
the solution to enter the vagina and could be a source of contamination. After
having dried the perineal area, the anal region is washed separately by turning the
mother onto her side. If the patient does the perineal care herself, she should be
told to wash her hands before cleansing the perineum.
b. Care of the Episiorrhaphy. This perineal discomfort when aggravated by the

presence of sutures from the episiorrhaphy causes a tugging sharp pain which
may interfere with rest and sleep, eating and even in caring for the newborn.
Several nursing measures may be utilized to relieve pain and discomfort such as:
b.1. An ice bag applied to the perineum for the first 24 hours after delivery does
a great deal to reduce edema by means of vasoconstriction and thus
decrease tension on the suture line.
b.2. Exposing the perineum to a heat lamp after the first postpartum day helps
reduce edema by vasodilatation, promoting healing and providing
comfort. With the woman supine on bed (in dorsal recumbent position)
with knees flexed and properly covered with a linen, the heat lamp is
placed between her legs, about 12-16 inches away from the perineum,
and left in place for 20 minutes. This is done 3-4 times daily until healing
has taken place.
b.3. Place patient on Sim's position to minimize perineal discomfort because it
reduces tension on the suture line.
b.4. Teach post-partum patients to contract the muscles of the perineal floor
before sitting down or standing up, to prevent tissues from being pulled
apart.
b.5. Advise patients to use foam rubber rings to sit on to relieve perineal
discomfort.
c. Sexual Activity. In order to prevent infection and trauma to areas that have just
healed, sexual activity should be resumed only when lochia has stopped and
healing of the perineal area has occurred, which is about 4-6 weeks after
delivery.
d. Post-natal clinic follow-up. The woman should go to a health center or see a
physician for an examination 6 weeks after delivery to assure herself that she is
in good health and has no problems from childbearing.
e. NSD mothers are allowed to ambulate 4-8 hrs after chidlbirth

reasons for early ambulation:
e.1. prevent constipation
e.2. Prevent circulatory problems e.g. thrombophlebitis
e.3. Prevent urinary problems
e.4. promote rapid recovery
e.5. hastens drainage of lochia
e.6. improves GI and urinary function
e.7. provide sense of well being
f. Exercise:
Purpose:
f.2. promotes psychological well being
f.3. rapid return of woman’s figure
f.4. strengthen muscle of the back, pelvic floor, abdomen
Exercises:
f.1. abdominal breathing: tighten abdominal muscles
f.2. Kegel: tighten perineal muscle
f.3. Chin to chest: strengthen abdominal muscles
f.4. Arm raising: return breast and abdominal muscle tone
f.5 Leg raising: tighten abdominal muscles
f.6. Sit ups: tighten abdominal muscles
g. Nutrition:
g.1. high CHON, CHO, iron , Fiber, Calcium and vitamins to promote wound
healing
g.2. For lactating additional 500 calories
g.3. daily intake of vitamins and iron supplements for 4-6 weeks postpartum is
recommended for breastfeeding mothers to ensure nutritious milk supply to the
infant
B. SYSTEMATIC CHANGES
1. Hormonal System
a. Pregnancy hormones begin to decrease as soon as the placenta is no
longer present.
b. HCG in urine is almost negligible by 24 hours.
c. Progestin, Estrone and Estrodiol are at pre-pregnancy levels by one
week.
2. Urinary System
a. Pressure on the bladder and urethra as the fetus passes may leave
the bladder with a transient loss of tone and such edema surrounding
the urethra that result to difficult voiding.
b. A full bladder puts pressure on the uterus and may interfere with effective
uterine contractions.
c. Women who had epidural, spinal or general anesthesia for delivery can feel
no sensation in the bladder area until the anesthesia has worn off.
d. In cases of poor bladder tone, some women retains large amount of
residual urine following voiding which may result to bladder infection
since urine harbors bacteria.
e. Urinary volume rises from a normal level of 1,500 ml. to about 3,000 ml. during
the 2nd to 5th day after delivery, thus causes the bladder to fill rapidly.
This extensive diuresis begins to take place almost immediately
following delivery to get rid of the body fluid that accumulate excessively
during pregnancy.
f. The mother also experience diaphoresis (excessive sweating), another
way by which the body gets rid of excess fluid.
NURSING MANAGEMENT
a. Assess the woman's abdomen frequently in the immediate postpartal period

to see where bladder distention is developing by:
a.1. Palpating a hard or firm area just above the symphysis pubis.
a.2. Uterine position is a good gauge whether the bladder is full or empty,
since a full bladder displaces the uterus.
a.3. On percussion, a full bladder sounds resonant in contrast to the dull
thudding sound of non-fluid filled tissue.
b. Offer a bedpan or assist in a commode at intervals of 2-3 hours and measure
the amount of urine at each voiding until it has been established that she
is emptying her bladder completely.
c. If voiding is difficult, provide measures to encourage voiding such as alternately
pouring warm and cold water over the perineum, helping the woman
use the toilet seat, making her hear the sound of running water.
d. The first voiding after delivery should be measured to detect urinary retention.
If the woman is voiding less than 100 ml. at a time or has a displaced
uterus or palpable bladder, the physician usually order catheterization
for residual urine. If the residual urine is over 150 ml. the catheter is left in
place for 12-24 hours to give the bladder time to regain its normal tone and
to begin to function efficiently.
3. Circulatory System
a. The 30-50% increase in the total cardiac volume during pregnancy will be
reabsorbed into the general circulation within 5-10 minutes following
placental delivery, which implies a sudden increase in cardiac
workload.
b. The usual high level of circulating fibrinogen during the pregnancy
continues to be so during the first postpartum week, this is a protective
measure against hemorrhage; however this same condition encourages
thromboembolization.
c. All blood values of newly-delivered women are back to their prepregnant levels
by the third or fourth postpartum week.
d. Increased in the white blood cells count up to 30,000/mm

e. The woman continue to have increase level of plasma fibrinogen during the first
postpartal weeks.
f. Varicosities will recede but rarely will return to complete prepregnant
appearance.
g. Vascular blemishes, such as spider angina may fade slightly, in case may
remain.
NURSING MANAGEMENT
a. Monitor vital signs every hour during the first 4 hours postpartum, then every
four hours when stable.
b. Assess for adequate peripheral circulation by:
b.1. assessing the thigh for skin turgor.

b.2. assessing the presence of ankle edema and over the tibia on the
lower leg, observer for pitting edema.
b.3. assess for Homan's sign - it is done by dorsiflexing the foot and asking
her if she notices any pain in her calf. If there is pain in the calf
of her leg, it indicates that thrombophlebitis is beginning. DO NOT
MASSAGE THE AREA, it may cause circulatory emboli. This test
is done every shift or every 8 hours.
c. Encourage early ambulation (4-6 hours after delivery) to prevent bowel, bladder
or circulatory complication. Allow to dangle her legs on the edge of bed
for a few minutes the first time she is up to prevent feeling dizzy and assist
her in ambulating.
d. Encourage postpartum exercises like abdominal breathing and arm raising to

help strengthen the abdominal muscles, promote involution and a general
sense of well-being.
4. Gastrointestinal System
a. Digestion and absorption begins to be active soon after delivery.

b. Postpartum woman may feel thirsty and hungry from glucose used during labor.
c. There is delayed bowel evacuation during the immediate post-partum period
because of the following reasons:
- decreased muscles tone of the abdomen and intestines
- lack of food during labor and delivery
- dehydrating effects of labor and delivery
- fear of pain due to perineal tenderness (episiotomy) and presence of
hemorrhoids.
- enema administration during the first stage of labor.
NURSING MANAGEMENT
a. Provide a meal and encourage a postpartum woman to eat provided she is

not nauseated. Ideally, a postpartum diet should contain 2,500 to 2,600
calories per day and should be high in proteins, vitamins and minerals
needed for good tissue repair.
b. Encourage to increase fluid intake and roughage in her diet.

c. Administer mild laxatives or cathartic as prescribed if no bowel movement on
the third postpartum day.
d. Provide relief from hemorrhoid discomforts like:
- hot sitz bath, anesthetic sprays, witch hazel.
- gentle manual replacing of hemorrhoidal tissue.
- assuming Sim's position several times a day to provide good venous
return of the rectal area and to reduce discomfort.
5. Integumentary System
a. The stretch marks on the abdomen still appears reddened post-partum
and maybe even more prominent than during pregnancy.
b. Striae gravidarum may fade to become striae albicans over the next 3-6
months.
c. Chloasma over the face and neck, and linea nigra will be barely undetectable
in 6 weeks.
d. Abdominal wall and uterine ligaments are stretched and pouches forward
followingdelivery, making the woman feel overweight and unattractive and
usually require the full 6 weeks of the puerperium to return to their former
state.
NURSING MANAGEMENT
a. Provide abdominal binder or girdle during the first few weeks postpartum to
make her more comfortable, but does not aid in strengthening
abdominal tone.
b. Encourage the woman to perform postpartal exercises such as sit-ups,
abdominal breathing, chin to chest or head raising, Kegel's arm and leg
raising that give support to abdominal muscle, and aids involution, return
of abdominal tone, and strengthen abdominal and pelvis muscle.
c. Encourage good posture, proper body mechanics, and adequate rest.
6. Breast Modifications
For the first 2 days postpartum, the average women notices little change in her
breasts from the way they were during pregnancy. But on the third postpartum
day, the breasts tend to become full, feel tense and hot, with a throbbing pain.
Breast tissues appear reddened, simulating an acute inflammatory or infectious
process. This feeling of tension in the breasts on the third postpartum day is
called engorgement. Sometimes, body temperature may increase and this is
referred to as milk fever.
NURSING MANAGEMENT
a. Advise mother to use firm-fitting brassiere or breast binder for good support
of the breasts. The brassiere or breast binder will not only reduce discomfort
from breast engorgement but also prevent contamination of the nipples and the
areola.
b. Cold compress application on the breasts if the mother does not intend to
breastfeed, or warm compress application if the woman desires to
breastfeed. Cold causes vasoconstriction and will therefore, inhibit breast milk
production, while heat causes vasodilatation and will, therefore, encourage breast
milk production.
c. Breast massage or the use of the breast pump if the woman will breastfeed.
II. PSYCHOLOGICAL CHANGES
A. Emotional concerns
Psychologically, puerperium may be divided into these separate phases

namely:
1. Taking-in phase
The first 2 or 3 days following delivery is a time of reflection for the
woman. She is so passive that she relies on the nurse or family members to do things
for her, even make decisions for her rather than doing things for herself. The mother
focuses upon her own needs rather than the baby's and her verbalizations center on her
reactions to the recent delivery in an effort to integrate the experience into herself.
2. Taking-hold phase
The next days following the first phase the woman is beginning to do things for
herself and make decisions on her own. This is about the time when she begins to
develop strong interest in caring for her baby. Some women become overly concerned
with their bodily functions such as bladder and bowel control, since these are necessary
for independence. Health teachings regarding self-care, newborn care and family
planning can be discussed with the mother at this time. However, this may also be
the time when the newly delivered woman may experience an o verwhelming
feeling of sadness that cannot be accounted for. This is called postpartum blues. These
are believed to be the result of hormonal changes, or a response to dependency
or exhaustive, being away from home or sheer anxiety over the newly-acquired role.
The nurse should provide privacy at this time and reassure the mother that this is quite
normal and should not be a cause for alarm. Postpartum blues, however, should not
be confused with postpartum psychosis, the latter being more or less an indication of
an emotionally unstable neurotic
personality.
3. Letting-Go Phase
In the third phase, the woman finally redefines her new role. She gives up the
fantasized image of her child and accepts the real one; she gives up her old role of
being childless or the mother of only one. This process requires some grief work and
readjustment of relationships similar to what occurred during pregnancy. It is
extended and continues during the child growing years.
POSTPARTUM BLUES:
⮚ Are frequent the normal experiences of mother after the birth of the newborn.
⮚ They are characterized by labile mood and affect, crying spells, sadness,
insomnia (unable to sleep), and anxiety.
⮚ Symptoms begin approximately 1 day after delivery, usually its peak is 3-7 days,
and subside rapidly with no any medical treatments.
POSTPARTUM DEPRESSION:
● Meets all the criteria for a major depressive episode, with onset within 4weeks or
1month of delivery.
● Symptoms are: anxiety, appetite changes, difficulty concentrating or making
decisions, fatigue, unable to sleep, feeling of guilt, irritability and agitation, lack of
energy, less responsive to the need of the infant, loss of pleasure in normal
activities, and suicidal thoughts.
● Is a psychotic episode developing within 3 weeks of delivery and beginning with
fatigue, sadness, emotional lability, poor memory, and confusion and
progressing to delusion(false belief with stimuli), hallucination(false perception
occurring without any true sensory stimuli), poor insight and judgment, and
loss of contact with reality. This requires an immediate treatment.
Knowledge
CHECK
Watch this video about postpartum depression.

https://www.youtube.com/watch?v=MdrMDdbwFNw
After watching, explain the possible reasons for its occurrence postpartum. What
interventions or health teachings can we make to prevent its complications. Explain the
rationale for each intervention. This activity will be posted in the discussion tab of
MyClass.
ASSESSMENT
CHECK
CONCEPT MAP: Graded Acvtivity
A concept map is a diagram or graphical tool that visually represents relationships

between concepts and ideas. Most concept maps depict ideas as boxes or circles (also
called nodes), which are structured hierarchically and connected with lines or arrows
(also called arcs).
A concept map is a visual organization and representation of knowledge. It shows concepts and
ideas and the relationships among them. You create a concept map by writing key words
(sometimes enclosed in shapes such as circles, boxes, triangles, etc.) and then drawing arrows
between the ideas that are related. Then you add a short explanation by the arrow to explain
how the concepts are related
When new knowledge is integrated with and connected to existing knowledge that new
knowledge is easier to understand and to remember. A professor’s job is to build
scaffolding from existing knowledge on which to hang incoming new knowledge. Using
a concept map is one way to build that scaffolding.
In this activity you will summarized what you have learned from this module by making a
diagram of the changes that happens during the postpartum period. Changes will include,
local changes, systemic changes and psychological changes postpartum. Nursing
interventions for these changes must also be incorporated in the diagram. Activity
instructions and rubrics will be provided in the assignment tab in My Class.
ANSWER TO PRETEST:
1. C 3. B 5.A 7.C 9.A
2. A 4.B 6.B 8.B 10.B
REFERENCES:
Adopted From:
PRESCRIBED TEXT:
Books:
Leap, N. (2016). Supporting women for labour and birth: a thoughtful guide. London: Routledge/Taylor and Francis Group.
Leifer, G. (2015). Introduction to maternity and pediatric nursing. Boston: Pearson. .
PREPARED BY:
BRENDA B. POLICARPIO RN, RM, MN
NCM 0107 Instructor
PEER REVIEWED BY:

Ma. Corazon Tanhueco, RN, MAN
Sarah S. Nares, RN, MN Commented [2]: (SGD) SSN
Evaluated By:
Level 2 Coordinator
APPROVED BY:
Zenaida S. Fernandez, RN, PhD

ANGELES CITY
COLLEGE OF NURSING
1st Semester, A.Y. 2020-2021
Care of Mother, Child, Adolescent (Well Clients) LECTURE

NCM 0107
MODULE CONTENT
Module 7 Care of the Newborn
Module Overview
This module is designed and prepared for BSN II students in developing their knowledge
and skills in caring for the newborn. It presents knowledge on how to provide optimal
care to the neonate. It is therefore expected that the maternity nurse must possess a
considerable amount of theoretical knowledge, clinical expertise and superior judgment.
Careful monitoring of the neonate’s condition, proper manipulation of his environment and
assisting in the infant’s transition from intrauterine to a stable extrauterine environment
are all parts of the nursing role.
The birth of an infant marks the beginning of extra uterine existence and the continuation
of a process of growth and development, which began, with the fertilization of the ovum
by the sperm. Newborns undergo many profound physiologic changes at the moment of
birth and psychological changes as well. They are released from a warm, snug,
darkened, liquid-filled environment in which all their basic needs are met into a chilly,
glaring, unbounded, gravity-based outside world. At birth, the infant loses the metabolic
support of the placenta. Through his own breathing, he must inhale oxygen, perfuse vital
gases through his cardiovascular system, and exhale carbon dioxide. Negotiating
successfully from intrauterine to extrauterine life is a major challenge to the neonate.
Although most of the neonate's organ systems are prepared to adapt and function to extra
uterine life, they will not reach a state of mature functioning for varying periods of time
after birth. This relative immaturity makes it difficult for the newborn infant to adapt to
unusually stressful environmental conditions.
Within minutes of being plunged into this strange environment, a newborn’s baby must
initiate respirations and accommodate the circulatory system to extra uterine oxygenation.
Within twenty-four hours, neurologic, renal, endocrine, gastrointestinal, and metabolic
functions must be operating competently for life to be sustained. How well a neonate can
achieve these major adjustments will depend on his or her genetic endowment, the
competency of the recent intrauterine environment, the care received during labor,
delivery and neonatal period. It is during these periods especially during the first twenty-
four hours of life, that the infant is at high mortality and morbidity risk. Nursing has a
major contribution to make at all these stages. The way babies are cared for at birth may
have an effect on the child and family that lasts throughout their lives. The philosophy
of caring, health care providers has always been that newborns should be handled as
gently at birth as they are at any other time.
Course Learning Outcome 1. Apply concepts, theories and principles of sciences and
humanities in the formulation and application of appropriate nursing care during
childbearing and childrearing years.
Learning Outcome 1: Integrate concepts, theories and principles of sciences and

humanities in the formation and application of appropriate nursing car e (of well mother,
child, adolescent) during childbearing and childrearing years. (P01a)
At the end of the module, the learners will be able to:
1. Identify the principles of newborn care.

2. Assess the signs of normal growth and development of a neonate.
3. Describe the characteristics of a newborn infant.
4. Plan nursing care to enhance normal development of the newborn.
5. Apply knowledge learned on the immediate care needs of the newborn with the
nursing process to achieve quality maternal and child health nursing care.
Activity 1 10-item multiple choice quiz will be given through

Kahoot/ the poll results of MYCLASS Bigbluebutton.
Multiple Choice: Choose the BEST answer:

1. When suctioning the newborn, the nurse should suction the mouth first before the nose
in order to prevent:
A. Heat Loss
B. Bleeding
C. Bradycardia
D. Aspiration
2. Cold stress is harmful to newborn because of which of the following outcome?
A. Hyperglycemia
B. Metabolic Acidosis
C. Decreased metabolic activity
D. Peripheral vasodilation
3. You would expect the normal weight of a newborn to be:
A. 4.0 - 4.5 lbs.

B. 5.5 - 6 lbs.
C. 6.5 - 7.5 lbs.
D. 8.5 - 9 lbs.
4. Which of the following should be done first immediately after the baby is born?
A. Provide warmth
B. Provide patent airway
C. Place on trendelenburg
D. Identification procedures
5. Baby Cbhastian was born at 4:59 am by NSD. The nurse identified the following assessment
at 1 minute after birth: heart rate was 115 beats/ minute, grimace, pink body extremities blue
and some flexion of extremities. The nurse should document the APGAR as:
A. 5
B. 6
C. 7
D. 8
6. Health teachings related to the care of the newborn will NOT include:
A. Fold down the diaper to prevent the cord from getting wet with urine
B. Use 70 % isopropyl alcohol, Betadine or Bactroban ointment and observe for any
bleeding
C. Use binders to keep the cord in place
D. The cord will fall off in about 7 to 10 days
7. These discoloration on the buttocks of the newborn are normal and will disappear by school
age:
A. Mongolian spots
B. Milia
C. Milaria
D. Flea Bite Rash
8. Slight desquamation of the skin occurs during the:

A. First 2 to 4 weeks
B. First 7 to 10 days
C. First to 4th day
D. 2 to 3 months
9. As you prepare to inject vitamin K, you choose between which of the following sites?
A. Deltoid
B. Gluteal muscles
C. Vastus lateralis
D. Dorsogluteal
10. Which of the following newborn reflexes are present at birth and remain unchanged
throughout adulthood?
A. Moro, blink, cough, sneeze

B. babinski, swallowing, cough, sneeze
C. Blink, cough, sneeze, gag
D. Placing, blink, gag, cough
The Neonate
Neonatal Period - the time from birth through the first 28 days of life.
PRINCIPLES OF NEWBORN CARE
I. Establish and maintain a patent airway.
1. Never stimulate a baby to cry unless secretions have been drained out.
2. Mucus should be sustained from a newborn's mouth by a bulb syringe as soon
as the head is delivered.
3. As soon as an infant is born, he/she should be held for a few seconds with the
head slightly lowered for further drainage of secretion.
4. Suction the newborn properly:
a. Turn the baby's head to one side.
b. Suction gently and quickly. Prolonged and deep suctioning of the nasopharynx during
the first 5-10 minutes of life will stimulate the vagus nerve (located in the
esophagus) and may cause bradycardia.
c. Suction the mouth first before the nose. When suctioning the nose, the stimulation of
the nasal mucosa will cause reflex inhalation of pharyngeal material into the
trachea and bronchi, causing aspiration.
d. To test for patency of the airway, occlude one nostril at a time. If the newborn struggles
when a nostril has been occluded, additional suctioning is indicated. Remember:
Newborns are nasal breathers.
5. Record the first cry.
II. Keep newborn warm. Maintain appropriate body temperature. Chilling will increase
the body's need for oxygen. The newborn suffers large losses of heat (cold stress)
because he is wet at birth, the delivery room is cold, he does not have enough adipose
tissues and does not know how to shiver.
Four Mechanisms for Heat Loss:
1. Convection – is the flow of heat from the newborn’s body surface to cooler
surrounding air.
2. Radiation – is the transfer of heat to a cooler solid object not in contact with the
baby such as cold window or air conditioner
3. Conduction – is the transfer of body heat t a cooler solid object in contact with a
baby.
4. Evaporation – is loss of heat through conversion of a liquid to vapor
Effects of cold Stress:
a. Metabolic acidosis - brought about by accumulation of fatty acids because of the

breakdown of brown fat as a result from the infant's way of increasing metabolism
to produce heat.
b. Hypoglycemia - due to the use of glucose stored as glycogen.
1. Dry the newborn immediately (removing vernix caseosa at the same time) so that no
body heat is loss by evaporation.
2. Wrap him with a warm blanket but not too tight so as not to compromise respiratory
effort.
3. Lay infant on his side in a warmed bassinet or place under a droplight.
4. Place a head cap to conserve heat especially if they are in an open crib.
5. All nursing care should be accomplished as quickly as possible to minimize exposure

of the infant.
III. Immediate Assessment of the Newborn
A. Apgar Score - standardized evaluation of the newborn’s condition. Done at one minute
after birth to determine the general condition and then at 5 minutes to determine
how well the newborn is adjusting to extrauterine life.
The following points should be considered in obtaining an Apgar score:
1. Heart Rate - auscultation of the newborn's heart; observing and counting the pulsations
of the cord at the abdomen if the cord is still uncut at one minute after birth.
2. Respiratory Effort - a mature newborn usually cries spontaneously at about 30 seconds

after birth. At one minute, the infant is maintaining regular although rapid
respirations.
3. Muscle Tone - newborn hold the extremity tightly flexed, simulating their intrauterine
position, which is FLEXION. They should resist any effort to extend their
extremities.
4. Reflex Irritability - response to a suction catheter or response to having the soles of the
feet slapped.
5. Color - all infants appear cyanotic at birth and grow pink with or shortly after the first
breath.
Apgar Score
Sign 0 1 2
1. Heart Rate Absent Slow (<100) > 100

2. Respiratory Effort Absent Weak cry Good, strong Cry
3. Muscle Tone Limp, Some flexion Well-flexed

flaccid of extremities extremities
4. Reflex Irritability No response Grimace; sneeze; good
weak cry strong cry
5. Color Pale, blue Pinky body, Pink all over
blue extremities
Interpretation of results:
a. 0-3 - the baby is in serious danger and needs immediate resuscitation.

b. 4-6 - the baby's condition is guarded and may need more extensive clearing of the
airway and supplementary oxygen.
c. 7-10 - is considered good and in the best possible health.
Nursing Care:
B. Vital Statistics/ Anthropometric Measurements
1. Weight - newborn should be weighed nude and without a blanket in the delivery
room or nursery room.
- average birth weight = 6.5 to 7.5 lbs./ 3 to 3.4 kgs./3,000 to 3,400 gms.
- mature female newborn = 3.4 kg (7.5 lbs.); mature male newborn – 3.5 kg. (7.7 lbs.)
- arbitrary lower limit of normal is 2.5 kgs. (5.5 lbs.). Less than this weight, the
child is termed low birth weight and is given high-risk priority status.
- Physiologic weight loss of 5 to 10% (6-10 oz.) during the first few days after
birth is normal because the newborn:
a. is no longer under the influence of maternal hormones.

b. already voids and passes out stools.
c. If breast-fed, intake is limited by the relatively low caloric content of colostrum
until about the third day of life.
d. Because of the time needed to establish effective sucking.
- following this initial weight loss, infant will begin to gain about 2 lbs./month (6 to
8 oz/wk.) for the first 6 months of life.
2. Length - Average: 50 cms. (20 in.) arbitrarily lower limit: 46 cms. (18 in.)
3. Head Circumference - Average: 34 to 35 cm. (13.5 to 14 inches) Measured with a tape
measure drawn across the center of the forehead and most prominent portion of the
posterior
head.
4. Chest Circumference - Average: 31-33 cms. or 2 cms. less than the head circumference.
5. Abdominal Circumference - Average: 31-33 cms.
C. Vital Signs
1. Temperature - 36.5 to 37.2C (97.7 to 99F)
2. Pulse - 180 beats/minute immediately after birth, because the neonate struggles to
initiate respirations.
- 120-140 beats/min. average heart rate an hour after birth when it stabilizes.
- Heart is irregular because of immaturity of the cardiac regulatory center in the

medulla.
3. Respiration - 90 breaths/min. immediately after birth.

- 30-50 breaths/min. when it stabilizes.
4. Blood pressure - approximately 80/46 mmHg at birth.

- by 10th day, it rises to about 100/ 50 mmHG.
- not routinely measured not unless cardiac anomaly is suspected
Activity 2: The learners will watch a video on vital

signs pediatric assessment:
https://youtu.be/pXrGIZOLz4k
D. Proper identification of the newborn and footprints must be taken and kept in the chart.
Attach ID bracelet with a number that corresponds to the mother's hospital number,
mother’s full name, sex, date and time of birth.
IV. Care of the Umbilical Cord
1. Inspect for the presence of 2 arteries and one vein. Suspect a congenital anomaly
if blood vessels are not complete.
2. Apply triple dye or betadine for faster healing effect
V. Give initial oil both to cleanse the baby of blood, mucus and vernix, then followed with
sponge bath. Dry infant, wrap and keep him warm.
VI. Administer Eye Care
Credes prophylaxis - prophylactic treatment of the newborn’s eyes against gonorrheal

conjunctivitis also known as ophthalmia neonatorum, which the baby acquires as he
passes through the birth canal of a mother who has untreated gonorrhea.
Procedure:
1. Wipe the face dry.
2. Shade the eyes from light and open one eye at a time by exerting gentle pressure on
the upper and lower lids.
3. Apply Erythromycin/ Terramycin ophthalmic ointment from inner to outer canthus of

the eye. Antibiotic ointment eliminates the organism of gonorrhea and chlamydia
as well.
VII. Administration of Vitamin K
Vitamin K facilitates production of the clotting factor, thus preventing bleeding.
Method: Aquamephyton 1 mg. (Phytonadione), a synthetic Vitamin K is injected IM into

the lateral aspect of anterior thigh (vastus lateralis) within the first hour of
life
VIII. Hepatitis B Vaccination
Hepatitis B vaccine is administered within 12 hours after birth, a second dose will be
administered after a month and a third dose at 6 months
IX. Document Birth Record
X. Continue Physical Assessment
A. Characteristics of a Newborn
1. General Appearance
Position - full term infants assume an attitude of flexion.
Activity - may range from forceful crying to a deep sleep.
2. Skin - sensations of touch, pressure, temperature and pain are present soon after birth
A. Color - ruddy complexion because of the increased concentration of RBC in
blood vessels and a decrease in the amount of subcutaneous fat
which makes the blood vessels more visible. This ruddiness fades
slightly over the first month.
- Acrocyanosis - a line seems to be drawn across the wrist or ankle, with pink
skin on one side and blue on the other, as if some stricture were cutting off
circulation. The newborn's life, hands and feet are likely to appear cyanotic
from immature peripheral circulation. This is a normal phenomenon during
the first 24 to 48 hours after birth.
- Physiologic Jaundice - yellowish discoloration of the sclerae, skin and
mucus membrane. This occurs approximately 50-70% of all newborns
during the 2nd and 3rd day of life and subsides by the second week of life.
Causes:
a. Breakdown of RBC - forms a fat-soluble indirect bilirubin which cannot
be excreted by the kidney.
b. Immaturity of liver function - cannot yet produce the enzyme glucuronyl

transferase, responsible for converting indirect bilirubin to direct
bilirubin in order to be excreted.
c. Breast-fed babies - breast milk contains pregnanediol (a metabolite of

progesterone), which depresses the action of glucuronyl transferease.
- Harlequin Sign - a neonate who has been lying on his side will appear
red on the dependent side of the body and pale on the upper side as if
a line had been drawn down the center of the body, because of
immature circulation.
B. Texture - slight desquamation for the first 2 to 4 weeks of life.

C. Skin turgor - good elasticity
D. Vernix Caseosa - a white cream-cheese-like substance that serves as a skin lubricant.
E. Milia - pinpoint size white spots seen on the nose and chin due to obstruction of the
sebaceous glands, may disappear by 2 to 4 weeks of age as the sebaceous
glands mature and drain.
F. Erythema Toxicum - a newborn rash usually appears on the 1st to 4th day of life. It
begins with a papule, increases in severity to become erythema by the second
day, then is appears by the third day. It is sometimes called a flea-bite rash
because the lesions are so minuscule.
G. Lanugo - is the fine downy hair that covers a newborn's shoulders, back and upper
arms. The immature newborn has more lanugo than the mature infant.
Disappear within 1-2 weeks of life.
H. Birthmarks
1. Hemangiomas, these are vascular tumors of the skin. The three types of hemangiomas
are:
a. Nevus flammeus - is a muscular purple or dark red lesion, it is sometimes called a port-
wine stain because of its deep color. These lesions generally appear on
the face and thighs, and may be removed surgically.
b. Strawberry hemangiomas - these are elevated areas formed by immature capillaries and
endothelial cells. Formation is associated with high estrogen levels of
pregnancy. Application of cortisone may speed their disappearance by
interfering with the binding of estrogen to its receptor sites.
c. Cavernous hemangiomas - these are dilated vascular spaces. They are usually raised
and resemble a strawberry hemangioma in appearance. Cavernous
hemangiomas may bleed internally, leading to hyperbiliru-binemia or
anemia.
2. Mongolian spots - slate gray patches across the sacrum or buttocks and consist of
a collection of pigment cells. They disappear by school age without treatment
I. Forceps marks - these are circular or linear contusion matching the rim of the blade of
the forceps on the infant's cheeks. Disappears in 2 to 3 days along with the
edema that accompanies it.
3. Head - a newborn's head is disproportionately large, about 1/4 of the total length.
a. Fontanelles - spaces or openings where the skull bones join.
- Anterior fontanelle - is at the junction of the two parietal bones and the two fluid frontal
bones. It is diamond shaped and measures 2 to 3 cm. in width and 3 to 4 cm.
in length. Normally closes at 12 to 18 months of age.
- Posterior fontanelle - is at the junction of the parietal bones and the occipital bone. It is
triangular and measures about 1 cm. in length, closes by the end of the second
month.
b. Molding - the part of the infant's head that engages the cervix is molded to fit the cervix
contours and appears prominent and asymmetric. Restored to its normal
shape within a few days of birth.
c. Caput Succedaneum - is edema of the scalp at the presenting part of the head. Edema
will gradually be absorbed and disappear about the 3rd day of life.
d. Cephalhematoma - is a collection of blood between the periosteum of the skull bone

and the bone itself caused by rupture of a periosteum capillary due to the
pressure of birth. It takes weeks for it to be absorbed.
e. Craniotabes - is a localized softening of the cranial bones. The bone is so soft, it can
be indented by the pressure of an examining finger. The bone returns to normal
contour when the pressure is removed.
4. Eyes - vision is present as evidence of blinking reflex. However, limited to focusing at

a fixed point of 6-8 inches.
- usually cry tearlessly because the lacrimal ducts are not fully mature at birth.
- iris are gray and blue. They do not assume their permanent color until the child is about
3 and 12 months of age
- edema is often present around the orbit or on the eyelids and remain for the first 2-3 days
until the kidneys are capable of evacuating fluid efficiently.
- cornea should be round and proportionate in size to that of an adult eye.

- pupil should be dark.
5. Ears - hearing is present as soon as amniotic fluid drains or is absorbed from the middle
ear by way of the eustachian tube within hours after birth.
- external ear not completely formed as it will be eventually, and pinna tends to bend easily.
- the level of the top part of the external ear should be a line drawn from the inner canthus
to the outer canthus of the eye and back across the size of the head
6. Nose - may appear large for the face.
7. Mouth - should open evenly when the baby cries.
- palate should be intact.
- presence of Epstein's pearl one or two small round glistening, well-circumscribed cysts
are present on the palate - a result of the extra load of calcium that is deposited
in utero.
- sense of taste is more highly developed than sight or hearing. He accepts sweet fluids
and resists acid, sour or bitter ones.
8. Neck - it is short and chubby, creased with skin folds and head rotate freely.
- neck is strong enough to support the total weight of the newborn's head, but in
sitting position a newborn makes a momentary effort at head control. When lying
prone, newborn can raise their heads slightly. If they are pulled into a sitting
position from a supine position, their heads will lag considerably; however,
again, they should make some effort to control and steady their heads as they
reach the sitting position.
9. Chest - appear small in proportion to infant's head.
- Breasts may be engorged in both male- female and may secrete a thin watery fluid called
witch's milk. Disappears in 2 to 4 weeks.
- Chest should be symmetrical
10. Abdomen - contour of the newborn abdomen is slightly protuberant
- presence of bowel sounds within an hour after birth
- liver, spleen and kidneys are palpable at birth
- normally dome-shaped
11. Anogenital Area
- the anus of the newborn must be inspected to be certain that it is patent and not covered
by a membrane (imperforate anus) which can be determined by inserting a rectal
thermometer into the rectum at birth. Take note of the time meconium is first
passed, it should be within the first 24 hours of life.
- Male genitalia
a. scrotum may be edematous and rugated, maybe deeply pigmented in black or dark -
skinned neonates.
b. both testes should be present in the scrotum.
c. positive cremasteric reflex - this is a deep tendon reflex elicited by stroking the internal
side of the thigh. As the skin is stroked, the tests on that side mover
perceptively. This is a test for the integrity of spinal nerves T through. The
response maybe absent in newborns less than about 10 days old.
d. penis of newborns appears small. The urethral opening must be inspected that should
be at the tip of the glass.
e. the prepuce (foreskin) should be examined to be certain it is not stenosed.
- Female genitalia
a. vulva may be swollen because of the action of maternal hormones
b. mucus vaginal secretions are present, which is sometimes blood-tinged.
12. Back
- the spine of a newborn appears flat in the lumbar and sacral areas.
- newborn normally assumes the position maintained in utero, in which, typically, the back
is rounded and the arms and legs are flexed on the abdomen and chest.
13. Extremities
- arms and legs appear short

- hands are plump and clenched into fists
- should move symmetrically
- fingernails are soft, smooth and are usually long enough to extend over the fingertips.
- with good muscle tone, arms always remain in a flexed position.
- palm of hands should have three creases.
- legs are bowed as well as short
- soles of the feet appear to be flat because of an extra pad of fat in the longitudinal arch.
- presence of crisscrossed lines on the sole of the foot.
B. Physiologic Function/Systemic Evaluation
1. Cardiovascular System
When the cord is clamped, breathing is initiated, oxygenation takes place in the
lungs. The change from fetal to neonatal circulation is therefore associated with
lung expansion, causing pressure in the left side of the heart to become higher
compared to pressure in the right side of the heart that results in:
a. closure of the foramen ovale (opening between the right and left atria) by the 3rd month
of life to 1 year.
b. change of the ductus arteriosus into a mere ligament (ligamentum arteriosum) when
the infant is several weeks to 4 months old.
c. Ductus venosus becomes a mere ligament (ligamentum venosum) as well as due to

decrease pressure on the right side of the heart by 2 months.
d. 2 umbilical arteries and umbilical vein atrophied and degenerate by 2-3 months since
no more blood goes through these vessels.
Blood values - are all high in the newborn period as a response to the pulmonary
circulation.
a. Blood volume = 80-110 ml. per kg. of wt. or about 300 ml.
b. Erythrocytes count increase = around 6 million per cubic mm.
c. Hemoglobin level = 17-18 g/100 ml. of blood
d. Hematocrit level = 45 – 50 %
e. White blood cells = 15,000 to 30,000 cells per cubic millimeter at birth (40,000 cells/
cubic millimeter if the birth was stressful)
f. Bilirubin level = 1- 4 mg/100 ml. Any increase over this amount reflects that RBC are
beginning to break down.
2. Respiratory System
a. The first breath of a neonate is initiated by a combination of cold receptors, a lowered
PO2 and an increased PCO2.
b. A first breath requires a tremendous amount of energy to pull in. A pressure of about
40 to 70 cm. H2O is required.
c. The presence of fluid in the lungs eases the pulling apart of alveolar walls during the
baby's first breath, allowing the alveoli to inflate more easily than if the lung
walls were dry.
d. Once the alveoli have initially been inflated, breathing becomes much easier for the
baby requiring only about 6 to 8 cm. H2O pressure. Within 10 minutes of birth,
a newborn has established a good residual volume. By 10 to 12 hours of age
vital capacity is established at newborn proportions.
3. Gastrointestinal System
a. GIT is usually sterile at birth; bacteria may be cultured from the intestinal tract in most
babies within 5 hours after birth; they can be cultured from all babies at 24
hours of life.
b. Newborn's stomach can hold 60 to 90 ml. at birth; 2 wks. 3 oz; 5 mos.-7 oz.; 10 mos.-
10oz; It empties in 2 1/2 to 3 hrs.
c. It has limited ability to digest fats and starch because the pancreatic enzyme, lipase and
amylase are deficient for the first few months of life.
d. Regurgitates easily because of an immature cardiac valve between the stomach and
esophagus.
e. Salivation occurs within 2-3 mos. Drooling may start.
f. Stools
- Meconium - a sticky, tar-like, blackish green, odorless material formed from mucus,
vernix, lanugo, hormones and carbohydrates that accumulated during
intrauterine life.
- first stool of the neonate is usually passed within 24 hours after birth.
- Transitional stool - about the 2nd or 3rd day of life, the neonate stool changes in color
and consistency, becoming green and loose.
By the day of life stool changes again and depends on the type of feeding:
- Breast-fed babies pass 3-4 light yellow stools a day. These are sweet smelling because
it is high in lactic acid, which reduces the amount of putrefactive organisms
in the stool.
- Bottle-fed babies passes 2-3 bright yellow stools a day. These have a slightly more
noticeable odor.
4. Urinary System
a. Average neonate voids within 24 hours after birth.
b. Urine is odorless and light in color because kidneys do not concentrate urine well.
c. A single voiding in a newborn is about 25 ml., Daily urine output for the first 1-2 days of
life is 30-60 ml. and may increase to about 300 ml. after 1 week.
d. Specific gravity is 1.008-1.010.
e. May have small amount of protein due to immature glomeruli.
f. First voiding maybe pink or dusky because of uric acid crystals that were formed in the
bladder in utero.
5. Immune system
The neonate has difficulty forming antibodies against invading antigens until reaching 2
months of age. This is the reason that immunizations against childhood diseases
are not given to babies less than 2 months old.
- Passive immunity = poliomyelitis, measles, diphtheria, pertussis, chicken pox,
rubella and tetanus
6. Neuromuscular System
- Newborn demonstrate general neuromuscular function by moving extremities and

attempting to control head movement, exhibiting a strong cry, and demonstrating
reflexes.
- Occasionally makes twitching movements of extremities in the absence of stimulus

because of the immaturity of the nervous system.
A number of reflexes can be tested with consistency by using simple maneuvers:
6.1. Blink reflex - serves to protect the eye from any object coming near it by rapid eye
closure. It can be elicited by shining a strong light such as flashlight or
otoscope light on the eye.
6.2. Rooting reflex - serves to help the baby find food. of a neonate's cheek is brushed or
stroked near the corner of the mouth, he will turn his head in that direction.
Disappears about 6th week of life, when infant is already capable of seeing
things past the visual midline.
6.3. Sucking reflex - as the lips touch the mother’s breast or bottle, the baby sucks and
takes in food. Diminish about 6 months of age and disappear immediately if it
is never stimulated.
6.4. Swallowing reflex - food that reaches the portion of the tongue is automatically
swallowed. Gag, cough, and sneeze reflexes are also present to maintain a
clear airway. This reflex will never disappear.
6.5. Extrusion reflex - extrude any substance that is placed on the anterior portion of the
tongue. It prevents the swallowing of inedible substances. It disappears at
about 4 months of age.
6.6. Palmar grasp reflex - newborn will grasp an object placed in their palm by closing
their fingers on it. Disappears at about age 6 weeks to 3 months. A baby
begins to grasp meaningfully at about 3 months of age.
6.7. Step-in-Place Reflex - newborns held in vertical position with their feet touching a
hard surface will take a few quick, alternating steps. It disappears by 3 months
of age.
6.8. Placing reflex - is similar to step-in place reflex, except it is elicited by touching the
anterior surface of a newborn's leg against the edge of a bassinet.
6.9. Plantar grasp reflex - when an object touches the sole of a newborn's foot at the base
of the toes, the toes grasp in the same manner as the fingers do. Disappears
at about 8-9 months of age in preparation for walking, although it may be
present in sleep for a longer period of time.
6.10. Tonic neck reflex - when on his back, the infant’s arm and leg are extended on the
side where the head is turned while the arm and the leg on the opposite side
are flexed. It is also called a boxer or fencing reflex because the newborn’s
position simulates that of someone preparing to box or fence. Disappears
between the second and third months of life.
6.11. Moro reflex - singular most important reflex indicative of neurological status. If the
bassinet is jarred or the infant's head is allowed to drop backward in supine
position (change infant’s equilibrium), the infant will abduct and extend their
arms and legs. Their fingers assume a typical "C" position, then they bring
their arms into an embrace position and pull up their legs against their
abdomen (adduction). Is appears by 4-5 months of life, when infant can roll
away from danger.
6.12. Babinski's reflex - when the side of the soles of the foot is stroked in an inverted "J"
curve from the heel upward, the newborn fans the toes (+ Babinski sign). It
occurs because of the immaturity of the nervous system. It remains positive
until at least 3 months of age.
6.13. Magnet reflex – while the newborn is lying on a supine position, pressure is applied
to the soles of the feet, where he pushes back against the pressure.
6.14. Crossed Extension reflex – when a newborn is lying supine, if one leg is extended
and the sole of that foot is irritated or rubbed with a sharp object, the baby
raises the other leg.
6.15. Trunk Incurvation reflex - Place the newborn on prone position and stroke the
paravertebral area on the back, he would flex his trunk and swings the pelvis
towards the area that was touched
6.16. Landau reflex - when held in a prone position with a hand underneath supporting the
trunk should demonstrate some muscle tone. This is a test of spinal card
integrity.
6.17. Deep Tendon reflexes - a patellar reflex can be elicited in a newborn by tapping the
patellar tendon with the tip of the finger. The lower leg will move perceptibly if
the infant has a mature reflex. This is a test for spinal nerves L through L
- To elicit a biceps reflex, place the thumb of your left hand on the tendon of the biceps
muscle on the inner surface of the elbow. Tap the thumb as it rests on the
tendon, you are mere likely to feel the tendon contract than to observe
movement. This is a test for spinal nerves C 5 and C6.
Activity 3: The learners will watch a video on the

newborn examination:
https://youtu.be/cracmPo3iYo
The Senses - all are functional at birth.

a. Hearing – 25th to 27th week of gestation hearing is functional (can hear mother’s
heartbeat and voice); as soon as amniotic fluid drains or is absorbed from the
middle ear by way of the eustachian tube - within hours after birth-hearing in
newborns becomes acute, although they appear to have difficulty locating
sound, not turning toward it consistently.
b. Vision - all newborn can see at birth, although they cannot see part of the midline of
vision (not until 6 - 8 weeks). They focus best on black and white objects at a
distance of 9 to 12 inches.
c. Touch - most developed of all the senses. It is demonstrated by quieting at a soothing

touch. They react to painful stimuli.
d. Taste - taste buds are developed and functioning before birth to such an extent that a
newborn has discriminatory ability. He turns away from a bitter taste but
readily accepts sweet taste.
e. Smell - it is present in newborns as soon as the nose is cleared of mucus and amniotic
fluid. Their ability to respond to odors can be used to document alertness and
possibly intelligence.
X. Provide Discharge Instructions
1. Feeding
a. Breast-fed babies are fed immediately after birth and can be fed on demand or at least
every 2 hours for the first few days of life; alternating both breasts at 10-15
minutes each.
b. Bottle-fed babies routinely receive an initial feeding of about 1 oz. of sterile water at 4 -
6 hours of age to be certain the infant can swallow without gagging and
aspirating. Then, he is fed every four hours.
2. Sleep patterns - newborns sleep 16-20 hours a day.
3. Bathing - may be given anytime convenient for the parents as long as it is not within
30 minutes after feeding because the increased handling during bathing can
cause regurgitation. Sponge baths are done until the cord falls off (7th - 14th
day).
4. Cord Care
a. Dab rubbing alcohol 70% 2 or 3x a day for faster drying.
b. Fold down diapers so that cord does not get wet during voiding.
c. Small, pink, granulating area may be seen on the day the cord falls off. If it remains
moist or with foul discharge, advise mother to bring baby to the doctor's clinic.
5. Car Safety
Until a child reaches a weight of 20 lbs., the best type of car seat is an "infant
only," seat that faces the back of the car. It is fairly lightweight and can double
as a household seat
Activity 4: Question and answer on the Discussion Board
What are my realizations after watching the selected videos

and discussion on the Care of the Newborn?
Activity 5: The learners will create a Mind Map illustrating link on a

particular system of the newborn assigned to their group.
The learners will accomplish a 30-item multiple choice quiz; this will
be accomplished within 30 minutes at a given date and time
Summary and conclusion
Reflection Question/Learning: posted in the Discussion

tab of MyClass
1. What are the significant concepts that you learned

from the discussion and activities in the care of the
newborn?
2. Identify at least 2 Nursing diagnosis in the care of a
newborn
References:
Adopted From:
PRESCRIBED TEXT:
Books:
rd
Green, C. (2016). Maternal newborn: nursing care plans. (3 edition). Burlington, MA:
Jones and Bartlett Learning.
Visovsky,C (2019) Introductory maternity and pediatric nursing, Philadelphia: Wolters

Kluwer
Williams and Wilkins Health. 6. Hockenberry, M. (2017). Wong’s essentials of pediatric

nursing. St. Louis.
Prepared by:
(SGD) Ma. Corazon M. Tanhueco, R.N.,MAN

NCM 0107 Instructor
Peer evaluated by:
(SGD) Sarah S. Nares, R.N., MN Commented [1]: (SGD) SSN

(SGD) Brenda B. Policarpio, R.N., MN Commented [2]: brenda b. policarpio
Reviewed and evaluated by:
Jennie C. Junio R.N., MAN

Level II Coordinator
Debbie Q. Ramirez, R.N., Ph. D.

Assistant Dean
Approved by:
Zenaida S. Fernandez, R.N., Ph. D.
ANGELES CITY
COLLEGE OF NURSING
Care of Mother, Child, Adolescent (Well Clients) LECTURE

NCM 0107
MODULE CONTENT
Module 8 Growth and Development
Module Overview
This module is designed and prepared to provide BSN II students the adequate
knowledge and skills in describing principles of growth and development and developmental
stages according to major theorists. This module presents 1) knowledge of factors influencing
growth and development 2) principles 3) theories and 4) characteristics of growth and
development from birth to adolescence.
Understanding the stage of development a child has reached is important, because

parents will ask a nurse what to expect from their child regarding developmental progress.
Likewise, understanding the psychosocial developmental stage a child has reached helps in
planning care that considers not only age but development progress as well. The child’s age and
stage of physical growth also provides the entire health care team much-needed information
about treatment concerns. For all these reasons, learning about growth and development is
essential to the development of complete and effective nursing care plans for children.
Course Learning Outcome 1. Apply concepts, theories and principles of sciences and
humanities in the formulation and application of appropriate nursing care during
childbearing and childrearing years.
Learning Outcome 1: Integrate concepts, theories and principles of sciences and

humanities in the formation and application of appropriate nursing care (of well mother,
child, adolescent) during childbearing and childrearing years. (P01a)
At the end of the module, the learners will be able to:
1. Differentiate growth from development

2. Describe the principles of growth and development.
3. Describe the developmental stages according to major theories.
4. Identify the factors influencing growth and development.
5. Describe the characteristics of growth and development.
6. Assess a child to determine the stage of development the child has reached.
7. Plan nursing care to assist a child in achieving and maintaining normal growth and
development.
8. Create a concept map per group based on the different stages from birth to adolescence
Activity 1 10-item multiple choice quiz will be given through

Kahoot/ the poll results of myCLASS Bigbluebutton.
Multiple Choice: Choose the BEST answer:
1. The following principles of growth and development are all correct, EXCEPT:
A. Growth and development are continuous processes from conception, until death
B. All body system develop at the same rate
C. Development is cephalocaudal
D. There is an optimum time for initiation of experiences or learning
2. The infant attends to speaking voice and social smile by:
A. 1 month
B. 2 months
C. 3 months
D. 4 months
3. The infant sits alone without support by:
A. 2 month
B. 4 months
C. 6 months
D. 8 months
4. All of the following are cognitive development of the toddler: EXCEPT:
A. Coordination of Secondary Education

B. Tertiary Circular Reaction
C. Invention of New Means Through Mental Combination
D. Preoperational Thought - Symbolic
5. Types of play for infant:
A. Solitary
B. Observation
C. Parallel
D. Associative
6. The toddler needs to be independent and make decisions for self in his psychosocial
development which is:
A. Initiative versus Guilt

B. Trust versus Mistrust
C. Autonomy versus Shame/ Doubt
D. Industry versus Inferiority
7. The stage of separation anxiety wherein the child may turn away from parents approach, prone
to minor ailments and often lies on abdomen:
A. Regression
B. Protest
C. Denial
D. Despair
8. As a result from their frustrations by restraints to their behavior, the Toddler will show:
A. Temper tantrums
B. Use the word “No”
C. Ask many questions
D. Separation Anxiety and Regression
9. Who among the following is/ are the significant persons of school - age children:
A. Mother
B. Parents
C. Peers
D. Peer Group
10. Nutritional need of a schooler will be best met by:
A. Provide short meals because of the brief attention span and environmental distraction
B. Provide protein - rich food at breakfast to sustain the prolonged physical and mental
effort required at school
C. Provide finger foods because they are very active and may rush through the meal
D. Provide snacks frequently because of active life - styles and irregular eating patterns
Characteristics of growth and development

GENERAL CONCEPTS:
GROWTH – is generally used to denote an increase in physical size or a quantitative change.
- indication of growth includes ht., wt., bone size and dentition (cm, inches, lbs., kg)
DEVELOPMENT – is used to denote an increase in skill or the ability to function or a qualitative

change.
- Development can be measure by observing a child’s ability to perform specific tasks, or by

using standardized tests such as Denver Dev. Screening Test.
FACTORS INFLUENCING GROWTH AND DEVELOPMENT
1. Genetic Influences – from the moment of conception when a sperm and ovum fuse, the
basic genetic make-up of an individual is determined.
2. Gender
3. Race and Nationality
4. Parent-Child Relationship
5. Ordinal Position in the Family
6. Health
7. Socioeconomic Level
PRINCIPLES OF GROWTH AND DEVELOPMENT
1. Growth and development are continuous processes from conception until death.
2. Growth and development proceed in an orderly sequence.
3. Different children pass through the predictable stages at different rates.
4. All body system do not develop at the same rate.
5. Development is cephalocaudal.
6. Development proceeds from proximal to distal body parts
7. Development proceeds from gross to refined skills
8. There is an optimum time for initiation or experiences or learning
9. Neonatal reflexes must be lost before development can proceed.
10. A great deal of skill and behavior is learned by practice.
THEORIES OF DEVELOPMENT
Developmental Task – is a skill or a growth responsibility arising at a particular time in an

individual’s life, the successful achievement of which will provide a foundation for the
accomplishment of futured tasks.
1. FREUD’S PSYCHOANALYTIC THEORY
Sigmund Freud (1856 – 1939), an Austrian neurologist and founder of psychoanalysis offered
the first real theory of personality development.
He described child development as being a series of psychosexual stages in which the child’s
interests become focused on a particular body site.
2. ERICKSON’S THEORY OF PSYCHOSOCIAL DEVELOPMENT
Erickson (1902 -1996) was trained in psychoanalytic theory but later developed his own
theory of psychosocial development that considers the importance of culture and society in
development of the personality.
One of the main concepts of his theory, that a person’s social view of himself of herself is
more important than instinctual drives in determining behavior, allows for a more optimistic
view of the possibilities for human growth.
According to Erikson, the successful resolution of each conflict, or accomplishment of the

development task of that stage, allows the individual to go on the next phase of development.
3. PIAGET’S THEORY OF COGNITIVE DEVELOPMENT
Piaget (1896-1980), a Swiss psychologist, introduced concept of cognitive development.

Within each stage are finer units or scheme.
To progress from one period to the text, the child reorganizes his or her thinking processes
to bring them closer to reality.
4. KOHLBERG’S STAGES OF MORAL DEVELOPMENT
According to Kohlberg (1984), recognizing these moral stages is important when caring
for children to help identity how a child may feel about an illness, whether the child can be
depended on to carry out self-care activities, or whether the child has internalized standards
of conduct so he or she does not “cheat” when away from external control.
Moral stages closely approximate cognitive stages of development, because a child must
be able to think abstractly before being able to understand how rules the child cannot see
apply to him or her, even when no one is there to enforce them.
Activity 2: The learners will watch videos on:

a. Piaget’s Theory of Cognitive Development
https://youtu.be/IhcgYgx7aAA
b. 8 Stages of Development by Erik Erikson
https://youtu.be/aYCBdZLCDBQ
https://youtu.be/6XxFmXkD8M8
c. Kohlberg’s 6 Stages of Moral Development

https://youtu.be/bounwXLkme4
Activity 3: Question and answer on the Discussion Board
What are my realizations after watching the selected videos

on the Theories of Growth and Development?
INFANTS (BIRTH TO 1 YEAR)

A. Physiologic Growth and Development
1. Babies usually gain weight at the rate of 5-7 ounce weekly for 6 months. By
4 to 6 months of age, infants usually reach twice their birth weight and three
times their birth weight by age 12 months.
2. Rate of increase in height is largely influenced by the baby’ size at birth and
by nutrition.
3. Motor and Social Development
MOTOR AND SOCIAL DEVELOPMENT IN INFANCY TO PRESCHOOLER
AGE MOTOR DEVELOPMENT SOCIAL DEVELOPMENT

1 month - Lift their head and turn it - Can differentiate between
easily to the side faces and other objects
- Has gross head lag
- Have a strong grasp reflex
- Able to follow object to
midline
2 months - Raise the head and - Differentiates a cry
maintain the position, but - Has social smile
cannot raise their chest - Makes cooing sounds
high enough to look
around
- Can hold head fairly
steady when sitting up,
although it does tend to
bob forward
3 months - Holds head and chest up - Squeal with
when prone pleasure/laughs out loud
- Has slight head lag when - Turn their heads to
pulled in sitting position attempt to locate a sound
- Reach for attractive
objects in front of them
- Follows object past
midline
4 months - Lifts chest off the bed and - Very “talkative”, cooing,
look around actively, babbling and gurgling
turning the head from side when spoken to
to side - Recognize familiar
- Can turn from front to objects
back
- No longer demonstrating
head lag in sitting position
- Brings the hands together
and pull at their clothes
5 months - Rests weight on the - says some simple vowel
forearm when prone sounds (goo-goo and
- Turn completely over gah-gah)
- Can straighten his or her
back when propped in a
sitting position
- Grasps object with whole
hand

6 months - Rest their weight on their - Starts to imitate sounds
hands with extended arms
- Can raise their chest and
the upper part of their
abdomen off the table
- Can sit momentarily
without support
- Support nearly their full
weight when in a standing
position
- Holds objects in both
hands
7 months - Sits alone but only when - Imitates vowel sounds
the hands are held well (oh-oh; ah-ah; oo-oo)
forward for balance - Shows beginning fear of
- Can transfer a toy from strangers
one hand to another
8 months - Can sit securely without - Has peaked fear of
additional support strangers
-
9 months - Creeps and crawls - Says first word (da-da or
- Sits so steadily that they ba-ba)
can lean forward and - Very aware of the
regain their balance changes in tone of voice
MOTOR AND SOCIAL DEVELOPMENT IN INFANT TO PRESCHOOLER

10 months - Pull themselves to a - Master another word such
standing position by as bye-bye
holding onto objects - Beginning of object
- Brings the thumb and first permanence
finger together in a pincer - Recognize their name and
grasp listen acutely when
spoken to
11 months - Learns to “cruise” by - Imitates speech sounds
holding onto objects - Reacts with frustration
when restricted
12 months - Stands alone at least - Can generally say two
momentarily words besides ma—ma
- Hold a cup and spoon to and da-da, use those two
feed self words with meaning
- Helps to dress (pushes
arm to sleeve)
15 months - Walks alone well - 4-6 words
- Can seat self in chair - Enjoy being read to
- Can creep upstairs - Drops toys for adult to
- Puts small pellets into recover (exploring sense
small bottles of permanence)
- Scribbles voluntarily with
a pencil or crayon
- Holds a spoon well but
may still turn it upside
down on the way to mouth

18 months - Can run and jump in - 7-20 words
place. - Uses jargoning
- Can walk up and down - Names 1 body part
stairs holding onto a - Imitates household
person’s hand or railing chores
- Typically places on one - Begins parallel play
step before advancing
- No longer rotates a spoon
to bring it to mouth
24 months - Walks up stairs alone still - 50 words, 2-word
using both feet on same sentences (noun-pronoun
step at same time and verb), such as Daddy
- Can open doors by go” “me come”
turning door knobs,
unscrew lids
30 months - Can jump down from - Verbal language is
chairs increasing steadily.
- Makes simple lines or - Knows full name; can
strokes for crosses with a name 1 color and holds up
pencil fingers to show age
- Imitating parents’ actions

3 years - Runs - Vocabulary of 900 words
- Alternates feet on stairs - Able to take turns
- Rides tricycles - Very imaginative
- Stands on one foot
- Undress self
- Stacks tower of blocks
- Draw a cross
4 years - Constantly in motion; - Vocabulary extends to
jumps, skips 1,500 words
- Can do simple buttons - Pretending is major
activity
5 years - Throws overhand - Vocabulary of 2,100
- Draw a 6-part man words
- Can lace shoes - Likes games with
numbers and letters
B. PSYCHOSEXUAL DEVELOPMENT
Oral Phase (0-1 year) – Infants seek for enjoyment or relief of tension, as well
as for nourishment.
Nursing Implications:
1. Provide oral stimulation by giving pacifiers.

2. Do not discourage thumbsucking.
C. PSYCHOSOCIAL DEVELOPMENT
Trust vs. Mistrust (0-8 mos.) – Child learns to love and be loved. Significant
person: Mother / Primary caregiver.
1. Responds promptly to an infant's needs.

2. Provide a predictable environment in which routines are established.
3. Provide experiences that add to security, such as cuddling, soft sounds,
touch or stroking, and rocking.
D. COGNITIVE DEVELOPMENT
Sensorimotor
1. Neonatal Reflex – 1month

- stimuli are assimilated into beginning mental images.
Behavior entirely reflexive.
2. Primary Circular Reaction – 1-4 months

- hand-mouth and ear – eye coordination develop. Infants spend much
time looking at objects and separating self from them.
- Beginning intention of behavior is present. Enjoyable activity for this
period: A rattle or parent’s voice recording, colorful musical hanging
objects over the crib.
3. Secondary Circular Reactions – 4-8 months

- Infants learn to imitate, recognize and repeat pleasurable experiences
from environment
- Memory traces are present and anticipate familiar events.
Good toy: Mirror, plastic blocks and rings (can grasp but not swallow)
Good game: Peek-a-Boo
4. Coordinating of Secondary Reactions – 8-12 months
- Perceives that others can cause activity and that activities of own body
are separate from activity of objects.
- Can search for and retrieve toy that disappears from view.
- Recognize shapes and sizes of familiar objects.
- Because of increased sense of separateness, infant experiences
separations anxiety when primary care-given leaves.
Good toys: Nesting toys such as different size colored boxes to use for put-
in, take-out toys. Toys that pull apart such as large plastic beads. Toys with
wheels that push back and forth.
Type of Play: OBSERVATION – Infant watches particular play intently,

although not actively engaged in it.
MORAL DEVELOPMENT
Preconventional Stage I: Punishment-Obedience Orientation. Child does right

because a parent tells him or her to and to avoid punishment.
1. Provide help to children to determine what are the right actions.

2. Gives clear instructions to avoid confusion.
3. Gives praise for doing as asked.
E. NUTRITION
1. Breastfeeding
Breastmilk is still BEST milk for babies.
Advantages:
1. It is readily available, convenient and economical.

2. Its composition is most suitable for infants.
3. It has immunologic substances, which help in the prevention of infections.
4. It enhances closeness between mother and child.
5. It prevents indigestion and diarrhea.
Procedure for Breastfeeding
1. The mother is taught to wipe her nipples gently with washcloth and plain water
to remove the small white crusts of milk, which have leaked out.
2. Before each feeding, the mother is taught to wash her hands, hold her baby,
and get into a comfortable position, either seated on a chair or lying on her side
in bed.
3. Position the body such that we can have a good grasp of her breast.
4. Press the breast tissue near the infant’s nose such that it does not interfere
with the baby’s breathing.
5. Allow to nurse 2-5 minutes at each break during the first few days after delivery,
later, when there is ample milk, the baby is breastfeeding from 10-20 minutes
on each breast.
I. BOTTLEFEEDING
The common types of milk formula used by Filipino mothers are:
1. Evaporated Milk – this is whole milk with 60% of its water removed. Average
dilution of formula 1 ounce or 30cc of milk to 2 ounces or 60cc of water.
2. Condensed Milk – evaporated whole milk, which contains 45% sugar, it has
100 calories per ounce.
Disadvantages:
a. The sugar content is too high, making the baby look pale, fat, fiabby, and
prone to diarrhea due to the fermentation of sugar.
b. Mothers also tend to dilute the milk to make it less sweet; extremely diluted
milk does not give sufficient nutrients to supply body needs.
3. Dried Milk – This is milk, which the water has completely evaporated. It is good
for babies who cannot tolerate the FAT of whole milk.
Dilution: 3 ½ level tablespoonful of dried milk to 7 ounces of water.
4. Propriety Infant Milk – The composition of this kind of milk stimulates breast
milk. It provides a “complete” diet for the infant and contains added vitamins
and iron. However, it is relatively expensive. May come in powdered or liquid
form.
F. Hospitalization Reactions
Infants adapt well if fed, touched, and cared for. In later infancy they
experience separation anxiety; exhibit total body rigidity, protest, detach from
parents and exhibit withdrawal behavior.
Nursing Interventions:
1. Encourage parents to stay with, visit, and continue routines of home care
for infants as much as possible.
2. Establish a sense of trust.
3. Maintain same nurse assignments and maintain routine.
4. Speak to, look at and touch infant.
5. Provide comfort sources as needed, such as pacifiers, bottles, blankets.
6. Make the environment safe such as side rails up, equipment out of reach.
7. Monitor growth and development
8. Provide appropriate interaction and toys
TODDLERS (1-3 years)
A. Physical Development
a. Toddlers develop from having no voluntary control to being able both to walk
and speak.
b. They learn to control their bladder and bowels by 3 years
c. They now usually appear chubby with relatively short legs and large head,
with pronounced lumbar lordosis and a protruding abdomen.
d. Two years old can be expected to weigh approximately four times their birth
weight.
Gains only about 5 to 6 lbs. (2.5 kg) and 5 inches (12 cm.) a year during this
period
e. Fine muscle coordination and gross motor skills improves.
f. Receptive language skills and expressive language skills are developing
quickly.
Receptive – ability to understand words.
Expressive – ability to use or weigh the words.
B. Psychosexual Development
ANAL PHASE (2-3 years)
a. Child learns to control urination and defecation.

b. Child finds pleasure and a sense of control in both the retention and
defecation of feces. This anal interest is part of the toddler’s SELF-
DISCOVERY, a way of exerting independence.
Nursing Implications
1. Help children achieve bowel and bladder control without undue emphasis
on its importance.
2. If at all possible, continue bowel and bladder training while the child is
hospitalized.
3. Toilet training should be a pleasurable experience, and appropriate praise
can result in a personality that is creative and productive.
C. Psychosocial Development
AUTONOMY VS. SHAME AND DOUBT (18 months – 3 years)
a. Child learns to be independent and makes decisions for himself.

b. They begin to develop their sense of autonomy by asserting themselves
with the frequent use of the word “NO”.
c. TEMPER TANTRUMS results from their frustration by restraints to their
behavior.
d. They are curious and ask many questions.
e. Response to stress: SEPARATION ANXIETY AND REGRESSION
ROBERTSON’S STAGES OF SEPARATION ANXIETY
1. PROTEST – The child cries loudly and demandingly; rejects any

attempts to be comforted.
2. DESPAIR – The child wails rather than cries; may turn away from
parent’s approach; often lies on abdomen, facial expression flat; may
loss weight and develop insomnia, loses developmental skills; prone to
minor ailments such as URTI; IQ measures lower than formerly.
3. DENIAL – The child is silent, face expressions less
- Deterioration in developmental milestones is apparent.
- May respond quickly but superficially to all caregivers.
- May have difficulty forming close relationships during life.
Significant Person: Mother/Primary caregiver
1. Provide opportunities for decision-making, such as offering choices of clothes

to wear or toys to play with.
2. Praise for ability to make decisions (they are proud of their accomplishments)
rather than judging correctness of any one decision.
3. Help the toddler to develop inner control by setting and enforcing consistent,
reasonable limits.
D. Cognitive Development
1. SENSORIMOTOR
Tertiary Circular Reaction – 12-18 months

a. Child is able to experiment to discover new properties of objects and
events.
b. Capable of space perception and time perceptions as well as
permanence.
INVENTION OF NEW MEANS THROUGH MENTAL COMBINATION
18-24 mos.
a. Uses memory and limitation to act.

b. Can solve basic problems, foresee maneuvers that will succeed or fail.
Good Toys: Blocks, colored plastic rings, those with several uses.
2. PREOPERATIONAL THOUGHT (2-7 years)
a. Thought becomes more symbolic; can arrive at answers mentally

instead of through physical attempt.
b. Comprehends simple abstractions but thinking is basically concrete and
literal.
c. Child is egocentric to see the viewpoint of others.
d. Displays static thinking, inability to remember what he or she started to
talk about so that at the end of a sentence the child is talking about
another topic.
Good Toy: items that require imagination, such as modelling clay
Good Activity: trips to the park, reading books
Type of Play:
1. PARALLEL PLAY – two children play side by side but seldom attempt
to interact with each other.
2. SOLITARY PLAY – involvement in independent activities
E. MORAL DEVELOPMENT
Pre-conventional Stage I: Punishment – Obedience Orientation
See infancy Moral Development
F. NUTRITION
1. By this time, toddlers can eat most foods and adjust to these meals each
day.
2. By age 3, most deciduous teeth have emerged, the toddler is able to bite
and chew adult table food.
3. They know how to feed themselves.
4. Meals should be short because of the toddler’s brief attention span and
environmental distractions.
5. Often toddlers display their liking of rituals by eating foods in a certain order,
cutting foods a specific way, or accompanying a certain food with a
particular drink.
6. Caloric requirement is decreased because of a decrease in the rate of
growth, but an adequate need for iron, calcium vit. D and A rich food should
be provided.
G. REACTION TO HOSPITALIZATION
1. Experience separation anxiety

2. Feel a loss of control and rituals
3. May exhibit temper tantrums or regression
4. Fear injury and pain: Fear of the unknown
5. May bite and kick during interaction
NURSING INTERVENTIONS:
1. Encourage parents to stay with, visit, and continue routines of home care as
much as possible.
2. Establish trust with parents and child.
3. Provide familiar routines and items or security objects such as security blanket.
4. Maintain the same nurse assignment.
5. Allow child a sense of independence.
6. Allow to play and interact with family members.
7. Stay with child when parents leave so a sense of abandonment is not felt.
8. Monitor growth and development and provide appropriate interactions and
toys. Motor development is important during this age.
PRESCHOOLERS (3-5 years)
1. During this period, physical growth slows, but control of the body and
coordination increase greatly.
2. They appear taller and thinner than toddlers because children tend to grow
more in height than in weight.
3. They are able to wash their hands, face and brush their teeth.
4. They run skillfully and can jump three steps, can balance on their toes and
dust themselves without assistance.
5. They are self-conscious about exposing their bodies.
PHALLIC STAGE (4-5 years) – Child learns sexual identity through awareness
of genital area. They play with their bodies largely out of curiosity.
1. Accept child’s sexual interest, such as fondling his or her own genitals, as
a normal area of exploration.
2. Help parents answer child’s questions about birth or sexual differences.
ELECTRA / OEDIPUS COMPLEX
The phase of close emotional relationship with both parents’ changes to the
phase Freud referred to as the ELECTRA or OEDIPUS complex. At this time,
the child focuses feelings of love chiefly on the parent of the opposite sex, and
the parent of the same sex may receive some hostile feelings.
INITIATIVE VS. GUILT (3-5 years)
a. Child learns how to do things (basic problem solving) and that doing things
is desirable.
b. They have to solve problems in accordance to their consciousness
c. The personalities develop.
d. Erickson views the crisis at this time as important for the development of
the individual’s self-concept.
Significant Person: Parents

. Provide opportunities for exploring new places or activities.

. Allow play to include activities involving water; clay (for modelling) or finger
paint.
. Enhance the development of the preschoolers by praising effort at new
activities and providing opportunities to repeat new activities until they are
mastered.
. Initiative is also encouraged when parents answer their child’s questions
(intellectual initiative) and do not inhibit fantasy and play activity.
4 Adaptive Mechanism Learned During Preschool Years
1. IDENTIFICATION – occurs when the child perceives the self as similar to

another person and behaves like that person.
2. INTROJECTION – is the assimilation of the attributes of others.
3. IMAGINATION – preschoolers have active imagination and fantasize in
play.
4. REPRESSION – removing experiences, thoughts, and impulses from
awareness.
PREOPERATIONAL THOUGHT (2-7 years) – intuitive thought (substage)

1. They still have immature perception.
2. Preschool thinking is also influenced by ROLE FANTASY or how children
would like something to turn out.
3. They believe that wishes are as real as facts; that dreams are as real as
day-time happenings.
4. Preschoolers learn through trial and error, and they think of only one idea
at a time.
5. They do not understand relationships such as those between mother and
father.
6. Preschoolers become concerned about death as something inevitable, but
they do not discuss it. They also associate death with others rather than
themselves.
7. Reading skills also start to develop at this age. They like fairy tales and
books about animals and other children.
Good Games: Make believe games; Hide and seek games that require simple
rules and cooperation.
Good Activity: Picnic, visit to zoo
Good Toys: Those that encourage role - playing, construction trucks, dress-up
dolls, toy cooking ware.
Type of Play: ASSOCIATIVE PLAY – children play together in a similar activity
E. Moral Development
PRECONVENTIONAL STAGE II (4-7 years) INDIVIDUALISM /

INSTRUMENTAL – RELATIVE ORIENTATION
1. Preschoolers tend to do good out of self-interest rather than out of true
intent to do good or because of a strong spiritual motivation.
2. Preschooler imitate what they see (MODELLING)
3. They usually control their behavior because they want love and approval of
their parents.
4. MORAL BEHAVIOR. Taking turns at play or sharing.
1. Encouraging parents to give preschoolers recognition for actions such as

sharing.
2. Encourage parents to answer preschoolers “why” questions and discuss
values with them.
3. Since they do things for others only in return for things done for him or her.
This means it may be necessary to remind the child of the actions taken on
his or her behalf or TRADE-OFF ACTIONS.
F. Nutrition
1. The preschooler eats adult foods and should have the required amounts
from the four food groups.
2. Children at this age are very active and may rush through the meal to return
to playing. May provide finger food, such as chicken, hot-dogs on sticks.
3. Children at this age may enjoy helping in the kitchen, and both girls and
boys should be encouraged to do so.
G. Reaction to Hospitalization
1. Experience separating from family but not to the point of anxiety.

2. Fear loss of routines and schedules.
3. Fear bodily injury believes all inside can come out any hole in skin (Bandaid
age).
4. Believes hospitalization is punishment for bad thoughts and actions.
5. May have nightmares.
Nursing Responsibilities
1. Encourage parents to stay or visit frequently.

2. Provide familiar routines and allow independence in daily care as much as
possible.
3. Keep night light on during sleep and allow familiar items with the child.
4. Explain in simple terms what procedures are going to be done just prior to
being done.
5. Utilize play therapy as much as possible to diminish fears.
6. Encourage interaction and play with other children in the hospital in age
group.
7. Monitor growth and development.
SCHOOL-AGE CHILDREN (6-12 years)
a. The school-age child gains weight rapidly, and this appears less thin than
previously.
b. At 6 years, both boys and girls are about the same height.
c. Children of both sexes have a growth spurt, girls between 10 and 12 years,
boys between 12 and 14 years. Girls may well be taller than boys at 12
years although boy are usually stronger because of muscles develop-
mental
d. Very little change takes place in the reproductive and endocrine systems
until the pre-puberty period.
e. During pre-puberty, at about age 9, endocrine functions slowly increase and
some of the secondary sex characteristics, apocrine, and sweat glands
begins to develop and increase in secretions.
f. Sexual maturation in girls occurs between the years 12 to 18; in boys,
between 14 and 20 years.
g. School-age children perfect their muscular skills and coordination. Thus, by
9 years, most children are becoming skilled in games of interest, such as
football or basketball.
LATENT STAGE (6-12 years)
During this time, the focus is directed toward physical and intellectual activities,
while sexual tendencies seem to be repressed.
Encourage child with physical and intellectual pursuits.
INDUSTRY VS. INFERIORITY (6-12 years)
1. At this time, children begin to create and develop a sense of competence

and perseverance.
2. They are motivated by activities that provide a sense of worth.
3. They concentrate on mastering skills that will help them function in the adult
world.
4. Children compare their skills with those of their peers, in a number of areas,
including motor development, social and language. This comparison assists
in the development of self-concept.
Significant Person: Peers, Teacher
1. Motivate to be industrious and provide recognition.
2. Guiding children to perform tasks in which they are likely to succeed.
3. Teaching the child how to get along with peers by collaborating, compromising,
cooperating and competing.
Adaptive Mechanism Developed by a Schoolchild:
1. REGRESSION – returning to a form of behavior that was suitable at an earlier

time.
2. MALINGERING – pretending to be ill rather than facing something unpleasant.
3. RATIONALIZATION – attempt to justify behavior by logical reason and
explanation.
4. RITUALISTIC BEHAVIOR
CONCRETE OPERATIONAL THOUGHT (7-12 years)
1. During this stage, the child changes from egocentric interactions to

cooperative interactions
2. School age children also develop an increased understanding of concepts
that are associated with specific objects.
3. They develop logical reasoning from intuitive reasoning.
4. They also learn about cause and effect relationships at this age.
5. They now learn the value of money and time periods.
Good Activity: collecting and classifying natural objects such as seashells,

vegetables, etc., Field trips and hobbies.
NURSING IMPLICATIONS:
1. To promote proper development of cognitive abilities, the nurse should

screen the child for any vision or hearing problems.
2. Promotes cognitive development by encouraging reading, showing interest
in the child’s work, and providing a home environment in which the child can
complete home assignments.
3. They enjoy watching TV and playing video games, and parents or significant
others may have to set limits on these activities.
4. Parents should be aware of the child’s progress in school, have realistic
expectations of their child’s abilities, and be encouraged to report any
concerns to the teacher or to the school nurse.
Type of Play: COOPERATIVE PLAY – children play with an organized structure

or complete for desired goal or outcome.
1. Conventional Level Stage III (7-10 years) – Good Boy – Nice Girl / Stage /
Interpersonal Concordance
It is the orientation of interpersonal relations to mutuality. Child

follows rules because of a need to be a “good” person in their own eyes and
the eyes of others.
1. Allow child to help with bed making and other activities.

2. Praise for desired behavior such as sharing.
2. Conventional Level: Stage IV (10-12 years)

LAW AND ORDER ORIENTATION
a. Child finds following rules satisfying.

b. Follows rules of authority figures as well as parents in an effort to keep
the “system” going.
F. Nutrition
1. School-age children require a balanced diet including 2,400 Kcal per day
2. School-age children eat three meals a day and one or two nutritious snacks.
3. They need a protein – rich food at breakfast to sustain the prolonged
physical and mental effort required at school.
4. Parents should be aware that children learn many of their food habits by
observing their parents.
G. Reactions to Hospitalization
1. Experience fear of separation from family and friends.

2. Fear of getting behind in school.
3. Fear of body mutilation and loss of independence.
4. Exhibit stress by attempting to negotiate, crying, fighting withdrawal, and
attempting to be brave.
5. They ask many questions.
1. Describe illness; treatments, and procedures to child and parent.

2. Allow questions and answer in simple terms.
3. Allow independence and choices as much as possible.
4. Encourage doing schoolwork.
5. Set limits, establish routines.
6. Utilize play therapy or playing with other children of the same age.
7. Tell the child crying okay, provide the child with privacy after procedures to
recompose self.
8. Monitor growth and development.
ADOLESCENCE (12 -20 years)
1. The period during which the person becomes physically and psychologically
mature and acquires a personal identity.
2. It is the period of Puberty, the first stage of adolescence in which sexual
organs begin to grow and mature. Also referred to as Adolescent Growth
Spurt.
3. Growth is fastest for boys at about 14 years and the maximum height is
often reached at about 18 or 19 years. With girls, at about 15-16 years.
4. Both primary and secondary sex characteristics develops.
5. Female internal reproductive organs reach adult size about age 18-20
years.
GENITAL STAGE (18 years and after)
Adolescent develops sexual maturity and learns to establish satisfactory

relationships with the opposite sex
1. Provide opportunities for the child to related with opposite sex.

2. Allow child to verbalize feelings about new relationships.
IDENTITY VS. ROLE CONFUSION (12-20 years)
Adolescents learn who he or she is and what kind of person he or she will be
by adjusting to a new body image, seeking emancipation from parents,
choosing a vocation, and determining a value system.
Significant Person: PEER GROUPS
The peer groups have a number of functions. It provides a sense of belonging,

pride, social learning, and sexual roles. In adolescence, the peer groups
change with age, they start as single-sex groups, evolves to mixed groups, and
finally narrow to couples who share activities.
1. Provide opportunities for the adolescent to discuss feelings about events

important to him or her.
2. Offer support and praise for decision-making.
FORMAL OPERATIONAL THOUGHT (Over 12 years)
1. Adolescents are highly imaginative and idealistic.

2. Adolescent’s capacity to absorb and use knowledge is great.
3. They usually select their own areas for learning; they explore interests from
which they may evolve a career plan.
4. The main feature of this stage is that people can think beyond the present
and beyond the world of reality.
5. They consider things that do not exist but that might be and consider ways,
things that should be or ought to be.
6. Thought processes: logical, organization, and consistency, Mature or adult
thought.
7. Can solve hypothetical problems with scientific reasoning.
8. Understands causality and can deal with the past, present, future.
1. Post - Conventional Level: Stage V – SOCIAL CONTRACT, LEGALISTIC

ORIENTATION – standard of behavior is based on adhering to laws that
protect the welfare and rights of others. Personal values and opinions are
recognized and violating the rights of others is avoided.
2. Post - Conventional Level: Stage VI – UNIVERSAL – ETHICAL
PRINCIPLES – Universal moral principles are internalized. Person respects
other humans and believes that relationships are based on mutual trust.
F. Nutrition
1. The need for protein, calcium, Vit. D, iron, B complex and calories increase
during adolescence because of growth spurt.
2. An adequate diet for an adolescent is 1 qt. of milk per day as well as
appropriate amount of meat, vegetables, fruits, breads, and cereals.
3. Teenagers have active lifestyles and irregular eating patterns. They tend to
snack frequently, often eating high-calorie foods such as doughnuts,
softdrinks, ice creams, and fast foods.
4. Parents can provide healthy snacks such as fruits and cheese and at the
same time limit the amount of junk foods available in the home.
5. The teenager’s food choice is related to physical, social, and emotional
factors and impulses and may not be influenced by teaching.
6. Common problems related to nutrition and self-esteem among adolescents
include obesity, anorexia, nervosa, and bulimia.
G. Reactions to Hospitalization
1. They experience fear of being different, embarrassment, bodily injury,

separation from family and friends, loss of privacy, and loss of
independence.
2. May exhibit overconfidence, withdrawal, non-compliance with regimen,
regression and acting out.
1. Maintain honest and open communication.

2. Provide information regarding illness and treatments.
3. Encourage questions and provide under-standable answers.
4. Provide privacy.
5. Encourage interactions with faculty, friends and others in age group who
are hospitalized.
6. Assist with maintaining homework.
7. Allow decision making as much as possible.
8. Set limits.
The learners will accomplish a 30-item multiple choice quiz; this will be
accomplished within 30 minutes at a given date and time
The learners will create a Concept Diagram illustrating link

between the different theories on a particular stage of
development assigned to their group.
Summary and conclusion
All children pass through predictable stages of growth and development. To make
care holistic, it is important to consider all aspects of the child’s health physical, emotional,
cognitive and social and remember that each child’s developmental progress is unique.
A child cannot be forced to achieve a milestone faster than that child’s own timetable will
allow. Through anticipatory guidance, a child, however, can be encouraged to reach his
or her maximum developmental potential. Nurses can play an important role in offering
guidance to both the child and family toward this end.
Reflection Question/Learning: posted in the Discussion

tab of MyClass
1. What are the significant concepts that you learned

from the sessions pertaining to Growth and
Development?
2. How did you find the activities for Growth and
Development?
References:
Adopted From:
PRESCRIBED TEXT:
childbearing and childrearing family. Volume 1 and 2 (Philippine edition); 8 edition. th
Books:
Green, C. (2016). Maternal newborn: nursing care plans. (3rd edition). Burlington, MA: Jones and Bartlett
Learning.
Visovsky,C (2019) Introductory maternity and pediatric nursing, Philadelphia: Wolters Kluwer
Williams and Wilkins Health. 6. Hockenberry, M. (2017). Wong’s essentials of pediatric nursing. St. Louis.
Prepared by:
(SGD) Ma. Corazon M. Tanhueco, R.N.,MAN

NCM 0107 Instructor
Peer evaluated by:
(SGD) Sarah S. Nares, R.N., MN Commented [1]: (SGD) SSN

(SGD) Brenda B. Policarpio, R.N., MN
NCM 0107 Instructors Commented [2]: (SGD)BRENDA POLICARPIO
Reviewed and evaluated by:
Jennie C. Junio R.N., MAN

Level II Coordinator
Debbie Q. Ramirez, R.N., Ph. D.

Assistant Dean
Approved by:
Zenaida S. Fernandez, R.N., Ph. D.

Angeles City
COLLEGE OF NURSING
NURSING CARE MANAGEMENT 0107

CARE OF THE MOTHER, CHILD, AND ADOLESCENT (WELL CLIENTS)
Module 9 Content
Scopes and Standards of Maternal and Child Health in the Philippines
MODULE OVERVIEW
Law and ethics are interrelated and affect all of nursing. Professional nurses must
understand their scope of practice, standards of care, institutional or agency policies, and
government laws. All nurses are responsible for knowing current information regarding
ethics and laws related to their practice.
Maternal and child health nursing carries some legal concerns because care is often
given to patients who are not of legal age for giving consent. The issues require specific
attention when caring for expectant families. New technologies can lead to potential legal
action, especially if the parents are uninformed about the reason or medical necessity for
these procedures.
Nurses are also legally responsible for protecting the rights of their patients,
including confidentiality, and are accountable for the quality of their individual nursing
care and that of other members of the health team. Understanding the scope of practice
and standards of care can help nurses practice within appropriate legal parameters.
LEARNING OUTCOME
Upon completion of the module, the student shall be able to:
LO13. Adhere to ethico-legal considerations when providing safe, quality and professional
maternal and child nursing care.
LO14. Adhere to established norms of conduct based on the Philippine Nursing Law and
other legal, regulatory and institutional requirements relevant to safe maternal and
child nursing practice.
LO15. Protect maternal, child, adolescent rights based on “Patient’s Bill of Rights and
Obligations”.
LEARNING OBJECTIVES
Upon completion of the module, the student shall be able to:
1. Differentiate the terms scope and standards
2. Enumerate the laws that govern practice of maternal and child care in the Philippines
3. Identify the provisions stated in each law
4. Describe the legal, ethicomoral considerations, and social issues in maternal-child
practice
5. List some of the advances in genetic technology
6. Enumerate the various alternatives to child birth
7. Discuss the Reproductive Health Bill and other DOH programs on maternal and child
Nursing Care Management 0107 1|P age

care
8. Identify nursing interventions appropriate to maintain safety, security, and privacy of
the patient with regards to ethico-moral standards of care
ASSESSMENT: PRETEST
Test I. Multiple Choice. Choose the best answer
1. A program that reflects the government’s response to the growing problem in
micronutrient malnutrition:
A. Food fortification program
B. Expanded program for immunization
C. Child health and development
D. Newborn screening
2. A program that ensure early detection and management of several congenital

metabolic disorders:
3. The study of all genes and includes interactions among genes as well as interactions
between genes and the environment:
A. Genetic engineering
B. Genetic technology
C. Genomics
D. Genetics
4. It involves a range of activities concerned with understanding gene expression, taking

advantage of natural genetic variation, modifying genes and transferring genes to new
hosts:
C. Genomics
D. Genetics
5. The following are alternative methods of child birth EXCEPT:

A. Surrogate
B. Adoption
C. Child-free living
D. In-vitro fertilization

6. A major strategy for child survival, healthy growth and development, and is based on
the combined delivery of essential interventions at community, health facility and
health systems levels:
A. IMCI
B. Unang yakap
C. ENC
D. National motherhood program
7. Which of the following is a key element in informed consent?

A. The person signing the consent should be of legal age
B. Physicians can sign as witness to the signing
C. Oral consent is not legal
D. The procedure should be explained in detail using medical terms
8. Which statement is TRUE regarding maternity benefits in the Philippines?

A. Mothers are given 160 days of paid leave
B. Mothers can transfer 20 days of leave to the father
C. Additional 30 unpaid days of leave can be filed
D. Additional 30 days of paid leave will be given to single mothers
9. The Philippine Nursing Act is known as:

A. R.A. 7322
B. R.A. 11210
C. R.A. 9173
D. R.A. 7610
10. It refers to the minimum criteria for competent, proficient delivery of nursing care:
A. Standard of care
B. Scope of practice
C. Legal responsibility
D. Bill of rights
FEEDBACK ON THE PRETEST

1. A 6. A
2. D 7. A
3. C 8. C
4. B 9. C
5. D 10. A
Note: If your score is 6 or higher, your understanding of Scope and Standards of Maternal
and Child Care is satisfactory; you may proceed in reading this module to further
enhance your knowledge.
If your score is lower than 6, you may proceed in studying this module and
approach the instructor for assistance in understanding the contents of the

module.
At the end of reading and studying this module, kindly accomplish the post-
test in order to evaluate your understanding of the Scope and Standards of
Maternal and Child Care.
RECOMMENDED PREPARATION
Before going through this module, the student is advised to read the following terms:
Genes – basic units of heredity that determine both the physical and cognitive
characteristics of people
Genetic technology – anything to do with understanding, making or adapting genetic
material
Genomics – the study of all genes and includes interactions among genes as well as
interactions between genes and the environment
Scopes of practice – the limits of nursing practice set forth in state statutes
Standards of practice – minimum criteria for competent, proficient delivery of nursing
care
Scope and Standards of Maternal and Child Health in the Philippines

Scope of Practice – defined as the limits of nursing practice set forth in state statutes. A
nurse must practice function within the scope of practice or risk being accused of
practicing medicine without a license.
Standards of Nursing Care – minimum criteria for competent, proficient delivery of

nursing care; such standards are designed to protect the public and are used to judge the
quality of care provided. Legal interpretation of actions within standards of care is based
on what a reasonably prudent nurse with similar education and experience would do in
similar circumstances
R.A. 9173, Scope 28 (The “Philippine Nursing Act of 2002”)

An act that stipulates the scope of nursing practice. It includes provisions on nurse’s
responsibility in maternal, newborn, and child care stated as follows:
“A person shall be deemed to be practicing nursing within the meaning of this Act when
he/she singly or in collaboration with another, initiates and performs nursing services to
individuals, families and communities in any health care setting. It includes, but not limited
to, nursing care during conception, labor, delivery, infancy, childhood, toddler, preschool,
school age, adolescence, adulthood, and old age.”
1987 Philippine Constitution, Article 13

Section 11: The State shall adopt an integrated and comprehensive approach to health
development which shall endeavor to make essential goods, health and other social
services available to all the people at affordable cost. There shall be priority for the needs
of the under-privileged, sick, elderly, disabled, women, and children. The State shall
endeavor to provide free medical care to paupers.

Section 14: The State shall protect working women by providing safe and healthful
working conditions, taking into account their maternal functions, and such facilities and
opportunities that will enhance their welfare and enable them to realize their full potential
in the service of the nation.
R.A. 9710 (Magna Carta for Women)

The Magna Carta for Women is a comprehensive women's human rights law that
seeks to eliminate discrimination through the recognition, protection, fulfilment and
promotion of the rights of Filipino women, especially those belonging in the marginalized
sectors of the society. It conveys a framework of rights for women based directly on
international law.
Features include:
1. Comprehensive health services and health information and education covering all
stages of a woman's life cycle, and which addresses the major causes of women's
mortality and morbidity, including access to among others, maternal care,
responsible, ethical, legal, safe and effective methods of family planning,
and encouraging healthy lifestyle activities to prevent diseases
2. Leave benefits of two (2) months with full pay based on gross monthly
compensation, for women employees who undergo surgery caused by gynecological
disorders, provided that they have rendered continuous aggregate employment
service of at least six (6) months for the last twelve (12) months
3. Equal rights in all matters relating to marriage and family relations. The State shall
ensure the same rights of women and men to: enter into and leave marriages, freely
choose a spouse, decide on the number and spacing of their children, enjoy personal
rights including the choice of a profession, own, acquire, and administer their
property, and acquire, change, or retain their nationality. It also states that the
betrothal and marriage of a child shall have no legal effect.
R.A. 7322 (Increasing Maternity Benefits in Favor of Women Workers in the Private
Sectors)
An act increasing maternity benefits in favor of women workers in the private
sector. As such, it states: “A covered female employee who has paid at least three monthly
maternity contributions in the twelve-month period preceding the semester of her
childbirth, abortion or miscarriage and who is currently employed shall be paid a daily
maternity benefit equivalent to one hundred percent (100%) of her present basic salary,
allowances and other benefits or the cash equivalent of such benefits for sixty (60) days”.
R.A. 11210 (Act Increasing Maternity Leave)

Under the measure, all working mothers in the government and private sector are
guaranteed with 105 days of paid maternity leave credits, with 7 days transferable to
fathers. An additional 15 days of paid leave will be granted to single mothers. Under the
previous law, employed women are entitled to 60 days of paid leave for normal delivery
and 78 days for caesarean delivery. The newly signed law gives mothers the option to
extend their leave for another 30 days without pay, provided that the employer is given
due notice in writing at least 45 days ahead before the end of the maternity leave. The

law also applies to every instance of pregnancy, removing the 4-pregnancy cap. It shall
be applied to all female workers regardless of civil status. For cases of miscarriage or
emergency termination of pregnancy, a 60-day paid maternity leave shall be granted to
a female worker. Maternity benefits shall also be given to female workers in the informal
economy, provided that they have remitted to the Social Security System at least three-
monthly contributions in the 12-month period immediately preceding the semester of her
childbirth, miscarriage, or emergency termination of pregnancy.
R.A. 7600 (The Rooming-In and Breastfeeding Act of 1992)

An act providing incentives to all government and private hospitals with rooming-
in and breastfeeding practices. Exception include mothers and babies with complications
or problems, hence do not permit rooming-in and breastfeeding. These infants shall be
fed expressed breastmilk.
R.A. 10028 (Expanded Breastfeeding Promotion Act)

An act signed in 2009 to support, protect and encourage women who are
breastfeeding working moms. Through the law, there were provisions which requires
workplaces to implement certain regulations. In turn, these will be highly beneficial to
breastfeeding moms at work. The law requires workplaces to establish a lactation station
for nursing mothers. For both health and non-health companies, there must be lactation
stations with complete equipment and facilities. Breastfeeding moms are entitled to an
additional break called “lactation periods”. These break intervals will include the time it
takes to get to and from their workplace to the company’s lactation station. The law
mandates that these are considered compensated hours. Although the Department of
Labor and Employment (DOLE) can approve adjustments, the law requires not less than
40 minutes of lactation break for every 8-hour working period. With this, breastfeeding
moms can have 2-3 breast milk expressions lasting 15-30 min each within a workday. The
law also mandates that employers must include breastfeeding programs as part of their
human resource development programs. They must disseminate the provisions to their
staff and employees.
National Safe Motherhood Program

This a DOH program that aims to provide rational and responsive policy direction
to its local government partners in the delivery of quality maternal and newborn health
services with integrity and accountability using proven and innovative approaches. The
program components include the following:
A. Local Delivery of the Maternal–Newborn Service Package
-This component supports local government units (LGUs) in establishing and
mobilizing the service delivery network of public and private providers to enable
them to deliver the integrated maternal-newborn service package. In each province
and city, the following shall continue to be undertaken:
1. Establishment of critical capacities to provide quality maternal-newborn services
through a network of Service Delivery Teams consisting of:
a. Barangay Health Workers

b. Basic Emergency Obstetric and Newborn Care (BEmONC) Teams composed
of Doctors, Nurses and Midwives
2. In collaboration with the Centers for Health Development (CHD) and relevant
national offices: Establishment of Reliable Sustainable Support Systems for maternal-
newborn service delivery through such initiatives as:
a. Establishment of safe blood supply network with support from the National
Voluntary Blood Program
b. Behavior Change Interventions in collaboration with the Health Promotion
and Communication Service
c. Sustainable financing of maternal - newborn services and commodities
through locally initiated revenue generation and retention activities
including PhilHealth accreditation and enrolment
B. National Capacity to Sustain Maternal-Newborn Services
1. Operational and regulatory guidelines
a. Identification and profiling of current family planning (FP) users and
identification of potential FP clients and those with unmet need for FP
(permanent or temporary methods)
b. Mainstreaming FP in the regions with high unmet need for FP
c. Development and dissemination of information, education, communication
materials
d. Advocacy and social mobilization for FP
2. Network of training providers
a. Training Centers that provide BEmONC Skills Training
3. Monitoring, evaluation, research, and dissemination with support from the
Epidemiology Bureau and Health Policy Development and Planning Bureau
a. Monitoring and supervision of private midwife clinics in cooperation with
PRC Board of Midwifery and Professional Midwifery Organizations
b. Maternal death reporting and review system in collaboration with provincial
and city review teams
c. Annual program implementation reviews with Provincial Health Officers and
Regional Coordinators
Legal, Ethicomoral Considerations, and Social Issues in Maternal-Child Practice

Abortion – has been legal in the United States since 1973. The procedure can be
performed until the period of viability; after that, abortion is permissible only when the
life or health of the mother is threatened. Before viability, the rights of the mother are
paramount; after viability, the rights of the fetus take precedence. The decision of abortion
is to be made by the mother and her physician. Nurses have the right to refuse to assist
with the procedure if abortion is contrary to their moral and ethical beliefs.
Cord Blood Banking – Cord blood, taken from a newborn’s umbilical cord at birth, may
play a role in combating leukemia, certain other cancers, and immune and blood system
disorders. This is possible because cord blood, like bone marrow and embryonic tissue,
contains regenerative stem cells, which can replace diseased cells in the affected
individual. The public, however, should be made aware that stem cells from cord blood

cannot be used to treat inborn errors of metabolism or other genetic diseases in the same
individual from which they were collected because it would have the same genetic
mutation. Issues may arise with issuing a consent for use, use of coercion, and issues on
ownership of the cord blood.
Embryonic stem cell research – human stem cells can be found in embryonic tissue and
in the primordial germ cells of a fetus. Research has demonstrated that these tissues can
be made to differentiate into other types of cells, which can be used to treat numerous
disorders. The availability of specialized tissues or even organs grown from stem cells
might also decrease society’s dependence on donated organs for transplants. Issues to
be considered are: what moral status should be attached to the human embryo? What
sources of embryonic tissue are acceptable for research (such as adult stem cell and
embryonic stem cell)? Ethical concern rises for the use of embryonic stem cell because the
process of obtaining these cells result in destruction of the embryo. Deliberations relate
whether the embryo is already considered a person with moral status.
Human Genome Project (HGP) – an international, multidisciplinary effort to explore and

map all human genetic material. Mapping the human genome is the first step in the
process of attempting to understand the nature of hereditary diseases and finding ways
to identify individuals who are at risk of transmitting a given disease. Potentially this
information could also be used to screen fetuses in utero for genetic diseases that are not
currently identifiable using standard screening tools.
Informed Consent – a legal concept that protects a client’s right to autonomy and self-
determination by specifying that no action may be taken without that person’s prior
understanding and freely given consent; it is usually enforced for such major procedures,
but it also pertains to any nursing, medical, or surgical intervention. It follows that the
informed consent includes the components of disclosure, comprehension, competency,
and voluntariness. The following are key elements of an informed consent:
-patient should be of legal age and understand the procedure, the rationale, and any
associated risks, possible alternatives
-physician provides information in a manner that is simple, concise, and appropriate
to the level of education and language of the individual making the decision
-oral consent is legal
-parents are granted the responsibility and authority for minor children; minor
mothers may consent treatment for her newborn, but not for herself
-refusal of treatment, medication, or procedure requires that a client sign a form
releasing the doctor and clinical facility from liability
Nursing responsibilities related to informed consent include the following:
1. Ensure that the consent form is completed with signatures of the client
2. Serve as a witness to the signature process
3. Determine whether the client understands what she is signing by asking pertinent
questions

Intrauterine fetal surgery – generally, considered experimental; therapy for anatomic
lesions that can be corrected surgically and are incompatible with life if not treated. The
procedure involves opening the uterus during the second trimester, performing the
surgery, and replacing the fetus in the uterus. The parents must be informed of the
experimental nature of the treatment, the risks of the surgery, the commitment to
cesarean birth, and alternatives to treatment.
Maternal-Fetal Conflict – The fetus is viewed as a client separate from the mother, and
that there is medical emphasis of duality; both the mother and the fetus deserve respect
and treatment. Fetal care becomes problematic when what is required to benefit one
member will cause unacceptable harm to the other. The ethical principle of beneficence
(be of benefit) and nonmaleficence (do no harm) can come into conflict.
Reproductive assistance – therapeutic insemination (TI) is accomplished by depositing

sperm to a woman obtained from the husband, partner, or other donor. Legal problems
may arise if donor sperm is used. The donor signs a form waiving parental rights, required
to furnish a complete health history, and his sperm tested for HIV. If the woman is married,
her husband may be asked to signa form to agree to the insemination and to assume
parental responsibility for the child. Assisted reproductive technology (ART) is used to
describe highly technologic approaches used to produce pregnancy. In vitro fertilization
and embryo transfer are perhaps the best-known ART technique. Slightly more than one-
third of pregnancies from ART technique result in multiple pregnancies. This is because
of the use of ovulation-inducing medications that trigger the release of multiple eggs.
This increases the risk of miscarriage, preterm births, and neonatal morbidity and
mortality. To help prevent a high-level multiple pregnancy, the American Society for
Reproductive Medicine has issued guidelines to limit the number of embryos being
transferred. This practice raised ethical considerations about the handling of unplanted
embryos. This raises ethical concerns. Surrogate childbearing occurs when a woman
agrees to become pregnant for a childless couple. She may be artificially inseminated with
the male partner’s sperm or a donor’s sperm or may receive a gamete transfer, depending
on the infertile couple’s needs. If fertilization occurs, the woman carries the fetus to term
and release the infant to the couple after birth. These method of resolving infertility raise
ethical issues about candidate selection, responsibility for a child born with congenital
defect, and religious objections to artificial conception.
Right to privacy and confidentiality – the right of a person to keep her or his person
and property free from public scrutiny. This includes avoiding unnecessary exposure of
the childbearing woman’s body. Nurses are legally responsible for protecting client rights
to confidentiality. This include patient rights to access medical record if necessary.
National standards for electronic transmission of health information is also observed.
Protection of medical records extends not only to clinical health care sites, but also to
ancillary health care providers such as pharmacies, laboratories, and third-party payers
(insurance). Information should only be shared with the client, legal partner, parents, legal
guardians, or individuals as established in writing by the client or the child’s parents.
Exceptions, however, exist. This may include information relating to abuse, injuries caused

by weapon or criminal act, and infectious disease that need to be reported to the local
health department. If health information must be disclosed, the client must be informed
that this will occur.
The complex ethical issues facing maternal-newborn nurses have many social, cultural,
legal, and professional ramifications. Ethical decisions in maternal-child nursing are often
complicated by moral obligations to more than one client. Straightforward solutions to
the ethical dilemmas encountered in caring for childbearing families are often, quite
simply, not available. Nurses must learn to anticipate ethical dilemmas, clarify their own
positions related to the issues, understand the legal implications of the issues, and
develop appropriate strategies for ethical decision making. It also essential to identify
high-risk group so that interventions can be initiated early on. Nurses also need to refine
their skills in logical thinking and critical analysis. Lastly, nurses must remain up to date
about new technologies and treatments and integrate high quality, evidence-based
interventions into the care they provide.
Advances in Genetic and Genetic Technology

Genes are the basic units of heredity that determine both the physical and
cognitive characteristics of people. Composed of segments of DNA, they are woven into
strands in the nucleus of all body cells to form chromosomes. In humans, each cell, with
the exception of the sperm and ovum, contains 46 chromosomes (22 pair of autosomes
and 1 pair of sex chromosomes). Genetics is the study of individual genes and their role
in in inheriting certain characteristics. Genomics is the study of all genes and includes
interactions among genes as well as interactions between genes and the environment.
A person’s phenotype refers to his or her outward appearance or the expression of
genes; whereas, genotype refers to the actual gene composition. A normal genome is
expressed as 46XX for females and 46XY for males. person’s genome is the complete set
of genes present (about 50,000 to 100,000). If a chromosomal aberration exists, it is listed
after the sex chromosome pattern. P- stands for short arm defect, q- stands for long arm
defects, and + means an extra chromosome. In Down Syndrome, the genome is expressed
as 47XX21+ or 47XY21+; this means that there is an extra chromosome 21.
Genetic technology can be anything to do with understanding, making or adapting
genetic material. It involves a range of activities concerned with understanding gene
expression, taking advantage of natural genetic variation, modifying genes and
transferring genes to new hosts. Genomics play a role in complex health conditions as
well as emerging areas of research such as that of pharmacogenomics (influence of
genetics on pharmacodynamics and pharmacotherapeutics).
Rapid development and implementation of advanced genetics technology include
ability to screen and diagnose a broader range of diseases and conditions. Today, nurses
are required to have basic skills and knowledge in genetics, genetic testing, and genetic
counseling so they can assume new roles and provide information and support to women
and their families. Nurses are expected to carry out the following responsibilities and roles
in genetic study and genetic counseling:
1. Knowing basic genetic terminology and inheritance patterns
Nursing Care Management 0107 10 | P a g e

2. Using therapeutic communication skills; active listening in particular, to identify
specific concerns and address emotional reactions
3. Safeguarding the privacy and confidentiality of client’s genetic information
4. Recognizing and defining the ethical, legal, and social issues concerning genetic
technology
5. Providing necessary information and counseling through the use of culturally
appropriate methods of conveying information
Human Genome Project

The National Human Genome Project begun in 1990 and was officially completed
in April 2003, a total of 13 years and cost $3 billion. The goal of the project included
sequencing the entire human genome and determine what makes us distinct from other
species and from each other, the function of individual genes, and studying the ethical,
legal, and social implications of genetic technology. This led to an increased
understanding of the genotype and has allowed development of targeted health
promotion strategies, potential disease prevention, genotype-tailored drug, and eventual
correction of disease by development of gene transfer technology (gene therapy).
First Life Saved by Genome Editing

Layla, a patient at Great Ormond Street Hospital in 2015 was cured of acute
lymphoblastic leukemia. This was made possible by being able to genetically edit donor
T-Cells (a type of immune cell) using TALENs. These cells had new genes added to them
so that when administered to Layla they became effectively invisible to a powerful
leukemia drug that would usually have killed them. They were also reprogrammed in such
a way that they only targeted and fought leukemia cells.
Genome Editing of Human Embryos

Following on from some earlier attempts by Chinese scientists, which had met with
limited success, the CRISPR-Cas9 system was used in 2017 to remove a genetic
predisposition to heart disease in human embryos. Although there are still some
remaining questions as to whether the editing worked in the way that the authors claimed,
it appeared to be efficient and without the undesirable side effects of introducing
unintended changes at other places in the genome (off-target effects) or failing to
introduce the change equally in all cells (mosaicism). Many of these side effects had been
found in the earlier work form China in 2015, 2016 and 2017. The embryos were only
allowed to develop for long enough to measure the changes introduced and they were
not implanted into women. The USA, where much of the work was carried out, does not
allow the implantation and gestation of a gene edited embryo. It is possible that this
technology could be used to enable people with hereditary diseases to avoid passing
them on to their children and future generations.
First Use of Crispr-Cas9 To Edit A Mammalian Genome

For the first time, the CRISPR-Cas9 system was used by researchers on both human
and mouse cells, as a method of genome editing. CRISPR is a molecular system based on
RNA that guides a protein called Cas9 to a specific target sequence of DNA. Cas9 then

cuts the DNA at that site. DNA repair mechanisms then try to repair the cut DNA, but may
leave a small gap or deletion, or even a small insertion. This is an efficient way to make a
change in a gene. Alternatively, if new DNA (a DNA template) is introduced at the same
time, it can replace the DNA sequence that was previously there. This can be used to alter
a single letter (base pair) in the DNA, or many, replace or insert a whole gene, or make
precise deletions. Compared with ZFNs and TALENs, CRISPR-Cas9 is easier to use, cheaper
to make and more efficient in that edits can be carried out at multiple locations of the
genome at the same time, so its development has made genome editing much more
accessible. The way CRISPR-Cas 9 is targeted to interact with DNA is also more precise
than ZFNs and TALENs.
The Future - First Synthetic Complex Organism

It is predicted that the year 2018 is the first in which the genome for a complex
organism is created from scratch in the lab. The Synthetic Yeast Genome Project is
currently in the process of building a yeast genome by shuffling around genes within
artificial chromosomes. Whilst yeast might not sound very complex, it has the same
specialized structures (organelles), and a nucleus to contain its DNA as human cells and
all other plants, animals and fungi. Previously, such work had only been carried out using
simpler organisms like bacteria. The work therefore gives insight into the workings of yet
more complex organisms.
Alternative Methods of Births

Surrogate
Surrogate mother is a woman who agrees to carry a pregnancy to term for a
subfertile couple. The surrogate may provide the ova and be impregnated by the man’s
sperm. In other instances, the ova and sperm both may be donated by the subfertile
couple, or donor ova and sperm may be used. Surrogate mothers are often friends or
family members who assume the role out of friendship or compassion, or they can be
referred to the couple through an agency or attorney and receive monetary
reimbursement for their expenses.
Several ethical and legal problems arise if the surrogate mother decides at the end
of the pregnancy that she has formed an attachment to the fetus and wants to keep the
baby despite the prepregnancy agreement she has signed. Another potential problem
occurs if the child is born imperfect and the subfertile couple no longer want the child.
Who should have the responsibility in this instance?
Adoption
Adoption, once a ready alternative for subfertile couples, is still a viable alternative,
although today there are fewer children available for adoption from official agencies.
Methods of adoption:
a. Agency adoption – A couple usually contracts an agency by first attending an
informational meeting and are then placed on a waiting list for processing. This
includes extensive interview and a home visit by an agency social worker to
determine whether the couple can be relied on to provide a safe and nurturing
environment for an adopted child. Once approved, the couple is placed on a second

waiting list until a child is available. This may extend from a few months to 5 or 6
years.
b. International adoption – this method can often provide a baby in less than a
traditional agency adoption. This also creates an unanswered question on the
infant’s prenatal health care or information about the birth parents. Problems may
also arise especially if the child will come from a country with war conditions (e.g.
release of the child from the country).
c. Private adoption – this serves as an alternative for families who cannot wait for
traditional agency adoption process or who have exhausted other options. The
adopting parents usually agree to pay a certain amount of money to a birth mother,
part of which goes to prenatal and medical expenses. In some instances, close
familiarity between the two parties creates difficulties such as when the birth mother
changes her mind about giving up the baby, contacting the adoptive family, and
vice versa.
Child-Free Living
Child-free living is an alternative lifestyle available to both fertile and subfertile
couples. For many subfertile couples who underwent frustrations of subfertile testing and
unsuccessful treatments, this method may emerge as a possible option. The couples may
wish to reexamine their thoughts and feelings about undergoing the emotional or
financial cost of other alternatives. The couples can look at the fact that they will have
more time to pursue their careers, travel more, pursue hobbies, engage in more family
connections, and participate various community recreational programs.
Reproductive Health Bill and other DOH Programs on Maternal and Child Care
The Responsible Parenthood and Reproductive Health Act of 2012 (Republic Act
No. 10354), informally known as the Reproductive Health Law or RH Law, is a law in
the Philippines, which guarantees universal access to methods on contraception, fertility
control, sexual education, and maternal care. These principles are based on
the four (4) pillars of Responsible Parenthood, Respect for Life, Birth Spacing, and
Informed Choice.
Reproductive health care refers to the access to a full range of methods, facilities,
services and supplies that contribute to reproductive health and well-being by addressing
reproductive health-related problems. The advancement and protection of women’s
human rights shall be central to the efforts of the State to address reproductive health
care.
The elements of reproductive health care include the following:
(1) Family planning information and services;
(2) Maternal, infant and child health and nutrition, including breast feeding;
(3) Prevention of abortion and management of post-abortion complications;
(4) Adolescent and youth reproductive health guidance and counseling;
(5) Prevention and management of reproductive tract infections (RTIs), HIV/AIDS and
sexually transmittable infections (STIs);
(6) Elimination of violence against women and children and other forms of sexual and
gender-based violence;

(7) Education and counselling on sexuality and reproductive health;
(8) Treatment of breast and reproductive tract cancers and other gynecologic
conditions and disorders;
(9) Male responsibility and involvement and men’s RH;
(10) Prevention, treatment and management of infertility and sexual dysfunction;
(11) RH education for the adolescents; and
(12) Mental health aspect of reproductive health care.
Summary of Provisions:
1. The bill mandates the government to "provide information and access, without biases,
all effective natural and modern methods of family planning that are medically safe and
legal."
2. The provision of reproductive health care, information and supplies (giving priority to
poor beneficiaries, including pro-bono services for indigent women) must be the
primary responsibility of the national government consistent with its obligation to
respect, protect and promote the right to health and the right to life.
3. Although abortion is recognized as illegal and punishable by law, the bill states that
“the government shall ensure that all women needing care for post-abortion
complications shall be treated and counseled in a humane, non-judgmental and
compassionate manner”.
4. The bill calls for a "multi-dimensional approach" integrating a component of family
planning and responsible parenthood into all government anti-poverty programs. Age-
appropriate reproductive health and sexuality education will be provided to
adolescents which shall be taught by adequately trained teachers and integrated in
relevant subjects. The Department of Education (DepED) shall formulate a curriculum
which shall be used by public schools and may be adopted by private schools. All
serious and life-threatening reproductive health conditions such as HIV and AIDS,
breast and reproductive tract cancers, and obstetric complications, and menopausal
and post-menopausal-related conditions shall be given the maximum benefits,
including the provision of Anti-Retroviral Medicines (ARVs), as provided in the
guidelines set by the Philippine Health Insurance Corporation (PHIC).
5. The national government and local governments will ensure the availability of
reproductive health care services like family planning and prenatal care.
6. The LGUs shall endeavor to hire an adequate number of nurses, midwives and other
skilled health professionals for maternal health care and skilled birth attendants. More
so, each LGU shall endeavor to establish or upgrade hospitals and facilities with
adequate and qualified personnel, equipment and supplies to be able to provide
emergency obstetric and newborn care. People in geographically isolated or highly
populated and depressed areas shall have the same level of access and shall not be
neglected by providing other means such as home visits or mobile health care clinics.
The national or the local government may provide each provincial, city, municipal and
district hospital with a Mobile Health Care Service (MHCS) in the form of a van or other
means of transportation appropriate to its terrain. The national government shall
provide additional and necessary funding and other necessary assistance for the
effective implementation of this provision.

7. The cities and municipalities shall endeavor that barriers to reproductive health services
for PWDs are eliminated by providing access to information and services that are
tailored accordingly to adapt the needs of women with disabilities (ex: information
printed on braille, sign language).
8. The bill also mandates the Department of Labor and Employment to guarantee the
reproductive health rights of its female employees. Companies with fewer than 200
workers are required to enter into partnership with health care providers in their area
for the delivery of reproductive health services. Employers with more than 200
employees shall provide reproductive health services to all employees in their own
respective health facilities. Employers shall inform employees of the availability of
family planning. They are also obliged to monitor pregnant working employees among
their workforce and ensure they are provided paid half-day prenatal medical leaves for
each month of the pregnancy period that they are employed.
9. Any person or public official who prohibits or restricts the delivery of legal and medically
safe reproductive health care services will be meted penalty by imprisonment ranging
from 1 to 6 months or a fine of 10,000 to 100,000, or both according to the discretion
of the competent court.
Other DOH Programs on Maternal and Child Care

1. Infant and Young Child Feeding (IYCF)
A global strategy for Infant and Young Child Feeding (IYCF) was issued jointly by
the World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF)
in 2002, to reverse the disturbing trends in infant and young child feeding
practices. Findings showed four out of ten newborns were initiated to breastfeeding
within an hour after birth, three out of ten infants less than six months were exclusively
breastfed and the median duration of breastfeeding was only thirteen months. The
complementary feeding indicator was also rated as poor since only 57.9 percent of 6-9
months children received complementary foods while continuing to breastfeed. The
assessment also found out that complementary foods were introduced too early, at the
age of less than two months. These poor practices needed urgent action and aggressive
sustained interventions. To address these problems on infant and young child feeding
practices, the first National IYCF Plan of Action was formulated. It aimed to improve the
nutritional status and health of children especially the under-three and consequently
reduce infant and under-five mortality. The policy was intended to guide health workers
and other concerned parties in ensuring the protection, promotion and support of
exclusive breastfeeding and adequate and appropriate complementary feeding with
continued breastfeeding.
2. Integrated Management of Childhood Illness (IMCI)

One million children under five years old die each year in less developed countries.
Just five diseases (pneumonia, diarrhea, malaria, measles and dengue hemorrhagic fever)
account for nearly half of these deaths and malnutrition is often the underlying condition.
Effective and affordable interventions to address these common conditions exist, but they
do not yet reach the populations most in need, the young and impoverish.

The Integrated Management of Childhood Illness strategy has been introduced
in an increasing number of countries in the region since 1995. IMCI is a major strategy
for child survival, healthy growth and development, and is based on the combined delivery
of essential interventions at community, health facility and health systems levels. IMCI
includes elements of prevention as well as curative, and addresses the most common
conditions that affect young children. The strategy was developed by the World Health
Organization (WHO) and United Nations Children’s Fund (UNICEF). In the Philippines, IMCI
was started on a pilot basis in 1996, thereafter more health workers and hospital staff
were capacitated to implement the strategy at the frontline level.
3. National Family Planning Program

In line with the Department of Health FOURmula One Plus strategy and Universal
Health Care framework, the National Family Planning Program is committed to provide
responsive policy direction and ensure access of Filipinos to medically safe, legal, non-
abortifacient, effective, and culturally acceptable modern family planning (FP) methods.
This ensures that Filipino women and men achieve their desired family size and fulfill the
reproductive health and rights for all through universal access to quality family planning
information and services.
4. Newborn Screening Program

The Comprehensive Newborn Screening (NBS) Program was integrated as part of
the country’s public health delivery system with the enactment of the Republic Act no.
9288 otherwise known as Newborn Screening Act of 2004. The Department of Health
(DOH) acts as the lead agency in the implementation of the law and collaborates with
other National Government Agencies (NGA) and key stakeholders to ensure early
detection and management of several congenital metabolic disorders, which if left
untreated, may lead to mental retardation and/or death. Early diagnosis and initiation of
treatment, along with appropriate long-term care help ensure normal growth and
development of the affected individual. It has been an integral part of routine newborn
care in most developed countries for five decades, either as a health directive or mandated
by law. It is also a service that has been available in the Philippines since 1996. Under the
DOH, NBS is part of the Child Development and Disability Prevention Program.
5. National Safe Motherhood Program

Guided by the Department of Health FOURmula One Plus thrust and the Universal
Health Care Frame, the National Safe Motherhood Program is committed to provide
rational and responsive policy direction to its local government partners in the delivery of
quality maternal and newborn health services with integrity and accountability using
proven and innovative approaches. The program aims to ensure Filipino women to have
full access to health services towards making their pregnancy and delivery safer. The
program also contributes to the national goal of improving women’s health and well-
being by:
a. Collaborating with Local Government Units in establishing sustainable, cost-
effective approach of delivering health services that ensure access of
disadvantaged women to acceptable and high quality maternal and newborn

health services and enable them to safely give birth in health facilities near their
homes
b. Establishing the core knowledge base and support systems that can facilitate
countrywide replication of project experience as part of mainstream approaches to
reproductive health care within the Kalusugan Pangkalahatan framework
6. Unang Yakap (Essential Newborn Care: Protocol For New Life)

Many initiatives, globally and locally, help save lives of pregnant women and
children. Essential Newborn Care (ENC) is one. ENC is a simple cost-effective newborn
care intervention that can improve neonatal as well as maternal care. It is an evidence-
based intervention that:
a. Emphasizes a core sequence of actions, performed methodically (step -by-step);
b. Is organized so that essential time bound interventions are not interrupted; and
c. Fills a gap for a package of bundled interventions in a guideline format
7. Women and Children Protection Program

In 1997, Administrative Order 1-B or the “Establishment of a Women and Children
Protection Unit in All Department of Health (DOH) Hospitals” was promulgated in
response to the increasing number of women and children who consult due to violence,
rape, incest, and other related cases. Since its issuance, the partnership among the DOH,
University of the Philippines Manila, the Child Protection Network Foundation, several
local government units, development partners and other agencies resulted in the
establishment of Women and Child Protection Units (WCPUs) in DOH-retained and LGU-
supported hospitals. As of 2016, a total of 94 WCPUs were established nationwide that
served about 8,000 cases in the past year. The DOH shall provide medical assistance to
victims through a socialized scheme by the Women and Children Protection Unit (WCPU)
in DOH-retained hospitals or in coordination with LGUs or other government health
facilities (RA 9262:Anti-violence Violence Against Women Against Women And Their
Children, Act Of 2004 ). The department shall refer the child who is placed under
protective custody to a government medical or health officer for a physical/ mental
examination and/or medical treatment (RA 7610: Special Protection of Children Against
Child Abuse, Exploitation and Discrimination Act). R.A. 10354 (The Responsible
Parenthood and Reproductive Health Act of 2012) highlights the elimination of violence
against women and children and other forms of sexual and gender-based violence. The
program also aims to institutionalize and standardize the quality of service and training
of all women and children protection units by:
a. Preventing violence against women and children from ever occurring (primary
prevention)
b. Intervening early to identify and support women and children who are at risk of
violence (early intervention); and
c. Responding to violence by holding perpetrators accountable, ensure connected
services are available for women and their children (response).

8. Child Health and Development 2000-2025
The Philippine National Strategic Framework for Development for Children or
CHILD 21 is a strategic framework for planning programs and interventions that promote
and safeguard the rights of Filipino children. Covering the period 2000-2005, it paints in
a vision for the quality of life of Filipino children in 2025. Children's Health 2025, a
subdocument of CHILD 21, realizes that health is a critical and fundamental element in
children's welfare. However, health programs cannot be implemented in isolation from
the other component that determine the safety and well-being of children in society.
Children's Health 2025, therefore, should be able to integrate the strategies and
interventions into the overall plan for children's development. It utilizes a life cycle
approach and weaves in the rights of children. The life cycle approach ensures that the
issues, needs, and gaps are addressed at the different stages of the child's growth and
development. The successful implementation of these strategies will require collaborative
efforts with the other stakeholders and also implies integration with the other
developmental plan of action for children.
A healthy Filipino child is:
• Wanted, planned and conceived by healthy parents; Carried to term by healthy
mother; Born into a loving, caring, stable family capable of providing for his or her
basic needs; Delivered safely by a trained attendant
• Screened for congenital defects shortly after birth; if defects are found,
interventions to correct these defects are implemented at the appropriate time
• Exclusively breastfed for at least six months of age, and continued breastfeeding
up to two years; Introduced to complementary foods at about six months of age,
and gradually to a balanced, nutritious diet; Protected from the consequences of
protein-calorie and micronutrient deficiencies through good nutrition and access
to fortified foods and iodized salt
• Provided with safe, clean and hygienic surroundings and protected from accidents;
Properly cared for at home when sick and brought timely to a health facility for
appropriate management when needed; Offered equal access to good quality
curative, preventive and promotive health care services and health education as
members of the Filipino society
• Regularly monitored for proper growth and development, and provided with
adequate psychosocial and mental stimulation; Screened for disabilities and
developmental delays in early childhood; if disabilities are found, interventions are
implemented to enable the child to enjoy a life of dignity at the highest level of
function attainable
• Protected from discrimination, exploitation and abuse
• Empowered and enabled to make decisions regarding healthy lifestyle and
behaviors and included in the formulation health policies and programs; Afforded
the opportunity to reach his or her full potential as adult.
9. Expanded Program on Immunization

The Expanded Program on Immunization (EPI) was established in 1976 to ensure
that infants/children and mothers have access to routinely recommended
infant/childhood vaccines. Six vaccine-preventable diseases were initially included in the

EPI: tuberculosis, poliomyelitis, diphtheria, tetanus, pertussis and measles. The over-all
goal of the program is to reduce the morbidity and mortality among children against the
most common vaccine-preventable diseases.
10. Food Fortification Program

The Food Fortification Program is the government’s response to the growing
problem in micronutrient malnutrition. It aims to contribute to the reduction of disparities
related to nutrition through a focus on population groups and areas highly affected or at-
risk to malnutrition and micronutrient deficiencies and to provide vitamin A, iron & iodine
supplements to treat or prevent specific micronutrient deficiencies.
ASSESSMENT: POST TEST

Test I. Multiple Choice. Choose the best answer
1. A program that reflects the government’s response to the growing problem in
micronutrient malnutrition:
2. A program that ensure early detection and management of several congenital

metabolic disorders:
3. The study of all genes and includes interactions among genes as well as interactions
between genes and the environment:
C. Genomics
D. Genetics
4. It involves a range of activities concerned with understanding gene expression, taking

advantage of natural genetic variation, modifying genes and transferring genes to new
hosts:
C. Genomics
D. Genetics

5. The following are alternative methods of child birth EXCEPT:
A. Surrogate
B. Adoption
C. Child-free living
D. In-vitro fertilization
6. A major strategy for child survival, healthy growth and development, and is based on
the combined delivery of essential interventions at community, health facility and
health systems levels:
A. IMCI
B. Unang yakap
C. ENC
D. National motherhood program
7. Which of the following is a key element in informed consent?

A. The person signing the consent should be of legal age
B. Physicians can sign as witness to the signing
C. Oral consent is not legal
D. The procedure should be explained in detail using medical terms
8. Which statement is TRUE regarding maternity benefits in the Philippines?

A. Mothers are given 160 days of paid leave
B. Mothers can transfer 20 days of leave to the father
C. Additional 30 unpaid days of leave can be filed
D. Additional 30 days of paid leave will be given to single mothers
9. The Philippine Nursing Act is known as:

A. R.A. 7322
B. R.A. 11210
C. R.A. 9173
D. R.A. 7610
10. It refers to the minimum criteria for competent, proficient delivery of nursing care:
A. Standard of care
B. Scope of practice
C. Legal responsibility
D. Bill of rights
FEEDBACK ON THE POST TEST

1. A 6. A
2. D 7. A
3. C 8. C
4. B 9. C
5. D 10. A

Note: If your score is 6 or higher, your understanding of Scope and Standards of Maternal
and Child Care is satisfactory; you may proceed in reading the next module.
If your score is lower than 6, you may need to restudy this module and approach
the instructor for assistance in understanding the contents of the module.
References
Ladewig, P. (2014). Contemporary maternal-newborn nursing care. Boston: Pearson.
Pilliteri, A. (2018). Maternal child health nursing: Care of the childbearing and childrearing
family. Volume 1 and 2 (Philippine edition); 8th edition. Philadelphia: Lippincott.
Ricci, S. (2017). Essentials of maternity, newborn, and women’s health nursing. 4th edition.
Philadelphia: Wolters Kluwer
https://www.pcw.gov.ph/law/republic-act-10354
https://www.doh.gov.ph/national-safe-motherhood-program
https://apps.who.int/iris/bitstream/handle/10665/249155/9789241511216-
eng.pdf;jsessionid=C76013EBDC95CDFB4AF50A613A6E3393?sequence=1
https://www.genome.gov/For-Health-Professionals/Competency-and-Curricular-
Resources
Prepared by:
Sarah S. Nares, R.N., M.N.

NCM 0107 Instructor
Peer Reviewed by:
Brenda P. Policarpio, R.N., M.N. Ma. Corazon M. Tanhueco, R.N., M.A.N.

CON, Faculty Member CON, Faculty Member
Reviewed and Evaluated by:
Jennie C. Junio, R.N., M.A.N

Level II Academic Coordinator
Debbie Q. Ramirez, R.N., Ph.D.

Assistant Dean, College of Nursing
Approved by:
Zenaida S. Fernandez, R.N., Ph.D.


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ANGELES UNIVERSITY FOUNDATION

CARE OF MOTHER, CHILD, ADOLESCENT (WELL CLIENTS) – NCM 0107

Module 1: A Framework for Maternal and Child Health Nursing

The area of childbearing and childrearing families is a major focus of nursing

Module Learning Outcomes:

Upon completion of this module, the student should be able to:

1. Integrate concepts, theories, and principles of sciences and humanities in the

Learning Hours: 4 hours

Maternal and Child Helath

A Framework for Maternal and Child Health Nursing Care

Goals and Philosophies of Maternal and Child Health Nursing

The area of childbearing and childrearing families is a major focus of nursing

A Philosophy of Maternal and Child Health Nursing

Maternal and Child Health Goals and Standards

2020 National Health Goals

The two main overarching national health goals are:

WHO’s 17 Sustainable Development Goals

QSEN: Quality & Safety Education for Nurses

Roles and Responsibilities of a Maternal and Child Nurse

Legal Considerations of Maternal-Child Practice

NCM 0107 Instructors

Jennie C. Junio, RN, MAN

CARE OF MOTHER, CHILD, ADOLESCENT (WELL CLIENTS) – NCM 0107

Module 2: Reproductive and Sexual Health

Whether or not someone is planning on childbearing, everyone is wiser for being

Module Learning Outcome:

Upon completion of this module, the student should be able to:

1. Integrate concepts, theories, and principles of sciences and humanities in the

CONCEPT OF UNITIVE AND PROCREATIVE HEALTH

Procreation – to produce other of its kind; create; reproduce; to multiply

Theories about Procreation

§ Single pair of ancestors (Adam and Eve)

Terminologies of Human Sexuality:

§ Sex – biological male or female status; specific sexual behavior

Aspects of Human Sexuality

1. Biologic Sex/Biologic Gender

1. Heterosexual – one who is sexually attracted to persons of the opposite sex

1. Provision of information on safe sex practice at 10 – 12 years old (beginning of

2. Homosexual – one who is sexually attracted to persons of the same sex

1. Unusual level of estrogen and progesterone in the utero

1. Be sensitive to their needs because they experience identify confusion especially

3. Bisexual – one who is sexually attracted to persons of both sexes.

4. Transsexual/Transgender – one’s belief that one is not the sex of one’s

Three Basic Elements of Sexual Health:

Factors Influencing Sexuality:

Human Sexual Responses (Masters and Johnson, 1966)

§ 600 men and women

Two primary physiologic changes:

Presence of clear lubricating Presence of mucoid fluid or

Increased in temperature, Vagina widens in diameter and

Increased muscle tension in both Increase in size and change in the

Flushing of the skin

Increased muscle tension in both

HR (100 – 175 bpm) and RR (40 cpm)

3. Orgasmic Phase/Orgasm – is the involuntary climax of sexual tension,

Contractions are followed immediately An average of 8 – 15 contractions at

Depend less upon ideal Proper mood or setting for intercourse

Does not achieve second orgasm Can achieve several consecutive

Concepts of Sexuality in the Philippines