WEEK 7

CHN Current Form of Public Health

▪ A community may be defined in many different ways. ▪ Public health in its present form, is combination of
One definition of community is “a social group of any scientific principles (e.g., epidemiology, biostatistics,
size whose members reside in a specific locality, share laboratory sciences, social sciences, demography) and
government, and often have a common cultural and skills & strategies (e.g., epidemiological investigations,
historical heritage” planning and management, intervention, surveillance,
▪ Culture – ethnicity, age, gender, sexuality all of these evaluation) that are directed to the maintenance &
can be characteristics which define a community improvement of health of the people.
▪ The community in which we live and work have a Concept of Community
profound influence on our collective health and well- ▪ A community is a collection of people who share some
being important feature of their lives
▪ Community health nurse work in every conceivable kind ▪ It can be society of people holding common rights and
of community agency privileges, sharing interests, living under same laws and
▪ Their duties range from examining infants in a well-baby regulations.
clinic, or teaching elderly stroke victims in their homes ▪ The function of any community includes its members of
to carrying out epidemiologic research or engage in collective sense of belonging and their shared identity,
health policy analysis and decision making values, norms, communications and common interests
▪ Combines all basic elements of professional clinical and concerns.
nursing with public health and community practice. ▪ It is not limited to a particular age or diagnostic group. It
Public Health is continuous and not episodic. The dominant
▪ The term public health came in general use around 1840. responsibility is to the population as a whole. Therefore,
It arose from the need to protect “the public” from the nursing directed to individuals, families or groups
spread of communicable diseases contributes to the health of the total population.
▪ Later, it appeared in 1848 in the name of law, the Public ▪ Health promotion, health maintenance, health education,
Health Act in England coordination and continuity of care are utilized in a
▪ In 1920, Charles Edward Armory Winslow, former holistic approach to the management of the health care of
professor of public health at Yale University, gave the individual, family, group and community
off-quoted definition of public health. ▪ The nurse’s actions acknowledge the need for
▪ The Science and Art of preventing disease prolonging comprehensive health planning, recognize the influences
life and promoting health and efficiency through of social and ecological issues, give attention to
organized community effort for the sanitation of the populations at risk and utilize dynamic forces which
environment, the control of communicable infections, influence change.” (ANA)
the education of the individual in personal hygiene, the Concept of CHN
organization of medical and nursing services for early ▪ The primary focus of community health nursing is on the
diagnosis and preventive treatment of disease and the health promotion
development of social machinery, to ensure for every ▪ Community health nursing practice is extended to benefit
individual a standard of living adequate for the not only the individual but the whole family and
maintenance of health, so organizing these benefits as to community
enable every citizen to realize his birth right of health and ▪ Community health nurses are generalist in terms of their
longevity practice
Definition of Public Health ▪ Contact with the client and/or family may continue over
▪ The term public health was defined by ‘C.E.A. a long period of time
Winslow’ (1851) as science & art of preventing disease, ▪ The nature of community health nursing practice requires
prolonging life & promoting health & efficiency through the current knowledge
organized community measures such as control of ▪ The dynamic processes of assessing, planning, provide
infection, sanitation, health education, health education, periodic measurement of progress, evaluation and a
health services & legislation, etc. continuum of cycle until the termination of nursing is
▪ Public Health is defined as “the art and science of implicit in the practice of community health nursing.
preventing disease, prolonging life and promoting health Philosophy of CHN
through the organized efforts of society” (Acheson, ▪ Philosophy of community health pertains to underlying
1988; WHO) ideas and beliefs which govern its practices. These are as
▪ Activities to strengthen public health capacities and under:
service aim to provide conditions under which people can ➢ Philosophy of individuals right of being healthy
maintain to be healthy, improve their health and well- ➢ philosophy of working together under a
being, or prevent the deterioration of their health competent leader for common good
▪ Public health focuses on the entire spectrum of health and ➢ philosophy that people in the community have
well-being, not only the eradication of particular potential for continued development and are
diseases. capable of dealing with their own problems if
▪ Many activities are targeted at populations such as health educated and helped.
campaigns ➢ Philosophy of socialism
▪ Public health services also include the provision of
personal services to individual persons, such as
vaccinations, behavioral counselling, or health advice.

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 Aims of CHN
▪ To promote health and efficiency
▪ To prevent and control diseases and disabilities
▪ To prolong life by providing basic needs, well balanced
comprehensive health care services to community at
large through organized community efforts.
Objectives of CHN
▪ The objectives of community health nursing are the same
as that of community health which are achieved by
meeting nursing needs of individuals, families, groups of
people and community at large
➢ To increase capability of individuals, families,
groups and community to deal with their own
health and nursing problems
➢ To strengthen community resources
➢ To control and counteract environment
➢ To prevent and control communicable and non-
communicable diseases
➢ To provide specialized services
➢ To conduct research and contribute to the
further refinement and improvement Home Care
➢ To participate in preparing health personnel to ▪ Extended nursing care services are received by number
function in community for community health of patients at their home when hospital is over-crowded
care services for admitting the patients who require indoor care or
➢ To supervise, guide and help health personnel in when a patient is in need of isolated treatment
carrying out their functions effectively ▪ Even preventive and promotive services are provided to
Nature/Characteristics of CHN the people at their home to maintain and achieve health.
▪ Community health nursing is an integral part of Nursing Care
community health ▪ The CHN includes nursing care of the family in sickness
▪ Community health nursing is a specialized field of and health. the CHN should be able to:
nursing ➢ To provide PHC in the community
▪ Community health nursing synthesizes community ➢ To conduct routine antenatal and postnatal visits
health with nursing and to conduct deliveries when required
▪ In community health nursing, the whole community is ➢ To carry out immunization
the client ➢ To promote health of the children by conducting
▪ Community health nursing emphasizes on primary level under five clinic and referring cases who require
prevention medical care
▪ Community health nursing promotes self-care ➢ To assess the social environmental and
responsibility nutritional needs of the community. And get the
▪ Community health nursing involves multi-disciplinary help of social workers to meet these needs.
team approach Geriatric Care
▪ Community health nursing is working for people, with ▪ The number of old people increasing in the world today.
people and by people The need of old is different and they need more care than
▪ Community health nursing is seeking support from the younger age groups. In many countries, the old age
giving support to personnel from other sectors working people are visited by the nurses and other health care
for welfare and development in the community workers
▪ Community health nursing is dealing with wide range of Occupational Health Nursing
health problems and health needs and providing need ▪ Occupational nursing is the application of nursing and
based generalized health services. public health philosophy and skills to the relationship of
▪ Community health nursing is providing continuous care people to their occupations for the purpose of prevention
and not episodic care of disease and injury and the promotion of optimal
health, productivity and social adjustment
▪ OHN identifies health and nursing needs of workers
following health and nursing needs of workers following
health assessment, plans and implements nursing care
within her capabilities, limitations, means and facilities
Domiciliary Nurse
▪ The areas where domiciliary nursing is practiced in our
country are
➢ Maternity services
➢ Health supervision
➢ Disease prevention services
➢ Services for illness and accidents

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 ➢ The scope for limitless for organizing depending on the government. PHC also gives
domiciliary visits importance to the participation of various sectors of
Mental Health Nursing government and the private sector in local health
▪ Many developing countries have mental health services activities.
today. These services include; A. Area of Selection on the Basis of Need
➢ Early diagnosis and treatment ▪ The introduction of PHC begun in 1979 by pilot
➢ Rehabilitation testing the methodology in one province in each
➢ Psychotherapy of the 12 regions
➢ Use of modern psychotropic drugs and after ▪ In 1982, the UPCPA revealed an important
care services approach to ensure the outreach of the
➢ MHN is yet to be developed in India government to the underserved areas. This was
MCH & Family Planning done through the selection of the 12 provinces
▪ The public health nurse plays a major role in the MCH on the basis on “need”
and FP services. It consists of: B. Social Preparation
➢ Antenatal ▪ The DOH conducted preparatory activities
➢ Postnatal among health and other sectoral implementers
➢ Childcare services for effective utilization of resources
➢ Nurse can easily motivate the mothers to accept ▪ Trainers were also identified at the provincial
the FP methods and gain their cooperation in levels in order to echo the essence of PHC at the
adopting to a small family norm. municipal level
School Health Nursing C. Identification of Volunteers
▪ In general, the functions of the school health nurse are ▪ An important component of preparatory
related to establishment and implementation of school activities for PHC was the identification and
health policies and programmes for the protection and mobilization of voluntary health workers
promotion of health of the students, the maintenance of (VHW’s).
a school environment which is conducive to healthful D. Creation of Intersectoral Structures
living. ▪ The government mobilizes PHC committees at
Rehabilitation Center the national and local levels; e.g.
▪ Rehabilitation means restoration of all treated cases to ➢ World Vision – conducted orientation
the highest level of functional ability seminars for BHW’s
▪ Nursing is an important component in the rehabilitation ➢ UP Institute of Health Science –
of the disabled. served as the institutional base for
Conclusion health manpower training
▪ Community as a field of practice seeks to provide ➢ Davao Medical School Foundation –
organizational structure, a broad set of resources and the involved in the training of BHW’s in
collaborative activities needed to accomplish the goal of Region XI
an optimally healthy community Institutionalization
▪ The primary focus of community health nursing is on the ▪ Bureaucratic Innovations
health promotion ▪ Identification/Preparation of Volunteers
▪ Community health nursing is a nursing aspect of ▪ Validation of Indigenous Methodologies
organized community health programme and is a ▪ NGOs as Conduits of Funds and as Chief Mobilizers for
specialized area of professional nursing practice PHC
▪ It is a unique blend of nursing and community health ▪ Incentives for Community Involvement
woven into a service which when properly developed and Bureaucratic Innovations
implemented can have a tremendous impact on health. ▪ In 1981 – under President Marcos, nationwide
Primary Health Care implementation of PHC took place through the vigorous
▪ WHO defines PHC as essential care made universally effort of the top leadership of Minister Jesus Asurin
accessible to individuals and families in the community ▪ 1982 – administrative innovations started to put in place
by means acceptable to them through their full which could facilitate the implementation of PHC. This
participation and at a cost that the community and enabled local field offices of the Ministry of Health to
country can afford at every stage of development have greater unity in pursuing health activities.
Background Validation of Indigenous Methodologies
▪ Primary Health Care (PHC) was declared during the ▪ Herbal gardening – was encourage to solve the existing
First International Conference on Primary Health shortage of supplies and high cost of drugs. This program
Care held in Alma Ata, Russia on September 6-12, was supported through the dissemination of manuals,
1978 by the WHO. The goal was “Health for all by the seedlings and plants.
Year 2000”. This was adopted by in the Philippines ▪ Oral Rehydration Therapy – using oral rehydration
through Letter of Instruction 949 signed by President (ORESOL) was a key innovation by the Ministry of
Marcos on October 19, 1979 and has an underlying Health. this simple inexpensive solution was proven
theme of “Health in the Hands of the People by 2020”. effective in preventing diarrhea-related deaths.
▪ This approach has influenced many countries including ▪ Strengthening the Botika sa Barangay (BSB)
the Philippines. Its innovativeness is indicated by the call
for participatory development management since
community members are expected to take an active role
in managing their own health requirements, instead of
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 NGOs as Conduits of Funds and as Chief Mobilizers for D. Research/Documentation
PHC ▪ Due to lack of information regarding the status
▪ In 1986, President Corazon Aquino gave importance to of PHC implementation, the government has
NGOs in the promotion of PHC adopted the conduct of researches
▪ The DOH experimented new approach which is the subcontracted to private institutions to
Partnership for Community Health Development determine the status of PHC
(PCHD) which entailed financial assistance to NGO’s Problems/Issues
which serves as conduits of funds to mobilize partnership ▪ The implementation of PHC has not been spared from
effects among LGUs, NGO’s and people’s organizations problems and difficulties
to undertake health and related development activities in ▪ Lack of political will of the top leadership of the DOH
the barangays. for the continued implementation of PHC.
▪ In 1991, the government issued Administrative Order ▪ Passage of BHW’s Incentives Act which violated the
No. 112 in the 1st National Convention for NGO’S principle of volunteerism and could be a tool for
which conducted by the DOH. It is a policy on politicking by local executives since the volunteer
collaboration between Public and Private Sectors on workers could beholden to them instead of the
Health Policies and Programs community
▪ According to studies from 1991-1995, the impact of ▪ The transfer of responsibility of PHC to local executives
PCHD pointed to the reduction of preventable diseases. under devolution is not easy. PHC could not be fully
E.g., achieved if the bureaucracy itself is not empowered.
➢ Malaria – 50% Family Health Nursing Process
➢ Acute Respiratory Infection – 42% ▪ It is a dynamic systematic organized method of critical
Incentives for Community Involvement thinking about the family. It is the problem solving with
▪ In the year 1994, various incentives and measures were the family to assist successful adaptation of the family to
implemented by the DOH; this included the provision to identified health care needs.
BHW’s such as free medical and dental check-up, blood Principles
typing, supply of drugs and medicines, laboratory ▪ Services without discrimination
examination and tetanus toxoid immunization ▪ Periodic and continuous appraisal and evaluation of
▪ Income generating projects were also encourage through family health situations
the provision of financial grants to BHW’s for livelihood. ▪ Proper maintenance of record and reports
Devolution ▪ Provide continuous services
▪ Direct responsibility for PHC is now assumed by mayors ▪ Health education, guidance, and supervision as integral
of municipalities and cities due to the Local Government part of family health nursing
Code of 1991 ▪ Maintain IPR
Implications of Devolution on PHC ▪ Plan and provide family health nursing with active
▪ Lack of understanding and appreciation by chief participation of family
executives of health services of PHC as an innovative ▪ Services should be realistic in terms of resources
strategy. available.
▪ The government launched the Minimum Basic Needs Characteristics
(MBN) approach as the management technology for ▪ Goal-directed
supporting the Social Reform Agenda to improve the ▪ Systematic
quality of the poorest of the poor. ▪ Dynamic
A. Capability Building ▪ Applicable to families and community groups at any
▪ The UPCPA assists in the conduct of seminars level of health
to convey the meaning of PHC ▪ Interpersonal and based on the nurse-client and family
▪ Under Ramos administration, the DOH had members relationship
strong commitment to enforcing the “health in ▪ Useful for community diagnosis and family diagnosis
the hands of the people”. Strong advocates of Advantages
PHC among professional civil servants urged ▪ Saves hospital beds that can be utilized for critical cases
the continuation of this motto. ▪ Cheaper than hospital nursing
B. Support to LGUs Through NGOs ▪ Patient under family health nursing enjoys privacy and
▪ The DOH sustains its support to PCHD in order emotional support
to provide assistance to LGUs not able to ▪ Patients on family health nursing can continue with their
employ participatory method in their area routine pursuits.
▪ Retained also by the DOH to propagate PHC Disadvantages of Family Health Nursing
was the provision of support for innovative ▪ It requires the nurse to carry portable laboratory
strategies. E.g., the grant to cooperatives to machinery to the patient home
engage in the operation of drugstore to reduce ▪ If the patient resides in a substandard house, family
the cost of drugs in a locality. health nursing could delay his recovery
C. Policy Formulation Family Centered Nursing Approach
▪ BHW’s Incentives Act or Republic Act 7883 ▪ Family as the context
of 1995 – directing the LGUs to provide ➢ The primary focus is on the health and
subsequent allowance for BHWs as they cater development of an individual member existing
to hazardous areas. within a specific environment.

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 ▪ Family as the client Types of Diagnosis:
➢ The focus is concentrated on each and every ▪ Actual diagnosis – the actual
individual as they affect the whole family. problems are those present in the
▪ Family as a system patient at the time of assessment,
➢ This approach focuses on the individual and e.g., pain
family members become the target for nursing ▪ Potential Diagnosis – a potential
interventions. E.g., the direct intervention problems is one which a patient
between the parent and the child. has a high risk or that may occur
▪ Family as a component of society in the future. E.g., Decubitus ulcer
➢ The family is a basic or primary unit of society, Examples: Four Part Diagnosis
as are all the other units and they are all a part There are four parts to a community
of the larger system of society. diagnosis:
Elements of Family Nursing Process 1. A description of the problem,
▪ Step 1: assessment of client’s problem response, or state (risk, concern,
▪ Step 2: diagnosis of client response needs that nurse can issue, potential or actual)
deal with 2. A statement of the aggregate,
▪ Step 3: planning of client’s care population, community, or focus
▪ Step 4: implementation of care (boundaries). THIS DIFFERS
▪ Step 5: evaluation of the success of implemented care FROM THE NURSING
Assessment It is the first major phase of family health DIAGNOSIS, the focus is added
nursing process which helps to explore the 3. An identification of factors
family as a client, its health needs and etiologically related to the
problems. It also finds the possible problem (factors), and
underlying factors that affect the health. 4. Those signs and symptoms
▪ Family assessment and its (manifestations) that are
parameters: characteristic of the problem.
➢ Family structure Example: a risk of low birth rate among
➢ Family environment pregnant adolescents in the downtown
➢ Daily routines area related to inadequate income and
➢ Family dynamics use of tobacco aeb insecure housing, use
➢ Family needs of the food bank, unemployment rates,
▪ Data collection methods for family and smoking rates among pregnant
assessment: teens.
➢ Observation *NOTE: the italicized area indicates the
➢ Physical Examination “focus” portion of the diagnosis (for
➢ Interview teaching purposes only).
➢ Record review
➢ Laboratory/Diagnostic tests Three Part Diagnosis
▪ Analysis of Data After Data ▪ Example: Ineffective marital and
Collection parental role performance related to
It includes the following steps: arrival of another baby, heavy child-
➢ Sorting of data care responsibilities, and inadequate
➢ Clustering of related cues family coping patterns as evidenced
➢ Distinguishing relevant from by mother stating that she is feeling
irrelevant cues overwhelmed, is unable to stop
➢ Identifying patterns siblings from fighting, and husband
➢ Comparing patterns working overtime every day.
➢ Interpreting inferences and Planning of Type of Goals:
drawing conclusions Client’s Care ▪ Client focused
According to Ruth Freeman, the family ▪ Nurse focused
problems is explained as: ▪ Short-term
a) Health deficit ▪ Long-term
b) Health threats Implementation Main consideration during
c) Foreseeable crisis situation of Care implementation:
Assessment through: ▪ Definition of roles and tasks
▪ Health records ▪ The selection, training
▪ Clinics motivation, and supervision of the
▪ Observation manpower involved.
▪ Physical health assessment ▪ Organization and communication
Diagnosis of Community diagnosis – it focuses and ▪ The efficiency of the institutions
Client Response highlight wide factors which influence such as primary health centers,
Needs that health and wellness status of family health centers, and hospitals.
Nurse Can Deal members. Monitoring
With ▪ It is day to day follow up activities
during the implementation to
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 ensure that they are proceeding as Philippine Healthcare Delivery System
planned and are on schedule. It is
a continuous process of
observing, recording, and
reporting
▪ The nurse may assist the family
by:
➢ Supplemental: direct
care by CHN
➢ Developmental: to
prepare family member
for giving care
➢ Facilitative: improve
physical facilities by
modifying old facilities
and adopting new one
Evaluation of Types of evaluation:
the success of ▪ Structure evaluation Demographic and Epidemiologic Trends
implemented - In nursing process, structure ▪ Has experienced considerable improvements in its
care evaluation tends to evaluate health status for the past 50 years, yet, also decline in
the total care plan which the recent years (Cuevas, 2007)
include assessment, care ▪ Experiencing epidemiologic shift
plan, and adequate resources ▪ Threatened with devastating effect of “triple
to meet the plan. whammy”
▪ Process evaluation
- It relates to evaluation of
implementation whether it is
carried out properly whether
any intervention left.
▪ Outcome evaluation
- It is the actual evaluation. It
is the evaluation of result
whether goals are met
properly.
▪ Formative evaluation
- It evaluates family health and
nursing care plan as it is
planned and implemented to
determine its strength and
weakness at each stage, and it
progress towards meeting the
objectives.
▪ Summative evaluation
- It concludes progress or lack
of progress towards the goal
after several objectives-based
actions are implemented.
Tools for Evaluation
▪ Direct observation
▪ Questioning
▪ Record review

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Sustainable Development Goals
▪ A set of goals to end poverty, protect the planet, and
ensure prosperity for all
▪ Each goal has specific targets to be achieved over the
next 15 years
▪ For the goals to be reached, everyone needs to do their
part: governrments, the private sector, civil society and
people like you

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8
 Expanded Program on Immunization ▪ Upper outer portion of the arms
▪ Established in 1976 ▪ At least 85% of measles can be prevented by
▪ Ensure that infants/children and mothers have access to immunization at this age
routinely recommended infant/childhood vaccines Neonatal Tetanus
Six vaccine-preventable diseases ▪ Infection occurs at unhealed umbilical stump (non-sterile
1. Tuberculosis equipment)
2. Poliomyelitis Pertussis
3. Diphtheria ▪ Whooping cough
4. Tetanus ▪ 100-day cough
5. Pertussis ▪ Highly contagious respiratory disease
6. Measles Tuberculosis
Over-all Goal ▪ Affects the lungs
▪ To reduce the morbidity and mortality among children ▪ Airborne
against the most common vaccine-preventable diseases. ▪ BCG (Bacillus Calmette-Guerin)
Specific Goals ▪ At birth
▪ To immunize all infants/children against the most ▪ 1 dose (0.5mL)
common vaccine-preventable diseases ▪ None
▪ To sustain the polio-free status of the Philippines ▪ Intradermal
▪ To eliminate measles infection ▪ Right deltoid region of the arm
▪ To eliminate maternal and neonatal tetanus ▪ BCG given at earliest possible age protects the
▪ To control diphtheria, pertussis, hepatitis b and German possibility of TB meningitis and other TB infections in
measles which infants are prone.
▪ To prevent extra pulmonary tuberculosis among children. Hepatitis B
Republic Act No. 10152 ▪ Viral infection
▪ “Mandatory Infants and Children Health ▪ Attacks the liver
Immunization Act of 2011” ▪ Transmitted through blood or other body fluids
▪ President Benigno Aquino III ▪ Hepatitis
▪ July 26,2010 ▪ At birth
▪ Basic immunization for children under 6 including other ▪ 3 doses
types that will be determined by the Secretary of Health ▪ 4 wks. interval
Polio ▪ Intramuscular
▪ Poliomyelitis ▪ Upper outer portion of the thigh
▪ Caused by poliovirus ▪ Prevents liver cirrhosis and liver cancer
▪ Crippling and potentially infectious Plants Approved by the DOH
▪ Infects the person’s brain and spinal cord causing Republic Act 8423
paralysis ▪ Otherwise known as TAMA
▪ OPV (Oral Polio Vaccination) ▪ Traditional and Alternative Medicine Act of 1997
▪ 6 weeks old ▪ An act creating the Philippine Institute of Traditional and
▪ 3 doses (2-3 drops) Alternative Health Care (PITAHC) to accelerate the
▪ 4 weeks development of traditional and alternative health care in
▪ Oral the Philippines, providing for a traditional and alternative
▪ The extent of protection against polio is increased the health care development fund and for other purposes
earlier the OPV is given. 10 Herbal Medicines Approved by the DOH
Diphtheria MNEMONIC: SANTALUBBY
▪ Bacterial infection 1. Sambong
▪ Affects the nose and throat 2. Akapulko
▪ Cause breathing problems and swallowing 3. Niyog-niyogan
Diphtheria-Pertussis-Tetanus 4. Tsaang gubat
▪ DPT 5. Ampalaya
▪ 6 wks. old 6. Lagundi
▪ 3 doses (0.5 mL) 7. Ulasimang bato
▪ 6wks (DPT 1), 10 wks. (DPT 2), 14 wks. (DPT 3) 8. Bawang
▪ Intramuscular 9. Bayabas
▪ Upper outer portion of the thigh 10. Yerba Buena
▪ An early start with DPT reduces the chance of severe Reminder on the use of Herbal Medicine
pertussis ▪ Avoid the use of insecticides as these may leave poison
Measles on plants
▪ Caused by a virus ▪ In the preparation of herbal medicine, use a clay pot and
▪ Airborne remove cover while boiling at low heat
▪ Infects the respiratory tract ▪ Use only the part of the plant being advocated
▪ MCV ▪ Follow accurate dose of suggested preparation
▪ Measles-Containing Vaccine ▪ Use only one kind of herbal plant for each type of
▪ 9 months old symptoms or sickness
▪ 2 dose (0.5 mL) ▪ Use only half the dosage prescribed for fresh parts like
▪ Subcutaneous leaves when using dried parts.
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 ▪ Decoctions loose potency after some time. Dispose of Ampalaya
decoctions after one day. To keep fresh during the day, ▪ Bitter gourd or bitter melon
keep lukewarm in a flask or thermos ▪ A climbing vine with tendrils that grow up to 20 cms long
▪ Leaves, fruits, flowers or nuts must be mature before ▪ Leaves are heart-shaped, which are 5 to 10 cms in
harvesting. Less medicinal substances are found on diameter
young parts. ▪ Fruits have ribbed and wrinkled surface that are fleshy
▪ Stop giving the herbal medication in case untoward green with pointed ends at length and has a bitter taste
reaction such as allergy occurs ▪ Scientific Name: Momordica charantia
▪ If signs and symptoms are not relieved after 2 or 3 doses Uses
of herbal medication, consult a doctor. ▪ Lowers blood sugar levels
Sambong ▪ Diabetes Mellitus (Mild-non insulin dependent)
▪ A plant that reaches 1 ½ to 3 meters in height with rough Preparation
hairy leaves. ▪ Gather and wash young leaves very well. Chop, boil 6
▪ Young plants around mother plant may be separated tablespoon in two glassfuls of water for 15 minutes under
when they have three or more leaves low fire. Do not cover pot. Cool and strain, take 1/3 cup
▪ Scientific Name: Blumea balsamifera 3 times a day after meals.
Akapulko Lagundi
▪ Ringworm bush ▪ 5 leaved-chaste tree
▪ Bayas-bayasan ▪ A shrub growing wild in vacant lots and waste land
▪ This plan is about 1 to 2 meters tall ▪ Matured branches are planted
▪ The leaves are embraced with 8 to 20 oblong-elliptical ▪ The flowers are blue and bell-shaped
shaped leaflets ▪ The small fruits turn black when ripe. It is better to
▪ It has flowers with oblong sepals collect the leaves when they are in bloom
▪ Scientific Name: Cassia alata ▪ Scientific name: Vitex negundo
Uses: Preparation
▪ Anti-fungal: Tinea Flava, Ringworm, athlete’s foot and ▪ For asthma, cough and fever. Boil chopped raw fruits or
scabies leaves in 2 glasses of water, leave for 15 minutes until the
Preparation water left in only 1 glass (decoction). Strain.
▪ Fresh, matured leaves are pounded ▪ For Dysentery, cold and pain, boil a handful of leaves and
▪ Apply as a soap to the affected part 1 to 2 times a day flowers in water to produce a glass full of decoction 3
Niyog-Niyogan times a day.
▪ Chinese Honey Suckle ▪ For skin diseases (dermatitis, scabies, ulcer, eczema) and
▪ A vine which bears tiny fruits and grow wild in backyard wounds, prepare ta decoction of the leaves. Wash and
▪ The seeds must come from mature, dried but newly clean the skin/wound with the decoction
opened fruits. ▪ For headache crushed leaves may be applied on the
▪ Propagated through stem cuttings about 20cm in height forehead
▪ Scientific Name: Quisqualis indica L. ▪ For rheumatism, sprain, contusions, and insect bites,
Uses: pound the leaves and apply on the affected part.
▪ Anti-helminthic (used to expel parasitic worms) Ulasimang Bato
Preparation ▪ Silver bush or shiny bush
▪ Seeds of niyug-niyogan are eaten raw two hours before ▪ Pansit-pansitan
the patient’s last meal of the day. ▪ A weed with heart-shaped leaves that grow in shady parts
▪ Adults may take 10 seeds; children 4 to 7 years of age of the garden and yard
may eat up to four seeds only; ages 8 to 9 may take six ▪ Scientific name: Peperomia pellucida
seeds and seven seeds may be eaten by children 10 to 12 Uses
years old ▪ Lowers uric acid (rheumatism and gout)
▪ Not to be given to children below four years old Preparation
Tsaang Gubat ▪ Wash the leaves well, one and a half cup leaves are boiled
▪ Forest tea or wild tea in two glassfuls of water over low fire. Do not cover pot,
▪ A shrub with small, shiny nice-looking leaves that grows cool and strain. Divide into three parts and drink each
in wild uncultivated areas and forests part 3 times a day
▪ Scientific Name: Carmona retusa ▪ May also be eaten as salad. Wash the leaves well. Prepare
one and a half cups of leaves (not closely packed). Divide
Uses into three parts and take as salad 3 times a day
▪ Diarrhea Bawang
▪ Stomach ache ▪ Garlic
Preparation ▪ A low herb and grows up to sixty cms high
▪ Boil the following amount of chopped leaves in 2 glasses ▪ Leaves are flat and linear
of water for 15 minutes or until amount of water goes ▪ Bulbs consists of several tubers
down to 1 glass. Cool and strain ▪ Scientific name: Allium sativum
▪ Wash leaves and chop. Boil chopped leaves in 1 glass of Uses
water for 15 minutes. Cool and filter/strain and drink. ▪ For hypertension
▪ Toothache
▪ Lowers cholesterol levels in the blood

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Preparation WEEK 8
▪ May be fried, roasted, soaked in vinegar for 30minutes, CARE OF THE MOTHER, CHILD AND FAMILY
or blanched in boiled water for 5 minutes. Take two
pieces, 3 times a day after meals.
▪ For toothache, pound a small piece and apply to affected
part
▪ Caution: take on full stomach to prevent stomach and
intestinal ulcers.
Bayabas
▪ Guava
▪ A tree about 4-5 meters high with tiny white flowers with
round or oval fruits that are eaten raw.
▪ Scientific name: Psidium guajava
Uses
▪ For washing wounds
▪ For toothache
▪ For diarrhea Normal Menstrual Cycle
Preparation ▪ Mean duration of the MC
▪ Warm decoction is used for gargle ➢ Mean: 28 days (only 15%)
▪ Freshly pounded leaves are used for toothache. Guava ➢ Range: 21-35
leaves are to be washed well and chopped. Boil for ▪ Average duration of menses
15minutes at low fire. Do not cover pot, cool and strain ➢ 3-8 days
before use. ▪ Normal estimated blood loss
Yerba Buena ➢ Approx. 30ml
▪ Peppermint ▪ Ovulation occurs
▪ A small multi-branching aromatic herb, the leaves are ➢ Usually, day 14
small, elliptical and with toothed margin ➢ 36 hrs. after the onset of mid-cycle LH surge
▪ The stem creeps to the ground, and develop roots. ▪ The phases of the MC & ovulation regulate by:
▪ Scientific Name: Mentha cordifelia ➢ Interaction between hypothalamus, pituitary &
Uses ovaries
▪ For pain in different parts of the body as headache, ▪ Mean age of menarche & menopause is:
stomach ache ➢ Menarche: 12.7
▪ Rheumatism, arthritis and headache ➢ Menopause: 51.4
▪ Cough and cold The Cycle
▪ Swollen gums & toothache ▪ Strongly linked to the endocrine system (hormone based
▪ Menstrual and gas pain on paracrine based)
▪ Nausea and fainting ▪ Typically takes 28 days to cycle through 4 phases
▪ Insect bites and pruritus ➢ Follicular
Preparation ➢ Ovvulation
▪ For pain in diff. part of the body, boil chopped leaves in ➢ Luteal
2 glasses of water for 15 minutes. Cool and strain ➢ Menstruation
▪ For rheumatism, arthritis and headache, crush the fresh ▪ Hormone raise and fall
leaves and squeeze sap. Massage sap on painful parts of
the eucalyptus
▪ For cough and cold, get about 10 fresh leaves and soak
in a glass of hot water. Drink as tea. Acts as an
expectorant
▪ For toothache, cut fresh plant and squeeze sap. Soak a
piece of cotton in the sap and insert this in aching tooth
cavity. Mouth should be rinsed by gargling salt solution
Follicular
before inserting the cotton
▪ Begins when estrogen levels are low
▪ To prepare salt solution: add 5g of table salt to one glass
▪ Anterior pituitary secretes PSH and LH, stimulation
of water
follicle to develop
▪ For menstrual pain and gas pain, soak a handful of leaves
▪ Cells around egg enlarge, releasing estrogen
in a glass of boiling water. Drink infusion. It induces
▪ This causes the uterine lining to thicken
menstrual flow and sweating
Ovulation
▪ For nausea and fainting, crush leaves and apply at nostrils
▪ LH and FSH still being released, for another 3-4 days
of patient
▪ Follicle ruptures, releasing ova into the Fallopian tubes
▪ For insect bites, crush leaves and apply juice on affected
Luteal
part or pound leaves until paste-like and rub this on the
▪ Now empty follicle changes to a yellow colour, becomes
affected part
corpus luteum
▪ Continues to secrete estogen, but now beings to release
progesterone
▪ Progesterone further develops uterine lining

11
 ▪ If pregnant, embryo will release hormones to preserve ➢ Vascular capillaries cross the basement
corpus luteum membrane & grow into the granulosa
Menstruation cells → ↑ availability of LDL-
▪ If no embryo, the corpus luteum begins to disintegrate cholesterole
▪ Progesterone levels drop, uterine lining ddetaches, ➢ LH → ↑LDL binding to receptors → ↑
menstruation can begin 3α OH steroid dehydrogenase activity
▪ Tissue, blood, unfertilized egg all discharged → ↑ progesterone
▪ Can take from 3-7 days ➢ ↓ estrogen & progesterone → ↑ FSH
Physiology of the Menstrual Cycle and LH
Ovulation divides the MC into two phases: ➢ The new cycle starts with the
1) Follicular Phase beginning of menses
▪ Begins with menses on day 1 of the menstrual ➢ If pregnancy occurs → hCG secretion
cycle and ends with ovulation → maintain the corpus luteum
▪ Recruitment ▪ Menstruation
➢ FSH →maturation of a cohort of ➢ Periodic desquamationof the endometrium
ovarian follicles “recruitment” → only ➢ The external hallmark of the menstrual cycle
one reaches maturity ➢ Just before menses the endometrium is
▪ Maturation of the Follicle (Folliculogenesis) infiltrated with leucocytes
➢ FSH → primordial follicle (oocyte ➢ Prostaglandins are maximal in the endometrium
arrested in the diplotene stage of the 1st just before menses
meiotic division surrounded by a ➢ Prostaglandins → constriction of the spiral
single layer of granulosa cells) → arterioles → ischemia & desquamation →
Primary follicle (oocyte surrounded arteriolar relaxation, bleeding & tissue
by a single layer of granulosa cells breakdown
basement membrane & thica cells) Process of Conception
→→ Secondary Follicle or preantral Introduction
follicle (oocyte surround by zona ▪ The term “conception” means to become pregnant
pellucida, several layers of granulosa ▪ Conception or pregnancy occurs when fertilized ovum
cells & theca cells) embeds in the uterus
▪ Preovulatory Period ▪ Numerous processes are directly or indirectly
➢ LH surge responsible for conception
• Lasts for 48hrs Conclusion
• Ovulation occurs after 36hrs ▪ Conception is essential process for continuity of life.
• Accompanied by rapid fall in Numerous processes together helps in the process of
estradiol level conception. Failure or abnormality in any physiological
• Triggers the resumption of process can lead to non-conception and ultimately
meiosis infertility
• Affects follicular wall → Process of Conception
follicular rupture ▪ Gametogenesis
• Granulosaa cells → ▪ Ovulation
lutenization → progesteron ▪ Copulation
synthesis ▪ Fertilization
▪ Ovulation ▪ Development of fertilized ovum
➢ The dominant follicle protrudes from ▪ Implantation
the ovarian cortex Gametogenesis
➢ Gentle release of the oocyte ▪ The process of formation of male and female gamete
surrounded by the cumulus granulosa i. SPERMATOGENESIS
➢ Mechanism of follicular rupture ➢ Process of formation of male gamete
1. ↑ Follicular pressure (spermatozoa) in seminiferous tubule
• Changes in composition of testis
ii. OOGENESIS
of the antral fluid → ↑
➢ Process of formation of female gamete
colloid osmotic pressure
(ovum) in follicle of ovary
2. Enzymatic rupture of the
follicular wall
• LH & FSH → granulosa cells →
production of plasminogen activator
→ ↑ prostaglandin E → ↑plasminogen
activator → ↑ PG F2α →↑ lysosomes
under follicular wall
2) Luteal Phase
▪ Lasts 14 days
▪ Formation of the corpus luteum
➢ After ovulation the point of rupture in
the follicular wall seals

12
STRUCTURE OF SPERM

Development of Fertilized Ovum

▪ Further cell division called “cleavage” occurs.
▪ After 30 hrs of fertilization 2 celled stage is reached
called as “BLASTOMERE”.
▪ Blastomere continues to divide binary division through
4,8,16,32 cell stage
▪ The 16 celled stage resembles a mulberry like ball or
cluster of cells
called
“MORULA”
▪ Morula enters
uterine cavity
Ovulation and Copulation
on 4th day
▪ Ovulation
▪ Fluid enters
- The process of release of ovum from a mature
into morula
Graafian follicle of ovary is called as ovulation
and it is now
- Fertilizable life span of ovum is 12-24 hrs after
called as
ovulation
“BLASTOCYST”
▪ Copulation
- The process of sexual intercourse in which the penis
Implantation
of male is inserted into female vagina in order to
▪ The blastocyst attaching itself to uterine wall or lining is
release semen
called as implantation
- It is essential within 24-48 hrs of ovulation for union
▪ It penetrates in the compact layer of decidua near the
of gametes
fundus
- Fertilizable life span of sperm is 48-72 hrs
▪ It occurs on the 6th
Fertlization
day of fertilization
▪ Process of fusion of male and female gamete (sperm
and completed by
and ovum) is called fertilization
10th to 11th day
▪ Site-Ampulla of Fallopian tube
▪ The deeper
▪ Process: ovum is transported to ampulla after ovulation.
penetration of
Millions of sperms are deposited in vagina during
blastocyst into
copulation. Numerous sperms are destroyed in the acidic
decidua is called as
medium of vagina. Some of sperms undergoes
“Interstitial
“capacitation” and reaches vagina. The acrosomal cap of
implantation”
sperms release “Hyluronidase enzyme” which dissolutes
the layer of corona radiata. Few sperms penetrate the
zona pellucicda and only one sperm reaches the nucleus. Decidua
After entry of one sperm, the membrane is sealed to ▪ The endometrium of pregnant uterus is called as
avoid further entry of sperm and hence, fertilization Decidua.
occus and forms single celled zygote. ▪ Layers
I. Compact - superficial
II. Spongy – intermediate
III. Basal - thin
▪ After interstitial implantation of blastocyst into compact
layer of decidua, it is renamed as –
i. Decidua basalis/Serotina – portion of decidua
in contact with base of blastocyst

13
 ii. Decidua Capsularies/ Reflexa – portion of ▪ Extra embronic
decidua covering the blastocyst coelom – a cavity
iii. Decidua Vera/Parietalis – rest of decidua external to
lining the uterine cavity outside the site of developing
implantation. embryo. Also
▪ Functions: provides good nidus for implantation, called a chorionic
supplies nutrition to early stage of growing ovum and cavity
decidua basalis takes part in the formation of placenta.

Germ Layers
▪ Ectoderm
- Central and Peripheral Nervous System, Pituitary
Gland, Epidermis of skin with its appendages,
Salivary glands, Mucus lining of mouth, nostril and
anus.
▪ Mesoderm
- Bones, cartilages, muscles, cardiovascular system,
kidney, gonads, suprarenal glands, spleen, most of
genital tracts, lining of pericardium, peritoneum,
pleura
▪ Endoderm
- Liver, gall bladder, pancreas, epithelial lining of GI
tract, respiratory tract, mucus lining of urinary
bladder and urethra
▪ **EMBRYO IS DIFFERENTIATED AS HUMAN AT
Blastocyst 8TH WEEK.
▪ Fluid passes into the morula which separates the cells of THE ANTEPARTUM PERIOD
morula and it is called as Blastocyst ▪ The time period from the recognition of a pregnancy until
▪ Structure: Two Parts delivery is one of the greatest physical and psychological
i. Trophoblast (Placenta, Chorion) transitions that a woman undergoes in her lifetime.
ii. Inner Cell Mass (Fetus, Umbilical cord and During these months, the obstetrician, family physician,
amnion) or midwife serves a much larger role than just health care
Differentiation of Trophoblast provider. The clinician’s role during this time is not only
▪ Outer layer of blastocyst is called ass Trophoblast to assess the health of the mother and fetus, prescribe
▪ Differentiated into two layers: interventions, and try to influence behaviors but also to
i. Syncitiotrophoblast (Outer) advise and help patients as they undergo this challenging
ii. Cytotrophoblast (Inner) psychological passage. This presentation outlines the
▪ A 3rd layer called “Primitive Mesenchyme” is principles of prenatal care and addresses specific
developed. concerns of a woman’s general health during gestation.
▪ Syncitiotrophoblast produces irregular finger like ▪ Prenatal care has consisted of adherence to ritual and
projections called taboo for generations. Greek auothors suggested that
“Primary Stem Spartan women exercised in pregnancy to give birth to
Villi” better warriors. Roman physicians argued that strong and
▪ These villi are violent movements induced rupture of membranes. In the
differentiated into early twentieth century, hanging clothing to dry on a
blood cells and clothesline was said to increase the risk of the umbilical
blood vessels and cord wrapping around the baby’s neck. In the United
forms villus. States, the first organized prenatal care programs began
in 1901 with home nurse visits. The first prenatal clinic
Differentiation of Inner Cell Mass was established in 1911. The goal of early prenatal care
▪ The cells suspended in the blastocyst is termed as “Inner was to diagnose and treat preeclampsia in order to
Cell Mass” decrease maternal mortality. It is not surprising that this
▪ The Inncer Cell Mass is differentiated into bilaminar focus on maternal and infant health occurred as a direct
germ layer – 1) Ectoderm 2) Endoderm outgrowth of the woman suffrage movement.
▪ The bilaminar germ disc is connected with trophoblast by ▪ Over the three trimester of pregnancy, a woman must
connecting stalk or body stalk develop new aspects to her identity. Her self-image
▪ A 3rd germ layer appears during 3rd week called develops an additional sense of femininity beyond what
mesoderm. And now, bilaminar germ layer becomes was developed at puberty, and a maternal self-concept
trilaminar germ layer must develop as well. Reba Rubin, in her works on the
▪ Two cavities appears one on each side of bilaminar germ maternal experience, describes a new mother’s
layer psychological tasks as the woman grows into her new
i. Amniotic Cavity (filled with amniotic fluid) role.
ii. Yolk Sac (Incorporated into gut)

14
▪ These tasks include: ▪ For all patients, the appropriate content of prenatal care
1. Accepting a new body image, which is often in and the first prenatal visit is contained in the antepartum
conflict with accepted societal wires of record published by the American College of Obstetrics
attractiveness and Gynecology (ACOG). Identifying data, a menstrual
2. Accepting the child who is growing inside her history, and a pregnancy history are obtained. Past
3. Reordering her identity with her mother, her friends, medical, surgical, and social history are recorded, along
and with symptoms of pregnancy
4. The father of the pregnancy. Symbolically finding ▪ The patient’s current medications, including over-the-
acceptance and safety for her child (i.e., making a counter (OTC) and herbal supplements should be
new home) evaluated. A focused genetic screen, infection history,
Content of the Preconception Visit and risk status evaluation are performed or reconfirmed.
▪ The preconception visit is a focused visit for the women Gestational Age
who is planning to become or is considering becoming ▪ The Naegele’s rule is commonly applied in calculating
pregnant in the near future. The content of this interval an estimated date of confinement (EDC)
visit includes a complete history; when appropriate, a ▪ The clinician should remember that this is an
complete physical examination; approximate rule. Using the date of the patient’s last
▪ Risk assessment and intervention; selected laboratory menstrual period minus 3 months plus 1 week and 1 year,
testing based on the patient’s age and the results of the the rule is based on the assumptions that a normal
foregoing evaluation; ongoing management of medical gestation is 280 days and that all patients have 28-day,
conditions; 280 days is the currently accepted average gestation.
▪ And a plan of care. A purposeful discussion of After adjustment for patient’s actual cycle length,
contraception, sexually transmitted disease prevention, natality statistics indicate that the majority of
and timing of conception is appropriate. Timely pregnancies deliver within 2wks before or after the
administration of routine immunizations, educational estimated date.
counselling, and advice complete the visit. ▪ During prenatal care, the week of gestation can be
Risky Health Habits obtained based on the calculated EDC. When the last
▪ The use of illicit drugs or abuse of alcohol represents a menstrual period is unknown or the cycle is irregular,
significant health hazard to pregnancy. ultrasound measurements between the 14 and 20 weeks
▪ The alcohol is a known teratogen gestation provide an accurate determination of
▪ There is no consensus on the correlation between the gestational age. Care should be taken not change the
quantity of alcohol consumed and the manifestation of EDC unless the ultrasound differs by 10 or more days
adverse fetal effects. from the menstrual dates. Once dates are appropriately
▪ Therefore, the best advice to women who wish to become confirmed, continued alterations of EDC based on fetal
pregnant is to stop drinking. The T-A-C-E screen for size are problematic and ill advised
alcohol abuse has been well studied. The letters stand for Physical Examination
four questions asked in a nonjudgmental manner: ▪ A targeted physical examination during the first prenatal
1. T – “How much do you drink to feel drunk?” visit includes special attention to the patient’s BMI,
(tolerance) blood pressure, thyroid, skin breasts, and pelvis.
2. A – “Does your drinking annoy anyone?” ▪ On pelvic examination, the cervix is inspected for
3. C – “has anyone told you to cut down?” anomalies and for the presence of condylomata,
4. E – “do you drink in the morning to feel better?” neoplasia, or infection. A Pap Smear is performed, and
(eye-opener) cultures for gonorrhea and chlamydia are taken, if
▪ Smoking cigarettes is associated with adverse pregnancy indicated. A small amoount of bright red bleeding may
outcomes, including low birth weight, preamture birth, occur after these manipulations, and the patient can be
and perinatal death. Smoking by both the pregnant assured that this is normal. On bimanual examination, the
woman and members of the household should be avoided cervix is palpated to assess consistency and length as
during pregnancy and, preferably, not resumed well as to detect the presence of cervical motion
postpartum. The relative risk of intrauterine growth tenderness. Size, position, and contour of the uterus are
restriction (IUGR) among pregnant smokers has been noted.
calculated at 2.2 to 4.2. Because of the morbidty ▪ The adnexa are palpated to assess for masses. The pelvic
associated with smoking, various methods to assist examination may include evaluation of the bony pelvis –
women to quit smoking should be encourage prior to specifically, the diagonal conjugate, the ischial spines,
pregnancy. the sacral hollow, and the arch of the symphysis pubis.
Initial Prenatal Visit This evaluation need only be performed once during the
▪ This visit represents the first detailed assessment of the pregnancy.
pregnant patient. The optimal timing of this visit may Laboratory Evaluation
vary. For women who have not undergone the ▪ Blood Tests
comprehensive preconception visit, prenatal visits - Hematologic testing includes a WBC count,
should begin as soon as pregnancy is recognized. For hemoglobin, hematocrit, and platelet count. Full red
these women, much of the content of the preconception cell indices are advised for women of Asian descent
visit will need to be addressed at this time – for example, to evaluate for thalassemmia, a serologic test for
screening for domestic abuse and alcohol use syphyllis (RPR, rapid plasma region or VDRL), a
▪ All other women should be seen by about 8 menstrual rubella titer, a hepatitis B surface anitgen, a blood
weeks (6wks after conception) gestation. group (ABO), and Rh type and anitbody screen.

15
 - HIV testing should be recommended to all pregnant the like – an individualized frequency of visits
patients and documented in the chart should be established and documented. For example,
- Routine assessment for toxoplasmosis, a woman with a previous unexplained second
cytomegalovirus, and varicella immunity is not trimester loss that was suspicious but not diagnostic
necessary but may be obtained if indicated. The for incompetent cervix might be observed weekly
National Institutes of Health and ACOG between 17 and 24 wks, or a woman with chronic
recommend offering all white women testing for hypertension might be seen every 2wks throughout
cystic fibrosis status. Women for thromboembolic the first and second trimesters. In contrast, a woman
disease, should be evaluated at this time. Women with previous uncomplicated pregnancies mgiht be
with a history suggestive of thyroid disease should seen every 6wks in the first and 2nd trimesters and
also be evaluated. Although TSH is normally used to every other week in the last 8wks. The traditional
evaluate for thyroid disease, TSH may be affected timing of 14 prenatal visits was established
by other pregnancy hormones and not accurately empirically in the 1930s and has never been
affect thyroid status. Thus, a free T4 should always validated. In the mid 1980s and 1990s, several
be obtained when evaluating thyroid disease in randomized trials demonstrated that for low-risk
pregnancy. Appropriate screening for genetic carrier women, 6 to 8 total prenatal visits were equally
status, if not performed at the preconception visit, effective in achieving good pregnancy outcomes.
includes but is not limited to Tay-Sachs disease. ▪ Physical Examination
Canavan disease in women of Jewish ancestry, α- - The patient’s weight is measured, and total weight
and β-thalassemia in women in Asian and gain and trends are evaluated. The blood pressure is
Mediterranean descent, and sickle cell disease in taken and trends are assessed for possible
women of African descent. Women with a pregnancy-induced hypertension. As blood pressure
suggestive history of mental retardation should be tends to decrease during the second trimester,
screen for fragile X syndrome. increases of 30mmHg systolic or 15mmHg diastolic
▪ Urine Tests over first-trimester pressures are considered
- All women should have a clean-catch urine sent for abnormal and warrant further evaluation.
culture. Asymptomatic bacteriuria occurs in 5% to - The fundal height is measured with a tape from the
8% of pregnant women. Urinary stasis is present top of the symphysis pubis, over the uterine curve,
during pregnancy secondary to physiologic changes to the top of the fundus. This technique places an
in the urinary system, including decreased urethral emphasis on change in growth patterns rather than
peristalsis and mechanical uterine compression of the absolute measurement in centimeters, which can
the ureter at the pelvic brim as pregnancy progresses. vary between patients. In women who are obese,
- Bacteriuria combined with urinary stasis periodic ultrasound assessments of fetal growth may
predisposes the patient to pyelonephritis, the most be necessary. Gestational age is approximately equal
common nonobstetric cause for hospitalization to fundal height in centimeters from 16 to 36 wks
during pregnancy. gestation. Measurements that are more than 2cm
▪ Cultures and Infections smaller than expected for week of gestation are
- The use of routine genital tract cultures in pregnancy suspicious for oligohydramnios, IUGR, fetal
is contoversial. While it is clear that chlamydia, anomaly, abnormal fetal lie, or preamture fetal
gonorrhea, GBS disease, herpes infection, and descent into pelvis.
potentially bacterial vaginosis can be detrimental to Conversely, larger
the ultimate health of the fetus or newborn, the than expected
indications for and timing of cultures for these measurements may
infections are debated. indicate multiple
- The ACOG recommends assessment for gestation,
chlamydiosis and gonorrhea at the first prenatal visit polyhydramnios, fetal
for high-risk patients. The high-risk patient is macrosomia, or
defined as less than 25 years of age with a past leiomyomata. These
history or current evidence of any sexually concerns can be
transmitted disease, a new sexual partner within the resolved with
preceding 3 months, or multiple sexual partners. ultrasound
Any abnormal discharge should be assessed with a examination.
wet prep or Gram stain.
- Symptomatic patients should be treated.
Symptomatic bacterial vaginosis may be treated in
the first trimester.
- Tuberculosis skin testing in high-risk populations or
in certain geographic areas should be done if the
patient has not been vaccinated with BCG vaccine.
- BCG vaccination are not given in the United States.
▪ Routine Antepartum Surveillance
- It is at this in the patients’ care that individualization
should occur. For women in high-risk categories –
such as those with previous preterm birth, chronic
medical diseases, family history of problems, and
16
 First Trimester Screening Tests larger. Your child may also have low blood sugar in
▪ Ultrasound the days following delivery.
- An ultrasound uses sound waves to create an image - The tests is usually performed during the second
of the baby in the uterus. The test is used to trimester. It involves drinking a sugar solution,
determine the size and position of your baby, having your blood drawn, and then checking your
confirm how far along you are in your pregnancy, blood sugar levels. If you do test positive for
and find any potential abnormalities in the structure gestational diabetes, you have a higher risk of
of your baby’s growing bones and organs. A special developing diabetes within the following 10 years,
ultrasound called a nuchal translucency and you should get the test again after the pregnancy.
ultrasound is performed between the 11th and 14th 3rd Trimester Screening Tests
wks of pregnancy. This ultrasound checks the ▪ Group B Strep Screening
accumulation of fluid at the back of your baby’s - Group B Streptococcus (GBS) is a type of bacteria
neck. When there’s more fluid than normal, this that can cause serious infections in pregnant women
means there’s a higher risk of Down syndrome. and newborns. GBS is often found in the following
During the second trimester, a more detailed areas in healthy women:
ultrasound, which is often called fetal anatomy ✓ The mouth
survey, is used to evaluate the baby carefully from ✓ The throat
head to toe for any birth defects. However, not all ✓ The lower intestinal tract
birth defects are visible by ultrasound. ✓ The vagina
▪ Early Blood Tests - GBS in the vagina generally isn’t harmful to a
- During the first trimester, two types of blood tests woman regardless of whether she’s pregnant.
called a sequential integrated screening test and a However, it can be very harmful to a newborm baby
serum integrated screening are conducted. who doesn’t yet have a robust immune system. GBS
They’re used to measure the levels of certain can cause serious infections in babies exposed
substances in your blood, namely, pregnancy- during birth. You can be screened for GBS with a
associated plasma protein-A and a hormone called swab taken from your vagina and rectum at 35-37
human chorionic gonadotropin. Abnormal levels of weeks.
either mean there’s a higher risk of a chromosome - If you test positive for GBS, you’ll receive
abnormality. At your first prenatal visit, your blood antibiotics while you’re in labor to reduce your
may also be tested to see if you’re immunized baby’s risk of contracting a GBSS infection
against rubella and to screen for syphilis, hepatitis B, ▪ Prenatal Diagnostic Tests
and HIV. - Diagnostic tests are the next step after a screening
▪ Chorionic Villus Sampling test that yields a positive result. They leave virtually
- Chorionic villus sampling is an invasive screening no doubt as to the existence or absence of certain
test that involves taking a small piece of tissue from birth defects.
the placenta. It’s usually performed between the 10th - Diagnostic tests are more invasive than screening
and 12th wks and is used to test for genetic test. They’re usually only done if there’s a specific
abnormalities, like Down Syndrome, and birth concern, if a screening test indicates a problem, or if
defecets. There are two types. 1) one type tests your age, family history, or medical history suggests
through the belly, which is called that you may have an increased risk for a
Transabdominal Test, and 2) is through the problematic pregnancy. Diagnostic tests can carry a
ceervix, which is called a transcervical test. very small risk of miscarriage
Testing has some side effects, like cramps or Maternal Diet
spotting. There’s also a small risk of miscarriage. While weight gain is an important gauge of caloric intake, the
2nd Trimester Screening Tests quality of the diet and the frequency of meals may also affect
▪ Blood Tests patient and fetal well-being. A diet should be balanced by
- A quad marker screening test is a blood test containing foods from all of the basic food groups. Specifics of
conducted during the second trimester. It’s done to diet will vary considerably according to patient preference, family
test your blood for indications of birth defects, such eating patterns, and cultural and ethnic background. Women
as Down Syndrome. It measures four of the fetal should be instructed not to diet during pregnancy in terms of
protins. decreasing calories, but the issues of dietary requirements should
- A quad marker screening is typically offered if you be addressed.
start prenatal care too late to receive either the serum ▪ Vitamin and Mineral Supplementation
integrated screening or the sequential integrated - Multivitamin supplements are not routinely
screening. It has a lower detection rate for Down necessary in a woman eating a well-balanced diet.
Syndrome and other birth defects than a sequential However, 800 to 1,000 mg of supplemental folic
integrated screening test or serum integrated acid daily is necessary because the requirement
screening test cannot be met with food alone. Additional folate and
▪ Glucose Screening sometimes B12 may be necesssary for women with
- A glucose screening test checks for gestational a hemoglobinopathy or MTHFR mutation, for
diabetes. This is usually a condition that can develop women on anti-seizure medications, or for women
during pregnancy. It’s usually temporary. with a history of neural tube defects. Vitamin D
Gestational diabetes can increase your potential supplementation is appropriate. Most women will
need for a caesarean delivery because babies of have low levels of vitamin D, particularly women in
mothers with gestational diabetes are usually born northern latitudes and women in their mid-thirties.
17
 Mineral supplementation is also not needed in the maternal serum phenylalanine levels to <20 mg/dL
healthy women. The exception is iron. The iron before and during the pregnancy
requirements of pregnancy total about 1g. Due to the Megadose Vitamins
monthly menses, most women have less than ▪ The misuse of megadose nutrients can be categorized as
optimal iron stores during their reproductive years. a fad type of dietary manipulation. Water-soluble
Therefore, supplementation with 30mg of elemental vitamins such as vitamin C cannot be consumed in
iron is recommended in the second and third harmful quantities because they are readily excreted in
trimesters to prevent anemia and to meet this the urine. However, a problem occurs with fat-soluble
requirement. One tablet of iron salts per day, vitamin A. there is an association between high doses of
ingested between meals or at bedtime, is sufficient supplemental vitamin A and birth defects similar to those
to meet this requirements. Women with iron seen witth isotretinoin. Although the minimum
deficiency anemia require 60 to 120 mg of elemental teratogenic dose in humans has not been identified, it
ferrous iron per day. Additional zinc (15mg) and may be a llittle as 10,000 IU per day.
copper (2mg) are then needed, as iron inhibits the ▪ Beta-carotene is a provitamin of vitamin A, but it does
absorption of these ions. Iron is better absorbed in not produce similar toxicity. Most prenatal vitamins
the ferrous states and with an acid pH. contain less than 5,000 IU of vitamin A and, until further
- For women taking H2 blockers and PPI, taking the data are available, this should be considered the
iron with orange juice or in a citric acid compound maximum safe supplemental dose.
may be helpful. Pregnancy is a time in which the Women Who Have Had Bariatric Surgery
mother usually experiences bone loss of calcium. ▪ Women with gastric bypass and gastric stapling have an
Calcium supplementation is not necessary in women increased risk of nutritional problemss. Calcium and iron
with a diet thata includes adequate dairy foods. are best absorbed in an acidic pH, and thus extra
Unfortunately, many women will not meet their supplementation is recommended for these women in
dietart needs for calcium. Absent this, calcium combination with an acid such as citric acid and vitamin
supplementation may be used on an as-needed basis D. because many women with bariatric surgeries can eat
to meet the recommended dietary allowance (RDA) only small meals, such supplements need to be spread
of 1,200 to 1,500 mg per day during pregnancy and out, and counseling regarding adequate protein intake is
2,000 mg daily. Women in their mid-thirties should recommended as well. B12 absorption is promoted by an
also receive increased dosing. Calcium is best acidic environment in the stomach and by the binding of
absorbed in an acidic pH, similar to iron. To absorb intrinsic factor made in the stomach. Thus, women with
calcium, adequate vitamin D is needed. Many gastric bypass will develop B12 deficiency if they do not
women have insufficient vitamin D. calcium receive either parenteral B12 supplementation or the B12
supplements that contain vitamin D are desirable. formulation that is absorbed in the mouth. It is
Zinc is a trace mineral. A zinc is deficiency may be recommended that B12 levels are checked in women who
teratogenic in humans, although this has not yet been have had bariatric surgery at the first visit and providing
conclusively demonstrated. Zinc levels in amniotic appropriate supplementation 500mcg per day.
fluid correlate with antimicrobial activity, Caffeine
suggesting that zinc plays a role in protecting ▪ Several large human studies have failed to show that
against intrauterine infection. Low dietary intake of caffeine has deleterious effects on the fetus when
zinc has been associated with IUGR, although it ingested in low amounts. However, it is associated with
does not cause IUGR. The RDA for zinc during an incresaed risk of miscarriage when taken in greater
pregnancy is increased from 15 to 20 mg per day. than the equivalent of three cups of coffee. Adverse
Iodine deficiency can be associated in the most maternal effects of caffeine include insomnia, acid
severe forms with cretinism – congenital indigestion, reflux, and urinary frequency. As these
hypothyroid. Most table salt contains iodine. For problems are already exaggerated in pregnancy,
women who do not eat iodized salt, this can become moderation in the consumption of caffeine is advisable.
a concern. Seafood
Food Restriction ▪ High levels of seafood intake are associated with high
▪ Dieting and fasting on a chronic basis in an otherwise levels of mercury in umbilical cord blood samples as well
healthy woman can result in suboptimal fetal growth. as in maternal blood and tissue samples. Mercury is a
Eating disorders such as bulimia and anorexia nervosa teratogen and a neural toxin in the developing fetus and
reflect forms of food restriction and malnutrition child.
Pica Nausea and Vomiting
▪ PICA is the compulsive ingestion of nonfood substances ▪ Recurrent nausea and vomiting during the first trimester
with little or no nutrient value. The practice most occurs in over one half of pregnancies. While the term
commonly involves ice, clay (geophagia), or starch morning sickness is well know, it is a misnomer, as these
(amylophagia). Although pica is most commonly symptoms can occur at any time throughout the day or
recognized during pregnancy, it is not specific to the night. Symptoms usually begin in weeks 6 to 8, peak
gravid state. during weeks 12 to 14, and are significantly resolved by
Phenylketonuria week 22. The etiology of this problem is not clear.
▪ Women with phenylketonuria who are not on a Hormonal as well as emotional factors have been
phenylalanine-controlled diet are at increased risk of investigated without consistent results. Symptoms can be
bearing fetuses with microcephaly, growth retardation, mild or so severe that the patient becomes dehydrated
and mental retardation. The goal of dietary management and risks electrolyte imbalance and caloric malnutrition.
is to minimize these adverse fetal outcomes by reducing Nonpharmacologic measures often suffice and may
18
 completely relieve the symptoms in some women. These diseases such as parasites or inflammatory bowel
include avoidance of fatty or spicy foods; eating small, disease, the patient may be reassured.
more frequent meals, thus keeping something in the Exercise
stomach; and inhaling peppermint oil vapors. ▪ Exercise is a routine part of many women’s daily
Randomized trials have validated the effectiveness of activities. For a normal pregnancy, a low impact exercise
fresh ginger – which may be made into a tea, candies, or regimen may be continued throughout pregnancy.
compounded – in decreasing nausea and vomiting. Additionally, studies also show that women may increase
Several studies have evaluated vitamin B6, 25mg two to their levels of fitness during pregnancy without problems
three times a day, and found this helpful in eliminating ▪ There are no data to indicate that pregnant women must
nausea and vomiting. The use of the Nguyen pressure decrease the intensity of their exercise or lower their
point on the wrist is also suggested to be helpful. Motion target heart rates. However, physiologic changes of
sickness bands on the wrists employ this technique. In pregnancy may alter the effect of various exercises on the
more severe cases of emesis, various pharmacologic body’s ability to perform certain types of exercises.
agents have been used with varying success. These Varicosities and Hemorroids
include a variety of antihistamines, doxylamine, ▪ Varicosities most often occur in the lower extremities and
promethazine, metoclopramide, trimethobenzamide, may be seen in the vulva as well. Contributing factors
methylprednisolone, and serotonin 5-Ht3 antagonists include genetic predisposition, advanced maternal age,
such as ondansetron. Because supplemental vitamin and increased parity, and prolonged standing. Manifestations
mineral preparations may exacerbate symptoms of can range from mild cosmetic effects to chronic pain and
nausea, they should be stopped until the symptoms have superficial thrombophlebitis. Treatment includes
resolved. Women and their families may be reassured avoidance of garments that constrict at the knee and
that minimal weight gain in the first 18 weeks is uppeer leg, support stockings, and increased periods of
common. Hyperthyroid disease will exacerbate nausea rest with the legs elevated.
and vomiting, and if signs of thyroid disease are present, Fatigue
free T4 levels should be obtained and treatment initiated. ▪ Pregnant women will usually have an increased sense of
Some studies have found Helicobacter pylori infection in fatigue during pregnancy. This is a normal symptom. A
women with more severe hyperemesis and resolution or sense of breathlessness is also normal because of the
decrease in symptoms with treatment. progesterone of the respiratory centers.
Ptyalism Syncope
▪ Ptyalism is the increased production of saliva, sometimes ▪ Venous pooling in the lower extremities increases as the
induced by the consumption of starch. There is no cure, pregnancy progresses. This can lead to dizziness or
although reducing carbohydrate intake may be helpful. lightheadedness, especially after standing upright
The problem is often self-limiting. It is not uncommon in abruptly or for long periods of time.
pregnancy and is not associated with adverse outcome. Sleep Disturbances, Restless Leg Syndrome, and Leg Cramps
Heartburn ▪ Most women will develop alterations from their normal
▪ Heartburn is usually caused by reflux esophagitis from sleep patterns during pregnancy. More frequent
both mechanical factors (the enlarging uterus displacing urination, more common gastric reflux, and physical
the stomach above the esophageal sphincter) and discomfort with the growing pregnancy all contribute to
hormonal factors (progesterone causinng a relative poorer sleep. Some authors have described more
relaxation of the esophageal sphincter). Treatment common snoring (up to 30%), less rapid eye movement
consists of eliminating acidic and spicy foods, decreasing (REM) sleep, and much more vivid dreams.
the amount of food and liquid at each meal, limiting food Antihistamines are usually recommended as a first-line
and liquid intake before bedtime, sleeping in a semi- sleeping aid, if necessary. Restless leg syndrome (RLS)
fowler position or propped up on pillows, and use of is also common complaint for pregnant women
antacids. Liquid forms of antacids and H2-receptor (approximately 25% of women may develop RLS during
inhibitors provide the most consistent relief of pregnancy)
symptoms. Patients should be cautioned that antacids Backache
containing aluminum may cause constipation, while ▪ Most pregnant women experience lower backache as
diarrhea may be associated with use of those containing pregnancy progresses. These are usually alleviated by
magnesiuim. Proton pump inhibitors are sometimes minimizing the amount of time spent standing,
necessary in severe cases. In women with chronic antacid increasing rest, wearing a specially designed support belt
use, careful attention should be given to iron and calcium over the lower abdomen, and taking an analgesic such as
absorption. acetaminophen.
Constipation, Diarrhea and Gas Round Ligament Pain
▪ Progesterone-induced relaxation of the intestinal ▪ Round ligament pain most frequently occurs during the
smooth muscle slows peristalsis and increases bowel second trimester when women report sharp, bilateral, or
transit time. Dietary management of this common unilateral groin pain. It has been called round ligament
condition includes increased fluids and liberal intake of pain, although it is not know if round ligament stretch is
higher-fiber foods. Iron salts may exacerbate the the true etiology. The pain may be increased with sudden
problem. OTC products containing psyllium draw fluid movement or change in position..
into the intestine and promote a more rapid transit time. Headache
Enemas and strong cathartics should be avoided. Many ▪ Generalized headaches are not uncommon during the
women develop very different bowel patterns during first trimester of pregnancy. Muscle tension headaches
pregnancy. Extra gas and loose stools are not uncommon may occur intermittently. The frequency and intensity of
symptoms. As long as there are no signs of funderlying migraine headaches may increase or decrease during
19
 pregnancy. Headaches during the second and third towards lower
trimesters are not an expected symptom of pregnancy abdomen
Employment ▪ Not relieved by rest ▪ Often relieved by
▪ Most patients are able to continue to work throughout rest
their pregnancy. In general, work activities that increase ▪ Increase in duration, ▪ Does not increase in
the risk of falls or trauma, especially to the abdomen, intensity and duration, intensity or
should be avoided. Hazardous toxic or chemical frequency with time frequency
exposures should be identified early and avoided. ▪ “show” present ▪ “show” absent
▪ Strenous physical activity, including repetitive lifting and ▪ Accompanied by ▪ Not accompanied by
prolonged standing for more than 5 hrs, has been cervical changes cervical changes.
associated with a greater rate of adverse outcomes, and Stages of Labour
work routines should be modified accordingly. ▪ First stage: from onset of labor until full dilatation of
Urinary Frequency cervix
▪ Patients often experience urinary frequency during the ❖ Latent Phase
first 3 months of pregnancy, as the enlarging uterus ➢ Cervix <4cms
compresses th bladder, and again during the last weeks, ➢ Contractions are weak
as the fetal head descends into the pelvis. ➢ Less than 2 contractions per ten
Skin Changes minutes
▪ Hair growth has variable patterns in pregnancy, although ❖ Active Phase
many women experience increased growth during ➢ Cervix > or = 4 cms
pregnancy and hair loss postpartum. Skin commonly ➢ Contractions >3 per 10 min lasting 45-
darkens over the face and the median ventral line of the 50 sec
abdmone in many women. Any nevi that change color ➢ Rate of dilation 1cm / hr or more
should be excised. ➢ Descent present
Immunizations ❖ Points to Remember:
▪ Four immunizations using vaccines containing live ➢ Examine abdomen before vagine
viruses are relativcely contraindicated during pregnancy. ➢ Do not shave perineum
These are measles, mumps, rubella, and yellow fever. ➢ Wash hands, clean gloves, explain to
However, in certain circumstances, risk/benefit the female about PV
assessment may lead to recevingg the immunizations. ➢ If bleeding PV – PV not to be done
The risks of the fetus from the administration of rabies ➢ Supine position with her legs flexed
vaccine are unkown, and each case must be considered and apart
individually since the indications for prophylaxis are not ❖ During PV Examination
altered by pregnancy. Tetanus toxoid, if needed, is ➢ Cervical effacement
acceptable in pregnancy. Flu vaccine is recommended for ➢ Cervical dilatation in cms
pregnant women. Women who are receving Hepatitis B ➢ Presenting part
vaccine may continue receiving it during pregnancy. ➢ Station and position of presenting part
Immune globulin for acute exposures to hepatitis A also ➢ Status of membranes
is considered safe. ➢ Color of liquor
Travel ❖ Supportive Care During Labour
▪ Most issues concerning travel involve the comfort of the ➢ Keep woman informed of her progress
mother. When prolonged sitting is involved, the patient ➢ Maintain privacy
should try o stretch her legs and walk for 10 minutes ➢ Encourage her to keep herself clean,
every 2hrs to decrease the risk of thrombosis that can wash perineum
occur secondary to the hypercoagulable pregnancy state ➢ Enema NOT ROUTINE: only if
and mechanical compression of venous blood flow from needed
the extremities. Dependent edema may also be more ➢ Empty bladder frequently
pronounced after prolonged sitting. If the patient will be ➢ Presence of second person or birth
away from home for a significant period of time, she companion
should take a copy of her medical record with her. ➢ Woman to be ambulatory
Pregnant women can and should always wear seat belts ➢ Woman free to choose any position
when riding in a car. Travel in a pressurized airplain during labor & delivery
presents no additional risk to pregnant women. In ➢ Hold her hand, massage back
traveling abroad, especially to underdeveloped countries, ➢ Plenty of fluids, light fat free food.
the usual precauations should be taken regarding ❖ Non-Pharmacological Pain Relief
ingestion of unpurified drinking water and uncooked ➢ Calm and gentle voice
fruits and vegetables. ➢ Offering encouragement, reassurance
The Intrapartum Period and praise
▪ True & False Labour Pains ➢ Relaxation techniques deep breathing
True Labour Pains False Labour Pains exercises and massage
▪ Regular and ▪ Irregular ➢ Assisting the woman in voiding urine
predictable and in changing her position.
▪ Felt first in lower ▪ Remains confined to ▪ Second Stage: from full dilatation of cervix until
back & sweeps lower abdomen delivery of baby
➢ Full cervical dilatation
20
 ➢ Bulging thinned out perineum ▪ Fetal condition
➢ Gaping anus and vagina ➢ Count fetal heart rate every half hour
➢ Head visible at the perineum ➢ Count for one full minute, immediately
▪ Third Stage: from delivery of baby to delivery of following a uterine contraction
placenta ➢ Fetal distress
▪ Fourth Stage: for 2hrs after delivery of the baby o FHR <120 beats/minute or >160
Monitoring of First Stage of Labour beats/minute
▪ Latent Phase ▪ Arrange for referral
❖ Monitor every ½ hr Plotting a Partograph
❖ Monitor the following every 4hrs: temp, pulse, ▪ Chart the contractions every half an hour
blood pressure ➢ Number of contractions in 10mins
❖ Record time of rupture of membranes and color ➢ Duration in seconds
of amniotic fluid o Less than 20 seconds
❖ Emergency signs: difficulty in breathing, shock, o Between 20 and 40 seconds
vaginal bleeding o More than 40 seconds
▪ Maternal Condition
➢ Record maternal pulse every half hour and mark
with a dot (.)
➢ Record maternal BP every 4hrs using a verticl
arrow, with upper end signifying systolic BP
and lower end diastolic BP
➢ Recording the temperature every 4hrs and note
on temperature graph.
▪ Interventions
➢ Mention dose, route, and time of administration
of any drug
➢ Mention the food items and liquids consumed.
What are the indications for referral to FRU – on the basis of
Partograph?
▪ FHR is <120 beats/min or >160 beats/min
▪ Active Phase: Monitor the following every 30 minutes: ▪ Meconium and or blood stained amniotic fluid
❖ Monitor pulse, uterine contractions, FHR ▪ When cervical dilatation plotting crosses the alert line
❖ Look for presence of (moves towards the right side of the alert line)
➢ Meconium or blood stained liquor or ▪ Contractions not increasing in duration, intensity and
cord prolapse frequency (e.g., <2 contractions lasting for <20 sec in 10
❖ Monitor the following every 4hrs: min)
➢ Cervical dilatation (in cm) by P/V Monitoring of Second Stage of Labour
➢ Temperature ▪ Monitor the following every 5 minutes:
➢ Blood pressure ➢ Frequency, duration and intensity of
❖ In Active Phase contractions
➢ Never leave the woman alone ➢ FHR
➢ Monitor intensively using Partograph ➢ perineal thinning and bulging
➢ Refer immediately if no progress ➢ visible descent of fetal head during contractions
Partograph ➢ presence of any signs indicating an emergency
▪ Partograph is a Abdominal Palpation
graphic recording of ▪ watch for signs of imminent delivery
the progress of labor ➢ gapingg of vulva
& condition of mother ➢ thinning and bulging of perineum
and fetus ➢ pouting of anus
▪ Labor record, thus ➢ head of the baby seen at vulva
reduces paper work ▪ encourage the woman to push during contractions when
▪ Tool to identify she has an urge to do so while taking deep breaths
complications of Supportive Management During Second Stage
labor and make timely ▪ any position woman is comfortable: dorsal lithotomy,
referrals standing, sitting, squatting
▪ encourage bearing down when she has urge to push at
full dilatation
Filling a Partograph ▪ discourage bearing down before the cervix is fully dilated
▪ Identification data ▪ do not ask her to hold breath
➢ Name ▪ avoid ironing (sweeping and stretching) the perineum
➢ Age ▪ Oxytocics: not routinely recommended in second stage
➢ Parity ▪ Episiotomy: not routine
➢ Date and time of admission ➢ Complicated vaginal delivery (malpresent)
➢ Registration number ➢ h/o third/fourth degree perineal tears
➢ Time of rupture of membranes ➢ fetal distress
21
 ➢ instrumental/assisted delivery ➢ The claiming process includes the identification
▪ encourage rapid breathing with mouth open of the baby’s specific features, relating them to
▪ hydration – oral/IV fluids other family member
▪ DO NOT apply fundal pressure ➢ “Those long toes are just like his dad’s”
▪ 5 clean’s – surface, hands, cord tie, blade, cord stump ▪ Rooming-IN
▪ Prepare for active mngt. 3rd stage ➢ Infant stays in the room rather than in the
Delivery of Head nursery.
▪ Ensure a controlled delivery of the head by keeping one ➢ She can become better acquanted with her child
hand gently on the head and other supporting the and begin to feel more confident in her ability
perineum to care.
▪ Feel gently around the baby’s neck for presence of Pospartal Blues
umbilical cord ▪ 50% of women experience some feeling of
▪ If it is loose around the neck, deliver the baby through overwhelming sadness for which they cannot account
the loop of the cord, or slip the cord over the baby’s head ▪ Hormonal changes – decreased progesterone and
▪ If it is tight around the neck, doubly clamp and cut in estrogen
between. ▪ Response to dependence and low self-esteem caused by
Delivery of Shoulders and Rest of the Body exhaustion, being away from home, physical discomfort
▪ Wait for the spontaneous rotation and delivery of the and tension
shoulders. This usually happens within 1-2 minutes ▪ Fearfulness, feeling of inadequacy, mood lability,
▪ Apply gently pressure downwards to deliver the top anorexia and sleep disturbance
(anterior) shoulder ▪ Assurance and support
▪ Then lift the baby up, towards the mother’s abdomen, to Physiologic Changes of the Postpartal Period
deliver the lower (posterior) shoulder ▪ Involution
▪ Deliver one shoulder at a time ➢ Reproductive organs
▪ Rest of the baby’s body follows smoothly return to their normal
▪ Note the time of birth state
Postpartal Period ▪ Uterus
▪ Puerperium – “puer” – child, “parere” – to bring forth ▪ 2 Process
▪ 6 wks period after childbirth 1. The area where the
▪ Retrogressive – involution of the uterus and vagina placenta is sealed off
▪ Progressive – production of milk for lactation,
restoration of the normal menstrual cycle, and beginning
of a parenting role o Accomplished by rapid contraction of
Phases of Puerperium the uterus after the delivery of the
▪ Taking-In Phase placenta
➢ 2- to 3-days period, a woman is largely passive o Muscle fibers become shorter
➢ Woman usually wants to talk about her controlling the bleeding by
pregnancy, especially about her labor and birth compressing and sealing off blood
➢ ***Main nursing is to listen and help the mother vessels.
interpret events of the delivery to make them 2. The organ is reduced to its pregestational size
more meaningful and clarify and through
misconceptions o Autolytic Process – few cells of the
▪ Taking-Hold Phase uterine wall are broken down into their
➢ Occurs during day 1-3 following delivery protein component which is then
➢ Marked by a period of being dependent and absorbed in the blood stream and
passive behavior excreted in the urine
➢ Mother’s primary needs are her own – food and o Contraction
sleep o Immediately after birth – 100g
➢ Mother is talkative about her labor and delivery o At the end of 1st
experience wk – 500g
➢ ***It is the best time for teaching! o 6wks – 50g
▪ Letting-Go Phase o After placental
➢ Woman finally redefines her new role delivery the
➢ She gives up the fantasized image of her child uterus may be
and accepts the real one; she gives up her old palpated
role of being childless or the mother of only one through the
or two abdominal wall
Development of Parental Love and Positive Family halfway between the umbilicus and the
Relationship symphysis pubis
▪ En face position – eye to eye contact o 1hr after – level of umbilicus
▪ Explore with finger tips o Decrease 1 finger breath per day
▪ Hand and palmar contact
▪ Whole-arms – enfolds whole baby close to body
▪ Claiming or Bonding

22
 Nursing Care of the Uterine Changes ▪ Hypothalamus sends messages to the pituitatary gland
Assessment of the Uterus ▪ Anterior Pituitary – stimulates prolactin to be released
▪ Placement and size (location) which is the ultimate stimulation for milk production
➢ Should be level with the umbilicus after ▪ Posterior Pituitary – releases oxytocin which stimulates
delivery. The uterus then should decrease 1 FB/ the contraction of the cells around the alveolli in the
day. Should also be midline and the size of a mammary glands. This causes milk to be propelled
grapefruit. through the ducct system to the infant. This is the “LET
➢ Tone DOWN” reflex. Felt as a tingling sensation
o Should be firm. Assess by supporting Breastfeeding Care
lower portion with one hand and ▪ No soap on the nipples,wash in water wear supportive
palpate fundus with other. bra
o If found boggy, then massage. Do not ▪ Breastfeeding tips:
overmassage. ➢ Most important is the “latch-on”. Teach
➢ Lochia measures to assist with the infant getting the
nipple and areola in the mouth
➢ Teach different positions to hold the baby
➢ No timing
➢ Relax to allow for “let-down”
Suppression of Lactation
▪ Key: teach meaures to decrease stimulation of the breasts
➢ Tight-fitting bra or binder
➢ Do not express milk from the breasts
➢ Take shower with back to the warm water
➢ Ice packs
Elimination Changes Urinary System
▪ Assess and measure first two voidings post-delivery
▪ Important to attempt to void every 3-4 hours. If unable to
void – catheterize based on assessment
▪ Diuresis is common – loss of fluid of pregnancy
▪ Mild proteinuria is normal
Patient teaching
❖ Characteristics of Lochia ▪ Increase fluids, fiber, and activity
o Should not be excessive in amount ▪ Stool softeners, anesthetic sprays, tucks
o Should not have an offensive odor ▪ **DO NOT give an enema or suppository to a person
o Should not contain large pieces of who has a 3rd or 4th degree laceration
tissue or blood clots Regulatory Changes
o Should not be absent during the first 3- ▪ Most common problem is sleep deprivation – the
wks excitement and exhilaration following the birth may
o Should proceed from rubra – serosa – make it difficult to sleep
alba ▪ Exercise – should be individualized per the patient. Use
▪ Cervix caution until involution is complete.
➢ After birth – soft and malleable, internal and Postpartum Pain
external os is open ▪ Perineal pain
➢ Pre-pregnant ➢ Result of trauma during delivery-
appearance is a episiotomy/lacerations/hemorrhoids.
dimpled area in ➢ Interventions: comfort measures: sitz, tucks,
the center – post sprays/foams, oral analgesics.
pregnancy ▪ After birth pain
appears as a ➢ More common in multigravidas and
jagged slit. breastfeeding moms.
➢ Interventions: treat with mild analgesics
▪ Vagina (NSAIDS, Acetaminophen), heating pad, lie on
➢ May be edematous and bruised abdomen, discontinue use of oxytocins, Norco
➢ Rugae begin to appear when ovarian function for severe pain.
returns ▪ Breast engorgement
➢ May teach the mom to do Kegels exercises ➢ warm or cold packs, cabbage leaves, increase
Breast feedings if breastfeeding, decrease stimulation
▪ Teach to assess her own breasts – similar to doing a self- if not breastfeeding. Breast binder.
breast exam (SBE) ▪ Gas distention
▪ Assessment: ➢ No ice chips or cold liquids, provide warm/hot
➢ Individualize teaching for breasts for fluids, increase walking, rocking chair,
breastfeeding and non-breastfeeding moms Simethicone
Process of Lactation
▪ Sucking of infant stimulates the nerves beneath skin of
the areola to transmit messages to the hypothalamus
23
 Integumentary Changes ▪ Assess for Hemorrhage – related to uterine atony
▪ Skin – pigment changes will begin to disappear; ➢ Normal for loss of up to 500 cc during vaginal
diaphoresis is normal deliveery and 1000 cc in cesarean delivery.
▪ Striae – may have stretch marks over abdomen and legs ➢ Assessment of lochia: should be scant to small
▪ Diastasis Recti – can occur with overdistention of the with no large clots
uterus, caution with exercise ➢ Assessment of fundus: tone, location
▪ Episiotomy/Lacerations – important to treat as any ➢ If excess bleeding and decreased tone may
other incision and maintain cleanliness administer Methergine. Assess BP prior to
▪ C/S Incision – maintain pressure dressing for 24 hrs and giving – hold the dose if elevated >!40/90
then open to air, closure with staples/ steri mmHg. Other drugs to contract uterus
strips/dermabond. Document and assess approximation, Nutritional Alterations
and signs of infection ▪ Most moms are hungry and eager to eat. Progress slowly
Oxygenation Alterations Cardiovascular System Changes to avoid nausea and vomiting
▪ Plasma Volume – body rids itself of excess by: ▪ Diet should include
➢ Diuresis – urinary output of 3000 cc/day is ➢ High in protein, vitamin C, and fiber
common ▪ Lactating moms need about 500 extra calories for milk
➢ Diaphoresis production
▪ Blood Volume ▪ Prenatal vitamins and iron supplements are often
➢ Increase for about 24-48 hrs after delivery continued in the postpartum period.
➢ Increase in blood flow back to the heart when
blood from the placenta unit returns to central
circulation WEEK 9
➢ Extravascular interstitial fluid is moved into the INTRODUCTION TO RESEARCH: GENERAL
vascular system/intravascular CONCEPTS
➢ Leads to increasaed cardiac output mainly RT ▪ Research is an organized inquiry carried out to provide
increase stroke volume information for solving problems
Oxygenation ▪ It is the cornerstone of every science.
▪ Vital Signs What is Research?
➢ Temperature – may see a SLIGHT – 100. Rise ▪ Re – again
in temperature because of dehydration and ▪ Search – find
exertion of labor in first 24 hrs ▪ Process – step by step phase, phases
➢ Pulse – Bradycardia is common for 6-8 days ▪ Research is the systematic process of collecting and
postpartally. RT vagal response to increased analyzing information to increase our understanding of
sympathetic nervous system stimulation during the world in general and of the phenomenon under
labor and increasse in stroke volume study in particular.
➢ Respirations – Begin to fall to normal pre-birth Steps in Qualitative Research: THEORY
range 1) Acknowledge Social Self
➢ BP – should remain steady. Not elevated or 2) Actual perspective
decreased. 3) Design study
4) Collect data
5) Analyze data
6) Interpret data
7) Inform others
Purpose of Research
▪ Explore
▪ Describe
▪ Explain
Characteristics of Research
1) Empirical – research is based on direct experience or
observation by the researcher
2) Logical – research is based on valid procedures and
principles
3) Cyclical – research starts with a problem and ends with
a problem
4) Analytical – research utilizes proven analytical
procedures in gathering data, whether historical,
descriptive, experimental, and case study.
▪ Assess for Thromboembolism 5) Critical – research exhibits careful and precise
➢ During pregnancy, plasma fibrinogen judgment.
(coagulation) increases to prepare for delivery 6) Methodical – research is conducted in a methodical
and prevention of excess blood loss manner without bias using systematic method and
➢ Plasminogen (lysis of clots) does not rise procedures.
➢ Hypercoagulable state and the woman is at a 7) Replicability – research design and procedures are
greater risk for thrombus formation repeated to enable the researcher to arrive at valid and
➢ Assess for homan’s sign. conclusive results.

24
 8) Intellectual Curiosity – researcher undertakes deep Descriptive Research
thinking and inquiry of the things, problems, and ▪ It includes fact-finding enquiries of different kinds such
situations around him as what, why, when. How and all
9) Prudence – researcher is careful to conduct his study at ▪ The main aim of this research is description of the
the right time and at the right place wisely, efficiently, characteristics of a phenomena at present
and economically. ▪ This research has no control over the variable only have
10) Healthy Criticism – the researcher is always doubtful to report what is happening or what has happened
as to the truthfulness of the results. ▪ For description researchers use frequencies, averages
11) Intellectual Honesty – researcher is honest to collect or and other statistical calculations
gather the data or facts in order to arrive at honest ▪ The methods used by this researchers involves survey
results. method of all kinds including comparative and
12) Intellectual Creativity – a resourceful investigator correlational method
always creates new researches. ▪ The periodic table categorizes the elements is an
Qualities of a Good Researcher example of descriptive research
▪ Research Oriented Method
▪ Efficient ▪ Six steps in conducting descriptive research
▪ Scientific 1. Identify problem
▪ Effective 2. Review literature
▪ Active 3. Select participants and instruments
▪ Resourceful 4. Collect valid and reliable data
▪ Creative 5. Analyze data
▪ Honest 6. Report conclusions
▪ Economical Types and Actual Studies of Descriptive Research
▪ Religious ▪ Descriptive – Normative Survey
Types of Research ➢ The term normative is sometimes used because
There are different types of research based on different aspects survey are frequently made to ascertain the
such as: normal or typical condition, or practice, or to
▪ Purpose compare local test result with a state or national
▪ Process norm.
▪ Outcome

▪ Descriptive – Educational-Survey Research Studies

➢ This type of study looks into the teaching-
learning process, the child-teacher, the learner
and the environment, the attitudes, habits and
other characteristics of the learner, the
techniques and the methods, the building
equipment and materials used, etc. which all
pertain to education. The goal of this study is to
have a total improvement of the educational
system for the maximum development of the
individual learner.
Different types of research coming under the category purpose
are
I. Descriptive research
II. Analytical research
III. Exploratory research
IV. Predictive research

25
 unique characteristics of the participant may make the
result inconsistent and unreliable
▪ Bear in mind that seldom in the descriptive method per
se used as end in itself. It means that the primary
objective of descriptive methods is to make use of the
results to facilitate predictions or control of some
behaviors. As a researcher, for you to plan how your
findings can be used as means to further some ends
▪ Use statistical procedures to assure you of a level of
confidence that your results are trustworthy
▪ Data should not be manipulated
▪ Instrument use should be free from cultural bias.
Importance of Descriptive Research
▪ For scientific basis of judgement. This means that
descriptive research provide information which could be
used as basis for important decisions that are to be made.
▪ For a closer look into happenings, behavior, practice,
methods and procedures. Descriptive research provides
▪ Descriptive – Psychological Research Studies essential facts and understanding about the nature of
➢ This study pertains to the behavior of anything
individuals in different situations. ▪ For the formation of construction of test analysis of these
standardization of tools instruments used in research
Analytical Research
▪ This research mainly carrying out analysis on a
phenomena and which involves secondary data
▪ The aim of this research is to understand phenomena by
discovering and measuring causal relations among them
▪ Here the researcher use facts or information’s readily
available to them in order to analyze to make a critical
evaluation of the context
▪ It works within the constraint variables. It also tries to
explain existing state of affairs from available data
▪ How can the absentee rate among employees be reduced?
It is an example of analytical research.
▪ The researcher has to use facts or information already
available & analyze them to make a critical evaluation of
the material
▪ It involves the in-depth study & evaluation of available
information in an attempt to explain complex
▪ Descriptive – Social Survey phenomenon
➢ The purpose of this study is to change for the ▪ It concerned with testing hypothesis & specifying &
better existing practices of groups living a interpreting relationships, by analyzing the facts or
community. It is concerned with the formulation information already available
of constructive programs of social reform and Analytical Method
amelioration. A current social problem is ▪ The Analytical Method is a generic process combining
existing in a particular place, and the aim is to the power of the Scientific method with the use of formal
diagnosis the “root causes” of the ills, utilizing process to solve any type of problem. It has nine steps.
the research approach. STEPS
1. Identify the problem to solve
2. Choose an appropriate process (THE KEY STEP)
3. Use the process to hypothesize analysis or solution
elements
4. Design an experiment(s) to test the hypothesis
5. Perform the experiments
6. Accept, reject, or modify hypothesis
7. Repeat steps 3,4,5, and 6 until hypothesis is accepted
8. Implement the solution
9. Continuously improve the process as opportunities arise.
Importance
▪ Use of the analytical method is critical to solving the
Ethics of Descriptive Research sustainability problem because it appears that current
▪ Be sure when you describe any particular group of processes are inadequate. They are intuitive, simple, and
individuals in your population, you should include not based on how activists approach everyday problems.
only the characteristics which are common to the group
but also their unique as well. Failure to include the
26
 Conclusion ➢ Streamlined services and
In the teaching experiment ➢ Expedited application processing
a) Results show that application of multimedia technology For example, predictive modeling assist in:
in the teaching of physical education has greatly changed ▪ Moving from mass marketing to more personalized
the student’s physical source of knowledge structure. ▪ Targeted campaigns and offers
b) Learning ways of cultivating the students’ learning ▪ Provide insights into where airlines are or are not
ability, habits of lifelong learning has obvious role in meeting traveler expectations
promoting; ▪ Pricing products
c) Network teaching form can make up for the traditional ▪ Managing inventory or staffing
single teaching content, defect class too little; ▪ Customer and operational data to improve efficiency
d) The network education technology of asynchronous ▪ Reduce risk and
nature of teaching and modern teaching means more ▪ Increase profits
optimized teaching mode has brought inspiration for the EG4: HR
school sports exploration, is conducive to the deepening Things driving the use of predictive analytics in HR
of teaching reform. ▪ Getting better at using operational processes and
Exploratory Research technology by collecting good-quality data to make
▪ An exploratory-design is conducted about a research better decision-making
problem when there are few or now earlier studies to ▪ These rich data sources referring to the inclusion of both
refer to external and internal data
▪ The focus is on gaining insights and familiarity for later ▪ Vendors of HR solutions are increasingly building
investigation or undertaken when problems are in analytics into their core platforms.
preliminary stage of investigation. EG6: Coupons in Grocery Stores
▪ Gathers preliminary information that will help to define ▪ Retailers accumulate huge amounts of data on a day-to-
a problem and suggest a hypothesis day basis
▪ It commonly uses unstructured interview ▪ Using predictive analytics and data from loyalty cards,
▪ It involves generation of new ideas and assumption, computers in real-time crunch terabytes and terabytes of
development of tentative theories or hypothesis but historical purchases to figure out that favorite ice cream
conclusions cannot be drawn even though it provides was the one item missing from shopping basket that week
direction for future research and techniques. ▪ With bill, a coupon is received for the item that are most
Types of Exploratory Research likely to buy next time
▪ Literature Reviews ▪ The shift toward contextual marketing and retailing is
▪ Experience Surveys driven by data – big data
▪ Analysis of Stimulating Examples (i.e., Case Analyses)
▪ Unstructured Methods (i.e., Pilot Studies)
Conclusion
▪ Exploratory research study which merely leads to insight
or hypothesis, whatever method or research design
outlined above is adopted, the only thing essential is that
it must continue to remain flexible so that many different
facets of a problem may be considered as and when they
arise and come to the notice of the researcher.
Predictive Research
▪ It studies determine the frequency with which something
occurs or its association with something else
▪ In diagnostic research, the researcher must be able to
define clearly, what he wants to measure and must find Different types of research coming under the category process are:
adequate method for measuring along with clear cut 1. Qualitative research
definition off ‘population’ he wants to study. 2. Quantitative research
▪ Statistical tools used in this research design includes Qualitative Research
regression, linear regression and logistic regression ▪ It is handled with qualitative phenomena that involves
▪ The major areas in which predictive/diagnostic research quality or kind
design used include: business, marketing, clinical setting, ▪ The research designed to find out how people feel or
govt agency and all. what people often think are coming under this research
EG1: Match.com ▪ It is important in behavioral sciences.
▪ Is powered by Synapse algorithm. ▪ Its aim is to discover the underlying motives of human
▪ It learns about its users (as Amazon, Netflix, and behavior through detailed description
Pandora) to recommend new products, movies, or songs ▪ The data is in the form of words, pictures or objects and
based on a user’s preferences all
▪ Excludes certain variables or take a multi-dimensional Research Question Considerations
scoring approach with different weights. ▪ Is the question easily and fully researchable?
EG2: Websites ▪ What type of information do we need to fully answer the
EG3: Airlines question?
▪ Customers needs and wants: Techniques ▪ Is the scope of the research question reasonable
➢ Analytical quality control ▪ Given scope, is the question too broad or too narrow?
➢ Reliability modeling ▪ Do I have access to the necessary sources?
27
Why is all this Important? Possible Applied Research Topics
▪ We can use these same steps when designing a new ▪ Forensic accounting
research project for a client ▪ Risk management
▪ Research questions will allow us to be more focused on ▪ Financial criminology
exactly what the client is looking to have answered. ▪ Financial integrity
Now what? ▪ Tax audit
▪ We have our research question, now what do we do? ▪ Corporate governance
▪ The next step is to design a research study that will ▪ Financial reporting
answer the necessary question(s) ▪ Financial fraud investigation competency
Research Methodology ▪ Whistle blowing
▪ Methods of data collection ▪ Fraud prevention
➢ Interviews (one-on-one, focus groups, etc.) ▪ CPD training programs for enforcement officers
➢ Observations ▪ Fraud surveillance
➢ Open-ended survey Fundamental or Basic or Pure Research
➢ Written documents ▪ This research is concerned with generalization and
▪ Analysis: Coding formulation of theory
➢ When coding we focus on whatever is necessary ▪ It is done for the intellectual pleasure on learning and it
to answer our research question has no commercial value attached to the discoveries that
➢ This may require: emotion coding, holistic result from basic research
coding, in vivo coding, initial coding, etc. ▪ This type of research has limited direct applications but
▪ Analysis: Theming in which researcher has careful control over the research
➢ Theming of the data setting
o Reducing data into meaningful and ▪ It involves collection and analysis of data to develop or
manageable groups enhances theory and have an understanding of theoretical
o May focus on repeated words or relationship between variables.
phrases For example:
o Evidence that answers the research ▪ Basic science investigations probe for answers to
question questions such as
▪ Research: Next Steps ➢ How did the universe begin?
➢ Use additional information to support your ➢ What are protons, neurons, and electrons
findings composed of?
➢ The final research presentation can vary based ➢ How do slime molds reproduce?
on the needs to the project ➢ What is the specific genetic code of the fruit fly?
➢ In research it is now acceptable to submit Basic Research Steps
findings visually, as a poem, a narrative or even ▪ Define research problem
a script. ▪ Review of literature
Quantitative Research ▪ Formulate hypotheses
▪ This research is based on the measurements of quantity ▪ Preparing the research design
or amount ▪ Data collection
▪ It can only be expressed in terms of quantity ▪ Data analysis
▪ Researcher use tools such as questionnaire or equipment ▪ Interpretation and report writing
to collect data and all aspect of the study are carefully Comparison between Basic and Applied Research
designated before data is collected Basic Applied
▪ Here data is in the form of numbers or statistics and this ▪ Done for the ▪ Testing of theories
data is more efficient and able to test. development of and principle
Examples: theories or principles
▪ The Impact of COVID-19 to Senior High School ▪ Domain-driven ▪ Deman-driven
Students’ Self-Learning Skills intended to lead intended to lead to
▪ Community Quarantine and Its Impacts on Family theoretical dvpt solution of specific
Relationships problems
Applied Research ▪ Focus on making ▪ Designed to solve
▪ It is defined as a research which is used to answer a things better and practical problems of
specific question, solve a specific problem or to gain creating a more the modern world
better understanding human society
▪ It also known as action research ▪ Done for the ▪ Done to test theories
▪ It aims at finding solution for an immediate problem intellectual pleasure in the field to
facing in society or an organization through systematic of learning achieve better
inquiry involving practical application of science, based validity
on the level and type of involvement researcher can differ ▪ Mainly concerned ▪ Aims at finding a
this research based on the scope of work. with generalizations solution for an
▪ It is designed to solve problem of modern world than and with the immediate problem
acquire knowledge. The main goal of applied scientist is formulation of a facing a society
to improve the human condition for example: treat or theory
cure a specific disease. ▪ No commercial ▪ There is commercial
value attached to the value
28
 discoveries that ▪ e.g., research to Proximodistal Direction
result from basic improve agricultural ▪ The process in proximodistal
research crop production from center or midline to
▪ Analytic ▪ Synthetic periphery direction.
▪ Involves a search for ▪ Involves a search for Development proceeds from
enduring or general pragmatics solutions near to far – outward from
truths to particular central axis of the body toward
problems the extremities
Some other types of researchers are also there General to Specific
▪ One time research/longitudinal research ▪ Children use their cognitive and language skills to reason
➢ In this research one group have to studied for and solve problems
long time and it studies different stages in an ▪ Children at first are able to hold the big things by using
individual’s life and all both arms. In the next part able to hold things in a single
▪ Field setting research/laboratory research/simulation hand, then only able to pick small objects like peas,
research cereals etc.
➢ This research is depending upon the ▪ Children when able to hold pencil, first starts draw circles
environment take into consider for research then squares then only letter after that the words.
▪ Clinical Research Factors Influencing Growth and Development
➢ There type of research follows case-study ▪ Genetic Factors
method and have an in-depth approach in order ➢ Genetic predisposition is the important factors
to study causal relationships which influence the growth and development of
▪ Historical Research children
➢ In this research, researcher utilizes historical ➢ Sex
sources like documents, events and all in order ➢ Race and nationality
to understand past, point of time and all ▪ Prenatal Factors
▪ Conceptual Research ➢ Intrauterine environment is an important
➢ This research is completely based on some predominant factor of growth and development.
abstract ideas or theory Various conditions influence the fetal growth in
▪ Empirical Research utero
➢ It is completely based on experiences or ➢ Maternal malnutrition
observations ➢ Maternal infection
WEEK 10 ➢ Maternal substance abuse
GROWTH AND DEVELOPMENT ➢ Maternal illness
GROWTH ➢ Hormones
▪ It is the process of physical maturation resulting an ➢ Miscellaneous
increase in size of the body and various organs. ▪ Postnatal Factors
▪ It occurs by multiplication of cells and an increase in an ➢ Growth potential
intracellular substance. It is quantitative changes of the ➢ Nutrition
body. ➢ Childhood illness
Development ➢ Physical environment
▪ It is the process of functional and physiological ➢ Psychological Environment
maturation of the individual. It is progressive increase ➢ Cultural influence
in skill and capacity to function. It is related to ➢ Socio—economic status
maturation and myelination of the nervous system. It ➢ Climate and season
includes psychological, emotional and social changes. It ➢ Play and exercise
is qualitative aspects. ➢ Birth order of the child
Principle of Growth and Development ➢ Intelligence
▪ Cephalocaudal Direction ➢ Hormonal influence
▪ Proximodistal Direction Growth and Developmental Age Periods
▪ General to Specific ▪ Infancy
Cephalocaudal Direction ➢ Neonate
▪ The process of o Birth to 1 month
cephalocaudal direction ➢ Infancy
from head down to tail. o 1 month to 1 year
This means that ▪ Middle Childhood
improvement in ➢ School Age
structure and function o 6 to 12 years
come first in the head ▪ Late Childhood
region, then in the trunk, ➢ Adolescent
and last in the leg region o 13 years to approximately 18 years
Growth and Development Monitoring
▪ Weight
➢ Weight is one of the best criteria for assessment
of growth and a good indicator of health and
nutritional status of child
29
 ➢ Among Indian children, weight of the full terms ▪ Fontanelle Closure
neonate at birth is approximately 2.5kg to 3.5kg ➢ At birth, anterior and posterior fontanelle are
➢ There is about 10% loss of weight first week of usually present. Posterior fontanelle closes
life, which regains by 10 days of age early few weeks (608wk.) of age
➢ Then, weight gain is about 25-30gm per day for ➢ The anterior fontanelle normally closes by 12-
1st 3 months and 400gm/month until one year of 18 months of age. Early closure of fontanelle
age indicates craniostenosis due to premature
➢ The infants double weight gain their birth closure of skull sutures.
weight by 5 month of age, trebled by one year, ▪ Chest Circumference
fourth time by 2 years, 5 times by 3 year, 6 times ➢ Chest circumference or thoracic diameters is an
by 5 year, 7 times by 7 year and 10 times by 10 important parameter of assessment of growth
year and nutrition status.
➢ Then weight increases rapidly during puberty ➢ At birth, it is 2-3cm less than head
followed by weight increase to adult size circumference. At 6-12 months of age both
▪ Length and Height become equal
➢ Increase in height indicates skeletal growth. ➢ After first year of age, chest circumference is
Yearly increments in height gradually greater than head circumference by 2.5 cm and
diminished from birth to maturity by the age of 5 year, it is about 5cm larger than
➢ At birth average length of a healthy Indian head circumference
newborn baby is 50cm ➢ Chest circumference is measured by placing the
➢ It increases to 60cm at 3 months, 70cm of 9 tape measure around the chest at level by
month and 75 cm at 1 year of age. placing the tape measure around the chest at the
➢ In 2nd year, there is 12 cm increase, 3rd year it is level of the nipple, in between inspiration and
9cm, 4th year it is 7cm and in 5th year it is 6 cm expiration.
➢ So the child double ▪ Mid Upper Arm Circumference (MUAC)
the birth by 4 to 4.5 ➢ This measurement helps to asses the nutritional
years of age status of younger children
afterwards there is ➢ There is growth due to inadequate nutritional,
about 5cm increase which can be this simple particle and useful
in every year until measurement
onset of puberty ➢ The average MUAC at birth is 11 to 12 cm, at
1 year of age it is 12 to 16 cm, at 1 to 5 years
▪ Body Mass Index (BMI) it is 16 to 17cm, at 12 years it is 17 to 18 cm
➢ It is an important criteria which helps to assess and at 15 years it is 20 to 21 cm
the normal growth or its deviations i.e ▪ Eruption of Teeth
malnutrition or obesity ➢ There is a variation for the time of eruption of
➢ BMI Weight in Kg/ Height in meter teeth. First teeth commonly the lower central
➢ BMI remains content up to the age of 5 years. If incision may appear in 6 to 7 months of age.
the BMI is more than 30kg//m2, it indicates ➢ It can be delayed even up to 15 months, which
obesity and if it is less than 15kg/m2, it indicates also can be considered within the normal range
malnutrition of time for teething
➢ BMI Categories ➢ So dentition is not dependable parameters for
o Underweight - <18.5 assessment of growth
o Normal weight – 18.5-24.9 ➢ There are two sets of teeth, temporary teeth
o Overweight – 25-29.9 bigger in
o Obesity – BMI of 30 or greater size for
▪ Head Circumference two sets
➢ It is related to brain growth and development of of teeth
intracranial volume. Average head
circumference measured about 35cm at birth
➢ At 3 months it is about 40cm, at 6 month 43 cm,
at 1 year 45cm, at 2 years 48cm, at 7 year 50cm
and at 12 years of age it is about 52 cm, almost
same a adult.
➢ If head circumference increase more than 1cm Osseous Growth
in 2 weeks during the first 3 months of age then ▪ Bony growth follows a definite pattern and time schedule
hydrocephalus should be suspected from birth to maturation
➢ Head circumference is measured by ordinal tap, ▪ It is calculated by the appearance of ossification center
placing it over the occipital protuberance at the by X-ray study
back, above the ear on the side and just over the ▪ Skeletal maturation or bone growth is an indicator of
supraorbital ridges in front measuring the point physiological development and continue up to 25 years
of height circumference of age.

30
 Growth Monitoring
▪ Assessment of growth may be done by longitudinal &
cross-sectional studies. The common parameters used for
growth monitoring include, head circumference, chest
circumference, UL/LS ratio. The following are the 3
members used for comparisons:
➢ Use of mean/median values
➢ Use of percentile
➢ Use of indices as weight for height & weight for
age
➢ Common reference values
o WHO reference value
o Indian standards
Gross Motor Development
▪ Motor development progress in an orderly sequence to
ultimate attainment of locomotion & more complex
motor tasks thereafter. In an infant it is assessed &
observed as follows:

Fine Motor Skill Development

▪ Fine motor development upon neural tract maturation.
Fine motor development promotes adaptive actives with Psychosexual Stages of Development
fine sensorimotor adjustments and include eye ▪ Psychosexual stages were given by Sigmund Freud
coordination, ▪ According to him, personality is mostly established by
hand eye the age of five. Early experiences play a large role in
coordination, personality development and continue to influence
hand to mouth bahavior later in life
coordination, ▪ Freud believed that personality develops through a series
hand skill as of childhood stages during which the pleasure-seeking
finger thumb energies of the Id become focused on certain erogneous
apposition, area. This psychosexual energy, or libido (sex drive), was
grasping, described as the driving force behind behavior
dressing etc. ▪ According to him from birth on, we have an innate
tendency to seek pleasure, especially through physical
Personal & Social Development stimulation and particularly through stimulation of
▪ Personal and social development includes personal parts/zones of the body that are sensitive to touch:
reactions to his own social and cultural situations with ➢ The mouth
neuromotor maturity and environment stimulation. It is ➢ The anus
related to interpersonal and social skill as social smile, ➢ The genitals
recognition of mother, use of toys. ▪ Which are referred to as erogenous zones
➢ Various body zones are active as per the age and
stage or there occur shift of dominant erogenous
zone from one age/stage to other.
Fixation
▪ If the child need’s at one of the psychosexual stages were
either unsatisfied or oversatisfied, fixation would take
place
▪ This means the child would show continued attachment
to an old stage even after moving on to a new one as per
his/her age.
31
 ▪ This results into problematic behavior patterns. ▪ If parents take an approach that is too lenient, Freud
Stages suggested that an anal-expulsive personality could
▪ There are five stages to his theory which include develop in which the individual is
1. The oral stage ➢ Messy
2. The anal stage ➢ Wasteful
3. The phallic stage ➢ Destructive
4. The latent stage ▪ If parents are too strict or gein toilet training too early,
5. The genital stage Freud believed that an anal-retentive personality
Oral Stage (Birth to about age 1) develops in which the individual is
▪ in this stage, the infant obtains sensual pleasure first by ➢ Stringent
sucking and later by biting. The center of libido is mouth ➢ Orderly
▪ the mouth is vital for eating, and the infant derives ➢ Rigid
pleasure from oral stimulation through gratifying ➢ Obsessive
activities such as tasting and sucking Phallic Stage (ages 3-5)
▪ also the infant is entirely dependent upon caretakers, the ▪ The child grow more interested in their genitals. At this
infant also develops a sense of trust and comfort through age, children also begin to discover the differences
this oral stimulation between males and females
▪ helpful ▪ In this stage, the focus of Libido, where pleasure is
▪ feeding and contact with the mother found, is in:
▪ mouthing new objects ➢ Awareness of sexual organs
▪ relief of teething pain by biting ➢ Love-hate relationship with the same-sex parent
▪ a conflict at this stage occurs with a child being weaned ▪ Some critrical episodes for development occur during
off the mother’s breast this stage, but these episodes occur differently for boys
▪ signs of Fixation or affects on adult personality in this (oedipus complex) and girls (Electra complex)
stage are: ▪ Signs of Fixation or affects on adult personality in this
➢ overeating or Pessimism stage are:
➢ Smoking ➢ Reckless or afraid of love
➢ Envy ➢ Narcissistic
➢ Gullibillity ➢ Self-Assured or Selfish
➢ Suspicion ➢ Poor opposite sex relationships
➢ Dependency ▪ Oedipus Complex
➢ Passivity ➢ Occurs in boys
Anal Stage (ages 1-3) ➢ Desire for stimulation or masturbation of his
▪ The region around the anus become highly sensitive to own genitals
the stimulation of “holding on” and “letting go” ➢ Have sexual/sensual desires for his mother
▪ Freud believed that the primary focus of the libido was ➢ Boys begin to view their fathers as a rival for
on controlling bladder and bowel movements the mother’s affections. The oedipus complex
▪ The major conflict at this stage is toilet training – the describes these feelings of wanting to possess
child has to learn to cocntrol his or her bodily needs the mother and the desire to replace the father
▪ Developing this control leads to a sense of ➢ The child also fears that he will be punished by
accomplishment and independence the father for these feelings, a fear Freud termed
▪ Toilet training is child’s first encounter with authority castration anxiety.
▪ First part of this stage involves pleasure from expulsion ➢ Starts identifying with father.
of feces; latter part involves pleasure from retention ➢ Idntification with father
▪ Fixation at first stage o Reduces anxiety behave like his father
➢ Messiness o Take up his ideas of right and wrong
➢ Disordered o Tries to dress like his father
▪ Fixation at second stage ▪ Electra Complex
➢ Excessive compulsiveness ➢ Occur in girls
➢ Over conformity ➢ Attracted towards their father
➢ Exaggerated self control ➢ Notice that she does not have the sex organs like
▪ Parenting play a very important role in success of this her father and brother
stage and development of personality ➢ Feeling of being castrated by her mother which
▪ Parents who utilize praise and rewards for using the toilet makes her angry and she starts devaluating her
at the appropriate time encourage positive outcomes and mother
help children feel capable and productive ➢ Still identify with her mother with the feeling
▪ Positive experiences during this stage served as the basis that by doing so she will stand better chance in
for people to become her own “romantic relationship”
➢ Competent ➢ Identification with mother in girls being with
➢ Productive feeling that by doing so she will stand better
➢ Creative chance in her own “romantic relationship”
▪ If parent punish, ridicule or shame a child for accident or ➢ It is well said saying “A father is a daughter’s
other inappropriate parental responses can result to first love”
negative outcomes.

32
 Larency Stage (Age 6 to Puberty)
▪ At this stage, sexual drive lay dormant. The stage begins
around the time that children enter into school and
become more concerned with peer relationships, hobbies
and other interests.
▪ Sexual energy is still present, but it is directed into other
areas such as intellectual puruits and social interactions
▪ Child usually has few opposite sex friends.
▪ This stage is important in the development of social and
communication skills and self-confidence
▪ A sign oof fixation in this stage is a lack of close friends
Genital Stage (Adolesence and Beyond)
▪ Marked by puberty
▪ Mature heterosxual interests appears
▪ A person becomes interested in dating and marriage
▪ The more libidal energy that a child has at this stage, the
greater his or her capacity will be to develop normal
relationships with the opposite sex.
▪ If the other stages have been completed successfully, the
individual should now be well-balanced, warm and
caring. The goal of this stage is to establish a balance
between the various life areas
▪ Sins of Fixation in this stage include:
➢ Guilt about sexuality
➢ Feelings of inadequacy
➢ Poor sexual relationships
➢ Anxious feelings regarding the opposite sex
Erikson’s Theory of Psychosocial Development
▪ Erik Erikson’s theory of psycosocial development is one
of the best-known theories of personality in psychology
▪ Much like Sigmund Freud, Erikson believed that
personality develops in a series of stages.
▪ Unlike Freud’s theory of psychosexual stages, Erikson’s
theory desscribes the impact of social experience across
the whole lifespan.
▪ One of the main elements of Erikson’s Psychosocial
stage theory is the development of ego identity
▪ Ego identity is the conscious sense of self that we
develop through social interaction
▪ According to Erikson, our ego identity is constantly
changing due to new experience and information we
acquire in our daily interactions with others
▪ In addition to ego identity, Erikson also believed that a
sense of competence also motivates behaviours and
actions
▪ Each stage in Erikson’s theory is conerned with
beecoming competent in an area of life
▪ If the stage is handled well, the perosn will feel a sense
of mastery, which he sometimes referred to as ego
srength or ego equality
▪ If the stage is managed poorly, the person will emerge
with a sense of inadequacy

33
 ▪ Assimilation: it is using an existing schema to deal with
a new object or situation. Here, the learner fits the newe
idea into what he already knows. In assimilation, the
schema is not changed, it is only modified.
▪ Example: A 2 year old child sees a man who is bald on
top of hi head and has long frizzy hair on th sides. To his
father’s horror, the toddler shouts “clown, clown”.
▪ Accomodation: this happens when the existing schema
(knowledge) does not work and needs to be changed to
deal with a new object or situation. In accomodation, the
schema is altered; a new schema may be developed.
▪ Example: In the “clown” incident, the boy’s father
explained to his son that the man was not a clown and
that even though his hair was like a clown’s, he wasn’t
wearing a funny costume and wasn’t doing silly things to
make peple laugh.
▪ With this new knowledge, the boy was able to change his
schema of “clown” and make this idea fit better to a
standard concept of “clown”
▪ Equillibration: Piaget believed that cognitive
development did not progress aat a steayd rate, but rather
in leaps and bounds. Equilibrium occurs when a child’s
schemas can deal witih most new information through
assimilation. As a child progresses through the stages of
cognitve development, it is important to maintain a
balance between apllying previous knowledge
(assimilation) and changing behavior to account for new
knowledge (accomodation). Equillibrium helps explain
how children are able to move from one stage of thought
to the next.
The Sensorimotor Stage
(Birth to 2 yrs – Infancy)
▪ Infants contruct an udnerstanding of the world by
Piaget’s Theory of Cognitive Development coordinating sensory exeriences (seeing, hearing) with
What is Cognition? motor actions (reaching, touching)
▪ The term cognition is derived from the latin word ▪ Develop object permanence (memory) - realize that
“cognescere” which means “to know” or “to objects exist even if they are out of sight
recognise” or “to conceptualise” ▪ Infants progress from reflexive, instinctual actions at
▪ Cognition is the “the mental action or process of birth to the beginning of problem solving (intellectual)
acquiring knowledge and understanding through and symbolic abilities (language) toward the end of this
thought, experience, and the senses” stage.
What is Cognitive Development Preoperational Stage
▪ Cognitive Development is the emergence of the ability to (2-7 Years – Toddler and Early Childhood)
think and understand ▪ This stage begins when the child starts to use symbols
▪ The acquisiton of the ability to think, reason and problem and language. This is a period of developing language
solve and concpets. So, the child is capable of more complex
▪ It is the proccess by which people’s thinking changes mental representations (i.e., words and images). He is
across the life span still unable to use ‘operations’, i.e., logical mental rules,
▪ Piaget studied Cognitive Development by observing such as rules of arithmetic. This stage is further divided
children in particular, to examine how their thougth into 2 sub-stages:
processes changed with age 1. Preconceptual stage (2-4 years) – Increased use of
▪ It is the growing apprehension and adaptation to the verbal representation but speech is egocentric. The
physical and social environment child uses symbols to stand for actions; a toy doll
Key Concept stands for a real baby or the child role plays mummy
▪ Schema: schema is an internal representation of the or daddy.
world. It helps an individual understand the world they 2. Intuitive stage (4-7 yrs) – Speech becomes more
inhabit. They are cognitive structures that represent a social, less egocentric. Here the child base their
certain aspect of the world, and can be seen as categories knowledge on what they feel or sense to be true, yet
which have certain pre-concieved ideas in them. they cannot explain the udnerlying principles behind
▪ For example: my schema for Chirstmas includes: what they feel or sense.
Chrismtas trees, presents, giving, money, green, red, The following are the key features of this stage:
gold, winter, Santa Claus etc.. Someone else may have ▪ Egocentrism – the child’s thoughts and communicationa
an entirely differnet schema, such as Jesus, birth, church, re typically egocentric (i.e., about themselves or their
holiday, christianity etc. own point of view) e.g.: “if I can’t see you, you also can’t
see me”. It is the the inability to see the world from
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 anyone else’s eyes. It is well explained by Piaget as Three Educational Implications
Mountain Task ▪ Emphasis on discovery approach in learning
▪ Animism – treating inanimate objects as living ones. ▪ Curriculum should provide specific educational
E.g: children dressing and feeding their dolls as if they experience base don children’s developmental level
are alive ▪ Arrange classroom activities so that they assist and
▪ Concentration – the process of concentrating on one encourage self-learning
limited aspect of a stimulus and ignoring other aspects. It ▪ Social interactions have a great educational value for
is noticed in Conservation. Conservation on the other Piaget. Positive social actions, therefore should be
hand is the knowledge that quantity is unrelated to the encouraged
arrangement and physical appearance of objects. ▪ Instruction should be geared to the level of the child. As
Children at this stage are unaware of conservation. the level of the child changes at each stage, the level of
Concrete Opearational Stage (7-12 Years) instruction or exploratory activities should also change
Childhood and Early Adolescence ▪ Simple to complex and project method of teaching
▪ The concrete operational stage is characterized by the ▪ Co-curricular activities have equal importance as that of
appropriate use of logic. Important processes during this curricular experiences in the cognitive development of
stage are: children
➢ Seriation – the ability to sort objects in an order ▪ Major goals of education according to Piaget are critical
according to size, shape or any other and creative thinking
characteristics. E.g.: if given different-sized Contribution to Education
objects, they may place them accordingly ▪ Piaget’s theory helped educators, parents and
➢ Transitivity – the ability to recognize logical investigators to comprehend the capaacity of children in
relationships among elements in a serial order. their different stages
E.g.: if A is taller than B and B is taller than C, ▪ He made us conscious with the way children and adults
then A must be taller than C. think
➢ Classification – the ability to group objects ▪ A lot of school programs have been redesigned taking as
together on the basis of common features. The base Piaget’s discoveries
child also begins to get the idea that one set can ▪ Piaget made a revolution with the developmental
include another. E.g.: there is a class of objects psychology concentrating all his attention to the mental
called dogs. There is also a class called animals. process and his role with behavior
But all dogs are also animals, so the class of The Antepartal Period
animals includes that of dogs. Anatomy and Physiology
➢ Decentring – the ability to take multiple aspects a. Uterus
of a situation into account. E.g.: the childd will ▪ Serves as an organ of implantation for the
no longer perceive an exceptionally-wide but fertilized ovum that becomes the fetus
short cup to contain less than a normally-wide, ▪ Responsible for expulsion of the fetus during
taller cup childbirth from the strong muscle contractions
➢ Reversibility – the child understands that as well as menstruation
numbers or objects can be changed, then ▪ Fundal height
reurned to their original state. Eg.: the child will a) At the level of the symphysis at 12-14 wks.
rapidly determine that if 4+4=8 then 8-4=4, the b) Rises at 1 cm/week until 36 weeks of
original quantity gestation
➢ Conservation – understanding that the c) At the level of umbilicus at 20 weeks
quantity, length or number of items is unrelated b. Cervix
to the arrangement or appearance of the object ▪ Goodell’s sign
or item ▪ Chadwick’s sign
➢ Eliminaation of Egocentrism – the ability to c. Vagina
view things from another’s perspective ▪ Slight acidic pH (4-5) to decrease risk of
➢ The child performs operations: combining, infections
separating, multiplying, repeating, dividing etc ▪ functions include out passage for menstrual
Formal Operational Stage (12 yrs and above) flow from the endometrium of the uterus, the
Adolescence and Adulthood female organ for intercourse, and a passageway
▪ The thought becomes increasingly flexible and abstract, for vaginal childbirth
i.e, can carry out systematic experiments ▪ during pregnancy the mucosa of the vagina may
▪ The ability to systematically solve a problem in a logical have a bluish violet color, has increased
and methodological way vascularity, and increase vaginal mucus
▪ Understands that nothing is abosulte; everything is discharge
relative d. External Structure
▪ Develops skills such as logical thought, deductive ▪ External genital organs, or vulva, include all the
reasoning as well as inductive reasoning and systematic structure found externally between the pubis
planning etc and the perineum
▪ Understands that the results of any game or social system ▪ Structures include the mons pubis, labia majora,
are developed by a man by mutual agreement and hence labia minora, prepuce, frenulum, fourchette,
could be changed or modified clitoris and vestibule
▪ The child’s way of thinking is at its most advanced, e. Ovaries
although the knowledge it has to work with, will change f. Placenta
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 ▪ Chorionic villi form and invade the lining of the tongue, small mouth and high
uterus where endometrial arteries fill with blood palate, epicanthal folds and
▪ Earliest functions is as an endocrine gland to slanted eyes, small rounded head
excrete: with flattened occiput, hypotonic
a. hCG muscle with hypermonility of
b. hPL joints, simian crease across the
▪ metabolic function of placenta: palm of hand and mental
a. respiration retardation
b. nutrition c. Turner’s Syndrome
c. excretion ▪ Characteristics
▪ fetal blood cells can leak into maternal ➢ Usually infertile
circulation from occasional breaks in the ➢ Small stature
placenta membrane and the mother may ➢ Cognitive functions unimpaired
develop antibodies to the fetal blood cells d. Klinefelter’s Syndrome
▪ interference with the circulation to the placenta, ▪ Characteristics
such as matenral vasoconstriction from ➢ Usually infertile
hypertension or cocaine or decreased maternal ➢ Cognitive functions vary from
blood pressure or decreased maternal cardiac unimpaired to mild metal
output, impedes the blood supply to the fetus retardation
g. membrane e. In-born errors of metabolism
h. umbilical cord 1. Phenylketonuria (PKU)
▪ two arteries 2. Tay-sachs disease
▪ one vein 3. Cystic fibrosis
▪ wharton’s jelly 4. Congenital adrenal hyperplasia
▪ usually located centrally as the placenta 5. Congenital hypothyroidism
develops from the chorionic villi
i. amniotic fluid
▪ functions include fetal lung dvelopment,
protection of the cord, and allows for normal
limb development and development of GI and
renal system
j. cardiovascular system
▪ vena caval syndrome
▪ blood volume increases 30-50% during
pregnancy
k. gastrointestinal system
▪ constipation and gastroesophageal reflux
l. urinary system
▪ similar relaxation of the urinary tract places the
pregnant client at risk for UTI or pyelonephritis
from bacteria ascending from perineum
m. endocrine system
▪ paancreas
▪ thyroid
▪ pituitary
n. respiratory system
▪ increased BMR requires more oxygen for the
pregnant body
▪ tidal volume and minute ventilation increase
unitl the third trimester when the large uterus
may impede lung expansion
▪ CO2 output increases, resulting in slight
respiratory alkalosis
o. Chromosomal Abnormalities Diagnostic Studies
a. Types of transmission to the fetus: a. Sterile Speculum Exam
1. Autosomal dominant - Indicated for suspected ruptured membranes
2. Autosomal recessive - Amniotic fluid will turn Nitrazine paper blue
3. Sex-linked transmission because of the alkaline pH
b. Down Syndrome - Free flow of fluid may be seen coming through the
▪ Risk increases in women over 35 years old cervix when the clients is asked to cough or perform
and continues to increase with each year of a valsalva maneuver
age - Pre-procedure
▪ Characteristics: ✓ Client is assisted into the lithotomy
➢ Low-set ears, large fat pads at the position
nape of a short neck, protruding ✓ Gather supplies
36
b. Urinalysis with reagent strips as for 3 hours after, serum glucose levels are
- Urine is tested with a reagent strip to test for the evaluated at 1,2 and 3 hours after dirnking the
presence of components in the urine such as WBS, glucose solution.
blood, protein, bilirubin, leukocytes, ketones, - Pre-Procedure
glucose, specific gravity, pH, urobilinogen and ✓ Obtain the glucose solution and arrange for
nitrite the blood draw on schedule
- Pre-procedure h. Daily Fetal Movement Count
✓ Instruct the client not to discard urine - Advised to do daily or twice daily in high-risk client
- Post-Procedure - Counting 10 movements in 1 hour is reassuring kick
✓ Compare the result with the legend on the count
side of the bottler to determine normal or i. Electric Fetal Monitoring (EFM)
abnormal findings j. Ultrasound
✓ Discard the urine and record the result - Ultrasound scanning can be either transvaginally or
c. 24-hour Urine transabdominally
- The clients total urine output for 24 hours is - Indication for antepartum care include estimation of
collected and analyzed for amount, specific gravity, fetal age, fetal weight and fetal presentation,
pH, presence and amount of protein and creatinine placenta position and integrity, or a follow-up of
clearance fetal anomalies or well-being
- Pre-procedure k. Biophysical Profile (BPP)
✓ Instruct the client not to discard any urine
for 24 hours
✓ Obtain specimen on ice for the duration of
the test
✓ Have the client empty the bladder and
record the start time
✓ Post sign in the bathroom to remind the
client, family, and all staff that the tests is
in progress
- Post-procedure
✓ Send the entire specimen to the lab
✓ Record the end time
d. Urinalysis and culture
- They are useful in determining the presence of a
UTI, which during pregnancy can result in preterm
labor
- Pre-procedure
✓ Obtain the specimen as ordered
✓ Label the specimen and send it to the lab
e. Laboratory Serum Evaluation l. Umbilical artery dopple velocimetry
- CBC - Non-invasive test is done via ultrasound, examining
- Metabolic Panel the umbilical artery
- Liver profile - Test is done when placenta/fetal perfusion
- D-dimmer and fibrinogen compromise is suspected
- Kleunhauer-Betke m. Amniocentesis
- C-reactive protein (CRP) - Amniotic fluid is then removed for the following
- Beta hCG indicators:
- Maternal serum alpha-fetoprotein (AFP or MS-AFP) ✓ Genetic screening
- OB panel ✓ Diagnostic for isoimmunization
- Torch ✓ Follow-up after an abnormal ultrasound
f. Fetal Fibronectin ✓ To evaluate fetal lung maturity
- A protein found in amniotic fluid, the placental ✓ To evaluate for subclinical infection
tissue itself and following injury to membranes- ✓ To aspirate amniotic fluid to reduce volume
either mechanical or inflammatory - Pre-procedure
- Used to gauge the risk of preterm birth for client ✓ Written consent discussion must take place
hospitalized with PTL between the client and the physician
- Pre-procedure ✓ Educate the client about the procedure
✓ Assist the client in assuming the lithotomy - Post-procedure
position ✓ EFM for minimum of 30 minutes
✓ Gather the equipments ✓ Give Rh immune globulin for women who
g. Oral glucose tolerance test (OGTT or GTT) are Rh negative
- Blood glucose greater than or equal to 140 indicates n. Group B Beta Streptococcus (GSBBS) Culture
an abnormal screen, and the 3 hour GTT is indicated - Universal screening at 35-37 weeks of gestation
- 3-hour GTT: 100 grams of glucose is given to the - Indicated for clients hospitalized preterm with high-
client to drink in a liquid form in 5 minutes; fasting risk pregnancy condition
is now required for 12 hours before the test as well
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 Normal Pregnancy - Baby can be placed in skin to skin contact with
a. 40 lunar weeks gestation mother (kangooring) to maintain temperature of
b. Term pregnancy is from the beginning of the 38 th weeks infant and facilitate breast feeding
until the completion of 42 weeks - Bathing at first day is avoided to prevent
c. Normal concerns of pregnancy hypothermia
d. Nausea and vomiting Breastfeeidng
e. Breast tenderness - The baby should be put to mother’s breast within
f. Urinary frequency half an hour of birth as soon as possible. The mother
g. Constipation and hemorrhoids has recovered from exertion of labour
h. Light headedness or dizziness - Colostrums feeding must be offered
i. Leg cramps - Mother should be informing about the importance
j. Fatigue and techniques of breast feeding
k. Heartburn - Deman feeding should be encouraged
l. Backaches - Exclusive breast feeding procedure should be
m. Emotional reactions explained to the mother and family members.
n. Sexuality and intimacy Skin Care and Baby Bath
Immediate Basic Care of Newborn - The baby must be cleaned off blood, mucus and
- As majority babies cry at birth and take spontaneous meconium
respiration, no resuscitation required at birth in - No vigorous attempts should be met to remove the
about 95-98% neonates vernix caseosa, as it provides protection to the
- These healthy normal neonates need only warmth, delicate skin
breast feeding, close observation for early detection - Baby bath can be given in the hopsital by using
of problems and protection from infections and warm water in a warm room gently and quickly
injuries - Bathing should be avoided in open place
- After cutting the umbilical cord aseptically the baby - During winter months the baby should have sponge
should be kept dried, wrapped with dry and warm bath rather than deep bath to avoid hypothermia
cloth, examine thoroughly and quickly to assess Care of Umbilical Cord
normal characteristics, to detect congenital - The umbilical cord is cut about 2-3 inches from the
malformation and then put the mother’s breast. navel with aseptic precaution during delivery and
- Identification tag to be tied to the mother and baby tied with cotton thread or disposable plastic clip
- Recording to be done accurately about the event of - The cord must be inspected for bleeding afterwards
the birth of the baby (especially birth date, time, sex, which commonly occurs due to shrinkage of cord
examination findings or presence of any problem and loosening of ligature
etc) in the delivery record sheet - No dressing should apply and the cord should be
- The mother and baby should transfer to ward usually kept open and dry
after 1 hr of observation in the delivery room and - Normally it falls of after 5-10 days
when the condition permits - Application of triple dye or junction violet is not
- Sick or at risk neonates need special care in special advocated as a routine any more
setting. Care of Eyes
- The APPGAR score rates - Eye should be cleaned at the bith and once every day
▪ Respiration, crying using sterile cotton swabs soaked in sterile water
▪ Reflexes, irritabbility - Each eye should be cleaned using a separate swab
▪ Pulse, heart rate - Application of kajal in the eyes must be avoided to
▪ Skin color of bodt and extremities prevent infection or lead poisoning
▪ Muscle tone - The eye should be observed for redness, discahrge
or the excessive tearing for early detection of
problems and prompt management
Weight Recording
- Assess daily weight gain in healthy term babies
which is about 30gm/day
- Most infants double their weight by 4-5 months but
in first week of life there is physiological loss of
body weight because of removal of vernix, mucus,
blood, passage of meconium and reduction of
Daily Routine Care of Neonates extracellular blood volume & also due to adaptation
- The major goal of nursing care of the newborn is to new environment
establish and maintain homeostatis i.e. stability in - With adequate breast feeding majority of babies
the normal physiological status. regain the weight within 7-10 days of birth.
Warmth Immunization
- Warmth is provided by keeping the baby dry with - Within first week of life
adequate clothing - The mother should be informed about national
- Baby should be kept to the side of the mother, so that immunization schedule and explanation should be
the mother’s body temperature can keep the baby given about important of complete immunization
warm and all possible reaction following vaccines

38
 - In institutional deliveries all neonates should be 4. Allergic or immunological basis
immunized with BCG vaccine and zero polio. 5. Decrease gastric motility is found to cause nausea
- In outside or home deliveries the BCG and OPV Clinical Course
should be given. ▪ Early
Conclusion ➢ Vomiting throughout the day
- The newborn care is very essential to reduce infant ➢ Normal day to day activities are disturbed
morbidity and mortality rate. ➢ No evidence of dehydration & starvation
▪ Late
➢ Evidence of dehydration and starvation
WEEK 11 ▪ Symptoms
HIGH-RISK ANTEPARTUM NURSING CARE ➢ Excess vomiting & retching day & night
HYPEREMESIS GRAVIDARUM ➢ Epigastric pain
Introduction ➢ Constipation
▪ Hyper – excessive ➢ Ptyalism
▪ Emesis – vomit ➢ Spitting
▪ Gravidarum – pregnancy ➢ Fatigue
▪ Nausea/vomit of moderate intensity are especially ➢ Anorexia
common until about 16wk. ➢ Complications will appear if not treated
▪ HCG occurs when vomiting becomes intractable in early ▪ Signs
pregnancy & cause fluid & electrolyte imbalances & ➢ Signs of dehydration and ketoacidosis
nutritional deficiency ➢ Dry coated tongue
▪ Women usually needs to be hospitalized ➢ Sunken eyes
▪ Hyperemesis gravidarum is a severe type of vomiting of ➢ Acetone smell in breath
pregnancy which has got deleterious effect on health of ➢ Tachycardia
the patient and/or incapacitates her day-to-day activities ➢ Postural hypotension
(D.C. Dutta) ➢ Raise in temperature
Etiology ➢ Jaundice (later stage)
▪ Limited to 1st trimester ➢ Vaginal examination and USG is done to confirm
▪ More common in 1st pregnancy pregnancy
▪ Tendency to recur again in subsequent pregnancies Investigation
▪ Familial history: mother and sisters also suffer from the ▪ Urinalysis
same manifestation ➢ Quantity (to see for oliguria)
▪ More prevalent in hydratiform mole and multiple ➢ Dark color (due to concentration)
pregnancy ➢ High specific gravity with acid reaction
▪ Common in unplanned pregnancies ➢ Presence of acetone, occasional presence of protein
Risk Factors and bile pigments
▪ Age below 17 years and over 35 years ➢ Diminished or even absence of chloride
▪ Primigravidae ▪ Biochemical and Circulatory Changes
▪ Multiple pregnancy ➢ Serum electrolytes (Sodium, Potassium and
▪ Underweight and obesity Chloride) has to be done
▪ Psychological factors such as unwanted pregnancy, ▪ Opthalmoscopic examination
marital problems ➢ It is required if patients is seriously ill. Retinal
▪ H/O hyper emesis gravidarum hemorrhage and detachment of the retina are the
▪ Trophoplastic disease most unfavorable signs
Theories behind Hyper Emesis Gravidarum ▪ ECG
1. Hormonal ➢ When there is abnormal serum potassium level
▪ High Hcg-hydratiform mole, multiple Diagnosis
pregnancy ▪ Pregnancy is confirmed first
▪ High estrogen ▪ Associated causes of vomiting are excluded like
▪ High progesterone-relaxation of cardiac Gynecological or Medical or Surgical causes
sphincter ▪ USG -pregnancy, hydratiform mole, multiple pregnancy
▪ other hormones involved: Complications
➢ thyroxin ▪ Neurological
➢ prolactin ➢ Wernicke’s encephalopathy due to thiamine
➢ leptin deficiency
➢ adreno-cortisol hormones ➢ Pontine myelinolysis
2. Psychogenic ➢ Peripheral neuritis
▪ It probably aggravated nausea once it begins it ➢ Psychosis
trigger neurogenic elements ➢ Ophthalmic: Retinal hemorrhage
3. Dietary Deficiency ➢ Convulsions
▪ Probably due to low carbohydrate reserve as it ➢ Coma
happens after a night without food. Deficiency Other complications
of vitamin B1, B6, and protein may be the effect ▪ Stress ulcer in the stomach
rather than cause ▪ Esophageal tears
▪ Jaundice due to liver damage
39
Prevention Intra-Partal Complications
▪ The only prevention is to import effective management to What is Intra-Partal Complication
correct simple vomiting of pregnancy ▪ Intrapartum complications, also known as intra-partal
Management complications, refer to medical issues or complications
▪ Principles that arise during the process of childbirth, typically from
➢ To control vomiting the onset of labor to the delivery of the baby and the
➢ To correct fluid & electrolyte imbalance expulsion of the placenta. These complications can
➢ To correct metabolic disturbance involve both the mother and the baby and may include a
➢ To prevent serious complications of severe wide range of medical issues that require prompt
vomiting recognition and intervention
Hospitalization What Causes Intra-Partal Complication
▪ Admit the patient ▪ Causes of intra-partal complications can vary and are
▪ Open IV line and correct fluids often multifactorial. These may include maternal factors
▪ Send for relevant investigations such as pre-existing health conditions (diabetes,
▪ Maintain an intake-output chart hypertension), maternal age, and lifestyle choices
▪ Monitor urine output (catheterize the patient) (smoking, drug use). Fetal factors can involve congenital
▪ Monitor the vitals abnormalities, or pre-existing health conditions.
▪ Test the urine periodically for ketone bodies Additionally, labor complications can be triggered by
Fluids issues like prolonged labor, malpresentation, or abnormal
▪ Oral feeding is withheld for at least 24 hrs after the cessation fetal positioning.
of vomiting Types of Intra-Partal Complications
▪ During this period, fluid given through IV drip method ▪ Labor that does not progress
▪ The amount of fluid to be infused in 24hrs is calculated as: ➢ Sometimes contractions weaken, the cervix
total amount of fluid approx. 3 liters, of which is 5% is does not dilate enough or in a timely manner, or
dextrose and half is Ringer’s solution the infant’s descent in the birth canal does not
▪ Extra amount of 5% dextrose equal to the amount of vomitus proceed smoothly. If labor is not progressing, a
and urine in 24 hours, is to be added. These measures help health care provider may give the woman
to correct dehydration, electrolyte imbalance and keto- medications to increase contractions and speed
acidosis up labor, or the woman may need a cesarean
▪ Enteral nutrition through nasogastric tube may also be given delivery.
Drugs ▪ Perineal Tears
▪ Antiemetic ➢ A woman’s vagina and the surrounding tissues
➢ Promethazine – 25mg IM BD or TDS are likely to tear during the delivery process.
➢ Trifluopromazine – 10mg IM Sometimes these tears heal on their own. If a
➢ Metochlopromide – 10mg IM tear is more serious or the woman has had an
➢ Hydrocortisone – 100mg IV in drip episiotomy (a surgical cut between the vagina
➢ Prednisolone orally and anus), her provider will help repair the tear
➢ Nutritional support: using stitches
o Vitamin B1, vitamin B6, vitamin B12, & ▪ Problems with the umbilical cord
vitamin C ➢ The umbilical cord may get caught on an arm or
Nursing Care leg as the infant travels through the birth canal.
▪ Sympathetic but firm handling of patient Typically, a provider intervenes if the cord
▪ Daily monitoring of the patient becomes wrapped around the infant’s neck, is
▪ Look for signs of improvement in the patient: subsidence of compressed, or comes out before the infant
vomiting, feeling hungry, better look, disappearance of ▪ Abnormal heart rate of the baby
acetone from breath and urine, normal pulse and blood ➢ Many times, an abnormal heart rate during labor
pressure, normal urine output does not mean that there is a problem. A health
▪ Monitor lab results for dehydration care provider will likely ask the woman to
▪ Monitor FHR, fetal activity and growth switch positions to helps the infant get more
▪ Encourage patient to sit in upright after meal blood flow. In certain instances, such as when
▪ Encourage small & frequent meals test results show a larger problem, delivery
▪ Liquids should be taken between meals to avoid distending might have to happen right away. In this
stomach and triggering vomit situation, the woman is more likely to need an
Obstetric Care emergency cesarean delivery, or the health care
▪ No therapeutic abortion is indicated if patient improve on provider may need to do an episiotomy to widen
therapy the vaginal opening for delivery.
▪ Therapeutic abortion is seldom indicated on pregnancy ▪ Water breaking early
associated with renal or neurological complications ➢ Labor usually starts on its own within 24 hrs of
Dietary Management the woman’s water breaking. If not, and if the
▪ Before IV fluids is given, oral small and frequent dry meals pregnancy is at or near term, the provider will
without fat are given likely induce labor. If a pregnant woman’s water
▪ First dry carbohydrates like biscuit, bread and toast breaks before 34 weeks of pregnancy, the
▪ Ginger is helpful woman will be monitored in the hospital.
▪ Gradually full diet is restored Infection can become a major concern if the
40
 woman’s water breaks early and labor does not ➢ Blood clots in the legs (deep vein thrombosis)
begin on its own or the lungs (pulmonary embolism) can develop
▪ Perinatal Asphyxia after childbirth, especially if the woman is
➢ This condition occurs when the fetus does not immobile for an extended period
get enough oxygen in the uterus or the infant ▪ Urinary Problems
does not get enough oxygen during labor or ➢ Issues like urinary incontinence (loss of bladder
delivery or just after birth control) or urinary retention (inability to empty
▪ Excessive bleeding the bladder) can occur
➢ If delivery results in tears to the uterus, or if the ▪ Psychological Complications
uterus does not contract to deliver the placenta, ➢ Post-partum depression (PPD) and postpartum
heavy bleeding can result. Worldwide, such anxiety are mental health conditions that can
bleeding is a leading cause of maternal death affect some women after childbirth. Symptoms
▪ Postpartum Hemorrhage may include persistent sadness, loss of interest,
➢ Excessive bleeding after childbirth can be a anxiety, and intrusive thoughts. It’s crucial to
complication and may require medical seek professional help if experiencing these
intervention conditions, as they can be effectively treated
▪ Infections with therapy, medication, or a combination of
➢ Intrapartum infections can affect both the both.
mother and the baby, potentially leading to ▪ Preeclampsia
sepsis or other health issues ➢ Preeclampsia is a condition characterized by
▪ Meconium Aspiration high blood pressure and damage to organs,
➢ When a baby passes meconium (the first stool) primarily the liver and kidney. In some cases,
in the womb and inhales it, it can lead to preeclampsia can persist or develop post-
respiratory problems. partum, requiring continued monitoring and
▪ Placental Abruption management of blood pressure
➢ This is a condition where the placenta detaches ▪ Puerperal Mastitis
from the uterine wall before the baby is born, ➢ This is an inflammation of the breast tissue that
potentially causing severe bleeding and oxygen can occur when breastfeeding. Symptoms
deprivation for the baby include breast pain, redness, and swelling. It can
▪ Instrument-Assisted Delivery lead to infection if not addressed, and treatment
➢ The use of forceps or vacuum extraction can involves antibiotics and continuing to
lead to complications, such as head molding or breastfeed or express milk
injury ▪ Wound Complications
Important ➢ If a woman had a cesarean section or other
▪ It’s important for healthcare providers to monitor labor surgical procedures during childbirth,
and be prepared to address any complications that may complications at the incision site can occur,
arise. The appropriate management and intervention can including wound infections, poor healing, or
help ensure the safety of both the mother and the baby keloid scarring. Proper wound care and, in some
during childbirth. In some cases, a cesarean section may cases, antibiotics may be needed.
be recommended to address complications and reduce ▪ Anemia
potential risks ➢ Some women may develop anemia after
Post-Partal Complication childbirth due to the blood loss that occurs
What is Post-Partal Complication during delivery. Symptoms may include fatigue,
▪ Refer to health issues and complications that can occur weakness, and pallor. Iron supplementation and
in women after giving birth. These complications can dietary changes can help manage anemia
vary in severity, and some may be more common than High-Risk Newborns
others. ▪ High-risk newborns, also known as neonates, are infants
Common Postpartum Complications who have a higher likelihood of experiencing health
▪ Postpartum hemorrhage problems or complications shortly after birth or during
➢ This is excessive bleeding following childbirth, the early stages of life. These risks can be due to a variety
often caused by the failure of the uterus to of factors, including prenatal, perinatal, and post-natal
contract properly after delivery. It can be life- conditions.
threatening condition if not treated promptly Classification of High-Risk Newborn
▪ Infection ▪ According to size
➢ Infections can occur at the site of a cesarean 1) Low birth weight
section or in the reproductive organs 2) Very low birth weight
➢ Endometritis is a common postpartum infection 3) Extremely low birth weight
that affects the uterine lining. 4) Appropriate for gestational age
▪ Perineal Tears and Episiotomy 5) Small for date
➢ Tears in the vaginal area can occur during 6) Intrauterine growth restriction
childbirth. Sometimes, healthcare providers 7) Symmetric IUGR
may perform an episiotomy (a deliberate cut to 8) Asymmetric IUGR
the perineum) to aid delivery. Both can lead to 9) Large for gestational age
complications if not managed properly.
▪ Thromboembolic Disorders
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 ▪ According to mortality o Danger, warm infant
1) Live birth ➢ Severe hypothermia – below 32 C (89.6 F)
2) Fetal death o Outlook grave, skilled care urgently
3) Neonatal death needed
4) Perinatal death Methods of Thermoregulation
5) HIV mortality ▪ Immediate drying and warming after delivery
▪ Radiant warmer incubator/isolette
Nutrition and Fluid Maintenance
▪ Drop factor is the number of drops in one milliliter used
in IV fluid administration (also called drip factor). A
number of different drop factors are available but the
commonest are:
➢ 1-10 drops/ml (blood set)
➢ 2-15 drops/ml (regular set)
➢ 3-60 drops/ml (microdrop, burette)
Type of Fluid
▪ Vomiting, NG aspiration, excess urine output in polyuria
(>4ml/kg/h): Replace with N/2 saline + 10 meq/L KCL
(0.5 ml KCL added every 100 ml of fluid)
▪ Chest tube drainage, third space losses with NS
▪ Diarrheal losses (10-20ml/stool) with N/5 in D 5% + 20
meq/L KCL (1ml KCL added every 100ml of fluid).
Factors Affecting IV Flow Rates
▪ Constricting band
Assessment of High-Risk Newborns ▪ Edema at puncture site
▪ Cannula abutting the vein wall or valve
▪ Administration set control valves
▪ IV bag height
▪ Completely filled drip chamber
▪ Catheter patency

Enteral Feeding
▪ Breast feeding
➢ Enhanced natural immunity
➢ Reduced allergy risk
➢ Bonding
➢ Weight normalization (mom)
Body Temperature in the Newborn Infant ▪ Formula Feeding
▪ Classification of hypothermia is based on core ➢ High sugar exposure
temperature ➢ High GMO exposure
➢ Normal – 3.5 to 37.3 C (97.7-99.2 F) ➢ Increased allergy risk
➢ Cold Stress – 36.0 to 36.4 C (96.8-97.6 F) ➢ Synthetic vitamins
o Cause for concern ➢ Increased risk fat deficiency
➢ Moderate hypothermia – 32-35.9 C (89.6-
96.6 F)
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Testing and Laboratory Procedures
▪ Blood group checking
▪ Complete blood count
▪ Arterial blood gas analysis
▪ Blood sugar level
▪ Electrolyte level
▪ Blood smear test
▪ X-ray
Special Management for High-Risk Newborns

Follow-up Schedule
▪ 2 weeks after discharge
▪ At 6, 10, 14 wks of post-natal age
▪ At 3,6,9,12 and 18 months of corrected age and 6
monthly visit until at least 5 years

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