Maternal and Child Nursing

FAMILY – is a group of people related by blood, marriage of adoption living - Companionship, shared resources
together
Negative Aspects
Types of Family
- Not sanctioned by law, disapproval by community,
 Family of orientation – the family one is born into: on oneself decreased value of women
mother, father and siblings (if any)
 Family of procreation – a family one establishes; oneself, spouse
5. The Extended Family/Multigenerational Family
or significant other and any children (if any)
- It includes not only a nuclear family but also other family
members such as grandmother, grandfather, aunts/uncles,
1. The Dyad Family cousins and children
- Two people living together without children
- It refers to single young adults who live together in shared Positive Aspects
apartments for companionship and financial secretary while
completing school or career - Many people for child care and member support
- A temporary arrangements but this could extend into a
lifetime arrangement Negative Aspects

Positive Aspects - Resources may be stretched because of few wage earners

- Companionship, possible shared resources 6. The Single Parent Family

- Low income is often a problem encountered by single-
Negative Aspects parent families, especially if a woman is the head of the
household
- Often a short term arrangement so can result in a sense of
- Such parent may develop self-esteem if things are not going
loss when true relationship ends
well, especially if a spouse left them

2. The Cohabitation Family Positive Aspects

- Composed of couples, perhaps with children who live
together but remained unmarried - Ability to offer a unique and strong parent-child bond

Positive aspects Negative Aspects

- Companionship, possibly financial security, encourages a - Resources may be limited

monogamous relationship
7. The Blended Family
Negative aspects - A divorced on widowed person with children marries
someone who also has children (stepfather/stepmother)
- Any result in feeling of loss if only short term and the break-
up is not desired by both partners Positive Aspects

3. The Nuclear Family - Increase security and resources

- Composed of husband wife and children
Negative Aspects
Positive Aspect
- Rivalry on competition among children, difficulty adjusting
- Support of family members, sense of security to stepparent

Negative Aspects 8. The Gay/Lesbian Family

- Gay men preferred to have sex with men
- May lack support people in crisis situation
Lesbian- woman preferred to have sex with woman
- They live together for companionship, financial security and
4. Polygamous Family several fulfillment or from the same structure as a nuclear
- A marriage with multiple wives and husbands family

Two types of Polygamous Family Positive Aspects

a. Polygymy – family with one and several wives - Provides the advantages of nuclear family
b. Polyandry – one wife with more than one husband
Negative Aspects
Positive Aspects
 Maternal and Child Nursing
- May suffer from discrimination from neighbors who do not  Monthly visit for the first 7 months of pregnancy without
thoroughly approve on accepting this family type problems
 During 8th months, visit usually every 2 weeks, and then weekly
during last month until delivery

Components of Prenatal Visits

9. The Foster Family
1. Assessment
- Children whose parents can no longer care for them may be
2. Diagnostic Test During Pregnancy
placed in foster or substitute home by a child protection
agency
ASSESSMENT
Positive Aspects
A. DATA COLLECTION of client’s health history in all pertinent areas
in order to form basis of comparison with data collected on
- Prevents children from being raised in large orphanage
subsequent visits and to screen for any high risk factors. Ask
settings
patient’s name, age, religion, economic status, and educational
Negative Aspects attainment and the ff:
1. Menstrual history: menarche, regularity, frequency and
- Insecurity and inability to establish meaningful relationships duration of flow, last period
because of frequent moves 2. Obstetrical history: all pregnancies, complications,
outcomes, contraceptive use, sexual history. Summarizing
pregnancy information: GTPAL/GTPALM: GPAb
10. The Adoptive Family
- Families of many types like nuclear, extended, cohabitation,
blended, single-parent, gay and lesbian A. GTPAL/GTPALM: (Pillitteri, Adele 2007)
- Was arranged privately/through an adoption agency, new parents Gravida = the number of pregnancy including the present
should visit a healthcare facility shortly after a child is placed in one
their home so a baseline of health information on the child can be Term = the total number of infants born at term 37 o more
established, potential problems can be discussed and solutions up to 42 weeks
can be replaced Preterm = the total number of infants born before 37 weeks
Abortions = the total number of spontaneous or induced
Family Functions and Roles abortions
Living = the total number of children currently living
 Financial manager Multiple pregnancies = the total number of multiple
 Problem solver pregnancies
 Decision maker Example:
 Mentorer 1. A woman who has had two previous pregnancies, has given
 Health manager birth to two term children, and is again pregnant would be
 Environmentalism 32002 or Gravida 3, Para 2002 (GTPAL)
 Gatekeeper 2. A pregnant woman with a boy born at 39 weeks gestation,
 Culture bearer now alive, a girl born at 40 weeks gestation, now alive; a girl
born at 33 weeks gestation, now alive would be 421030 or
Gravida 4, Para 21030 (GTPALM)
3. A woman who had term twins, then one preterm infant, and
is now pregnant again would be 321031 or Gravida 3, Para
21031 (GTPALM)
Note: a multigestation pregnancy like twins is considered
one para
A. GPAb:
Gravida – the number of times the woman has been pregnant,
including the current pregnancies
Para – the number of pregnancies that reaches the age of
viability- in 24 weeks regardless of whether babies born alive or
not
Example: A woman who has been pregnant three times, has had
two deliveries after 24 weeks gestation and has had one abortion;
the abbreviation should be G3,P2, Ab1
Nursing Care During Pregnancy
B. Medical history: include past illnesses, surgeries,
Antepartal Visits current use of medications, any drug or food
sensitivity, use of oral contraceptives, use of alcohol
 Initial visit for pregnancy test as early in pregnancy as possible, in and tobacco, blood transfusions, endocrine disorders
1st trimester infections, diabetes and heart disease
 Maternal and Child Nursing
C. Family history/psychosocial data: ask for congenital Place the tips of the first three fingers of each of hand on either
disorders, hereditary diseases, multiple pregnancies, side of the patient’s abdomen just above the symphysis and ask
diabetes, heart diseases, hypertension, mental the patient to take a deep breath and let it out
retardation, others. As she exhales, sink your fingers down slowly and deeply around
B. PHYSICAL EXAMINATION including internal gynecologic exam, the presenting part. Note the contour, size and consistency f the
bimanual exam, weight, vital signs, auscultation of fetal heart part
rate, palpation of fetal outline (Leopold’s maneuver) The head will feel hard, smooth and mobile if not engaged.
measurement of fundal height as correlation for appropriate Immobile if engaged.
progress of pregnancy, determine fetal length, calculation of fetal The breech will feel soft and irregular
weight In grams and age of gestation and expected date of
confinement by (Naegle’s rule) Fourth Manuever – answers the question: Where is the cephalic
prominence?
SEE THE FF: Finding cephalic prominence: this identifies the greatest prominence of the
fetal head palpated over the brim of the pelvis. When the head is flexed
1. LEOPOLD’S MANEUVER – performed in pregnancy after the (flexion attitude) the forehead forms the ceplahic prominence. When the
uterus becomes large enough to allow differentiation of fetal head is extended, the occiput becomes the cephalic prominence.
parts by palpation
Performing the Fourth Maneuver

FIRST MANEUVER – answers the question: What is the fundus? Head or Face the patient’s feet
breech? Gently move your fingers down the sides of the abdomen toward
Finding presentation: it identifies the part of the fetus that lies over the inlet the pelvis until the fingers of one hand encounter a bony
into the pelvis. The commonest presentations are cephalic (head first) and prominence. This is the cephalic prominence
breech (pelvis first)
If the prominence is on the opposite side from the back, it is the
baby’s brow and the head is flexed
Performing First Maneuver
If the head is extended, the cephalic prominence will be located
on the same side as the back and will be occiput
Facing the patient’s head, use the tips of the fingers of both hands
to palpate the uterine fundus
When the fetal head is in the fundus, it will feel hard, smooth, 2. MCDONALD’S METHOD AND RULE – measuring fundic height
globular, mobile and ballotable using tape measure. Uterine growth and estimated fetal growth
When the breech is in the fundus, it will soft, irregular, round and a. Fundus at symphysis pubis = 12 weeks gestation
less mobile b. Fundus between symphysis pubis and umbilicus = 16 weeks
The lie of the fetus – the relationship between the long axis of the c. Fundus at umbilicus = 20-22 weeks gestation
fetus and the long axis of the mother – can also be determined d. 2 fingersbreadths above umbilicus = 24 weeks
during the first maneuver e. Fundus 28cm from top of symphysis pubis = 28 weeks
The lie is commonly longitudinal or transverse, but occasionally be gestation
oblique f. Midway between umbilicus and xiphoid process = 30 weeks
g. Just below xiphoid process = 34 weeks
SECOND MANEUVER – answers the questions: Where is the back? h. Fundus at lower border rib cage or at the level xiphoid
Finding position: it identifies the relationship of the fetal body part to the process = 36 weeks gestations
front, back or sides of the maternal pelvis. There are many possible fetal i. Uterus becomes globular and drops = 40 weeks gestation
positions
Mcdonald’s rule: In months: Fundic height (cm) multiplied (x) 2/7
Performing Second Maneuver Example: 25cm X 2 = 50 = 7 months

Remain facing the patient’s head. Place your hands on either side In weeks: FUndic height (cm) multiplied (X) 8/7
of the abdomen Example: 25cm X 8 = 200 -28 -29 weeks
Steady the uterus with your hand on one side, and palpate the
opposite side to determine the location of the fetal back 3. Another method of calculating AGE OF GESTATION by weeks
The back will feel firm, smooth, convex, resistant  Ask the client’s first day of LMP. EX. February 19, 2009
 Subtract the date of LMP from the total no. of days of
The small parts (arms and legs) will feel small, irregularly placed,
that same month. EX. Feb has 28 days – Feb 19 (LMP) =
and knobby may be actively or possibly mobile
8 days difference
Third Maneuver – answer the questions: Where is the presenting part?  Add the difference to the present date of the month
Finding presenting part: it identifies the most dependent part of the fetus- when the client had consulted/visited the clinic
that is the part that lies nearest the cervix. It is the part of the fetus that first (present prenatal visit). EX. Difference 9 add Mrach 22
contracts the finger in the vaginal examination, most commonly the head or (present prenatal visit) = 31 total no. of days
breech.  Then the total no. of days will be divided by 7. EX. 31
divided by 7 = 4.42 weeks or 4 weeks and 3 days
Performing the Third Maneuver 4. NAEGLE’S RULE
o Formula in finding expected/estimated date of
Turn and face the patient’s feet confinement or estimated due date
 Maternal and Child Nursing
o Add 7 days to the first day of the LMP Preparation of client/nurse responsibilities
o Subtract 3 months
o Add 1 year  Ask the woman to void, to prevent bladder puncturing
EX. First day of LMP – September 16. 1998  Since the procedure involves penetration to the amniotic
Add 7 days – September 23 sac, such as frightening to the woman, explain the
Subtract 3 months – June 23 procedure and alleviate her fear
Add 1 year – June 23, 1999 will be the EDD  Place in supine position and provide privacy but exposing
5. HAASES’S RULE – is used to determine the length of the fetus in only her abdomen
cm  Place folded towel under her right buttock to tip her body
 During the first half (1 to 5 month) of pregnancy, slightly to the left and move the uterus off the vena cava to
square the number of months. EX. (3 months)2 = 9cm prevent supine hypotension
 During the 2nd half (6 to 10 month) of pregnancy,  Take maternal blood pressure and FHR for baseline then
multiply the number of months by 5. EX. (7 months) x attach to electronic fetal monitoring
5 = 3cm  Caution the woman that she may feel a sensation of
6. JOHNSON’S RULE – use to calculate the fetal weight in grams pressure as the gauge 20-22 spinal needle a 3-4 inches
Fundic height in cm – N multiplied K= weight of the fetus introduced for aspiration
K = 155 (constant); N is 12 (engaged) 11 (not engaged)  Caution the woman not to take a deep breath and hold it
EX. 30cm – 12 X 1 = 8X155= 2790 grams because the diaphragm lowers uterine and shifts
7. FETAL MOVEMENTS: Quickening (first fetal movement) felt by intrauterine contents
mother at 18-20 weeks and peaks at 28-38 every minute and 10-
12 X hour. Decreased movement: placenta; insufficiency, instruct Amniocentesis can provide information in some of these areas:
woman to seek consultation and tell her that fetal movements
 Color: normal color of amniotic fluid is color water, late in
vary in relation to mother’s activity
pregnancy is slightly yellow tinger, blood incompatibility is strong
8. FETAL HEART RATE – 5-8th week, heartbeat seen in ultrasound,
yellow results from billirubin release with hemolysis of RBC,
10-11th weeks heard with ultrasonic Doppler, 16 weeks heard at
meconium staining is green color suggest fetal distress
fetoscope
 Lecithin/Sphingomyelin Ratio – are protein components of the
lung enzyme surfactant that the alveoli begin to form at about
C. LABORATORY WORKS – including CBC and blood typing, 22nd to 24th weeks of pregnancy. After amniocentesis, the L/S ratio
urinalysis, urine and blood glucose, urine ketone and urine may be determined quickly by shake test (if bubbles appear in
protein; Pap’s smear test, rubella titer; testings for STD, HbsAg amniotic fluid after shaking, the ratio is mature) or sent to
and hepatitis; toxoplasmosis, ECG, TBtest and other tests as laboratory for lab analysis
indicated  Phosphatidyl Glycerol and Desaturated Phosphatidylcholine:
these are compound substances found in surfactant which are
2. DIAGNOSTIC TESTS DURING PREGNANCY present only with mature lung function at 35-36 weeks. This
means that fetus has no respiratory distress syndrome
 Pregnancy Test – measures HCG in urine, accurate early in  Billirubin determination: the blood specimen must be free from
pregnancy the presence of billirubin (yellowish pigment found in bile, a fluid
 Ultrasonography – identifies fetal and maternal structure. produced by the liver or a yellow breakdown product of red bloos
Measures the response of sound waves against solid objects; used cells)
to discover complications of pregnancy  Chromosomes analysis: used to detect chromosomal diseases
Purposes of ultrasound: through prenatal amniocentesis
 Diagnose pregnancy as early as 6 weeks gestation  Fetal fibronectin: fibronectin is glycoprotein that plays a part in
 To confirm the presence, size and location of the helping the placenta attach to the uterine deciduas, found in
placenta/amniotic fluid amniotic fluid until after 20 weeks of pregnancy and is assessed
 To see fetal abnormalities e.g hydrocephalus through cervical mucus. As labor approaches, it can be found in
 To establish sex, presentation and position of fetus. vaginal or cervical fluid, but higher amount of these substances in
Sex is seen as early as 15 weeks through 4 dimension the amniotic fluid would mean a preterm labor ay begin.
ultrasound  Inron errors of metabolism: some inherited diseases that are
caused by inborn errors of metabolism can be detected by
Preparation of client/nurse responsibilities:
amniocentesis.
 Alpha-fetoprotein: an increased level of aplhafetoprotein in the
 Explain test to client
amniotic fluid signifies anencephaly, myelomeningocele or
 Have client drink 6-8 glasses of water, without voiding before the
omphalocele. But if levels is found to be decreased, the result is
test so that fetal parts are more visible
down syndrome

 Amniocentesis – determines genetic disorder, sex and fetal lung

 Percutaneous umbilical blood sampling (PUBS) – also
maturity. It is done through the aspiration of 15 ml amniotic fluid
called cordocentesis or funicentesis is the aspiration of
from the uterus between 14th and 16th weeks of pregnancy. During
blood from the umbilical vein fro analysis
and 30 minutes after procedures, observe FHR to be certain that
the rate remains normal and that uterine contractions are not
Procedures and results:
occurring.
 Maternal and Child Nursing
 After the umbilical cord is located by sonography, a thin needle is be simulated with a loud sound.
inserted by amniocentesis technique into the uterus until it
pierces the umbilical vein.
 Chorionic villus sampling (CVS): aspiration of small sample of
 A sample of blood is removed for blood studies such as CBC direct
chorionic villus tissue at 8-12 weeks of gestation to detect genetic
coomb’s test, blood gases and karyotyping
abnormalities, chromosomal or DNA analysis. The chorion cells
 To ensure that the blood sample is from the fetus, it is submitted
are located by ultrasound. A thin catheter is inserted vaginally or
to a Kleihauer Betke test
abdominally and number of chorionic cells removed for analysis
 If a fetus is found to be anemic, blood maybe transfused using the
same technique Side effects of CVS:
 The fetus is monitored by nonstress test before and after the
procedure to be certain that there are no uterine contractions  Excessive bleeding, pregnancy loss, baby born with missing limbs,
and no vaginal bleeding threatened abortion

 Contraction stress test (CST) – based on principles that healthy  Maternal serum alpha-fetoprotein: assesses quantity of fetal
fetus can withstand decreased oxygen but compromised fetus serum proteins (substance produced by the fetal liver), done at 15
cannot; the FHR is analyzed in conjunction with the contractions weeks of pregnancy. If elevated, are associated with neural tube
defects. If the level is low, fetus has chromosomal defect e.g down
Types: syndrome
 Biophysical profile: looks at fetal hypoxia and fetal compromised
a. Nipple stimulated CST – massage or rolling of one or both
by measuring 5 parameters of fetal activity – FHR, fetal breathing
nipples to stimulate uterine activity and check effect on FHR
movement, gross fetal movement, fetal tone and amniotic fluid
b. Oxytocin challenge test (OCT) – infusion of calibrated dose
volume. It can be done daily during a high risk pregnancy
of IV oxytocin thru piggybacked to maintain IV line;
controlled by infusion pump; amount infused increased Results:
every 15-20 minutes until 3 good uterine contractions are
observed within 10 minute period  A score of 6 is suspicious;4 denotes fetal compromised; but score
of 10 (highest score) means good fetal well-being
Patient preparation:
NUTRITION
 Explain the procedure to he patient that IV infusion of oxytocin
were initiated A. WEIGHT GAIN – total weight gain of 25-3 lbs. (11-16kg) for the
 Then ask the woman to roll her nipples between her fingers and whole pregnancy
thumb until uterine contractions begin, which are recorded by a 1st trimester – 3.5-5lbs (1.6-2.3kg) or 1.16 -1.66 lbs/month or .29 -
monitor .42 lb/week or less than 1 ;b/week
Each of 2nd and 3rd trimester. 12-15lbs (5.5 – 6.8 kg) or 4-5
Results: lbs/month or 1-1.25 lbs/week or 0.45 – 0.56 kg/week which
consist of:
 3 contractions with a duration of 40 seconds or longer must be
 Fetus – 7-7.5 lbs (3.4kg)
present in a 10 minute window. If the test is negative, it means
 Amniotic fluid – 2lbs (0.9kg)
normal because there is no fetal heart decelerations (FHR
 Placenta and membrane – 1.5lbs (0.6 kg)
deviations seen through monitor)
 Breasts – 1.5-3 lbs (0.6-1.3kg)
 If the test is positive, it is abnormal, meaning 50% or
 Uterus – 2.5 lbs (1.1 kg)
more contraction cause late deceleration (there is
 Increased blood volume – 2-4lbs (0.90-1.8kg)
uteroplacental insufficiency resulting to the fetal
 Body fat – 7lbs (3.8kg)
hypoxia)
 Extravascular fluid and fat – 5-10 lbs (2.3-4.kg)
 Nonstress test (NST): evaluates FHR in response to
fetal movement, done in 10-20 minutes. The uterine
contraction monitors are attached to the rhythm strip B. SPECIFIC NUTRIENTS needs are:
and the woman pushes the button attached to the 1. Calories: usual addition is 300 kcal/day, but there will be
monitor whenever she feels the fetus moves. This can specific guidelines for those beginning pregnancy either
be done also at home as part of home monitoring over or underweight
program. 2. Protein: additional 30 gms/day to ensure intake of 74-76
gms/day
Results: 3. Carbohydrates: intake must be sufficient for energy needs,
using fresh fruits and vegetables as much as possible to
 When the fetus moves, the FHR should increase about 15 bpm derive fiber benefit
and remain elevated for 15 seconds 4. Fats: high energy foods, which are needed to carry the fat
 If no increase in bpm on fetal movements, there is poor fetal soluble vitamins
oxygen perfusion 5. Iron: needed by the mother as well as fetus; reserved
 If a 20 minute period passes without any fetal movement, the usually sufficient for first trimester should be taken with
fetus is only sleeping. The mother should be given an oral vitamin C to promote absorption
carbohydrates snack, enough to cause fetal movement; also may 6. Calcium: 1200mg/day needed; dairy products most frequent
source
 Maternal and Child Nursing
7. Sodium: contained in most foods, needed in pregnancy; 2. Due to the possible injury to the bay, the couples are often
should not be restricted without serious indication warned to avoid sexual intercourse during the last 6-8 weeks of
8. Vitamins: both fat and water soluble are needed in pregnancy
pregnancy; essential for tissue growth and development as 3. In healthy pregnancy, there is no medical reason to limit sexual
well as regulation of metabolism activity
9. Folate (folic acid): folate is a B vitamin which is essential for 4. The expectant mother may experience changes in sexual desire
the formation of RBC and must be taken before and during and response related to various discomforts that occur
pregnancy. The requirement for woman for folate increases throughout pregnancy
by 50% during pregnancy because this is a time of additional 5. During the first trimester, sexual desire is decreased due to
blood formation and rapid tissue growth for the baby. various discomforts brought about by fatigue, nausea and
Studies have shown that additional folate intake during early vomiting and breast tenderness
stages of conception helps prevent neural tube defects e.g 6. During the second trimester, woman may experience greater
cleft lip and cleft palate. sexual desires and satisfaction due to lessened discomforts
7. During the third trimester, interest in coitus may again decrease
due to fatigue, shortness of breath, pain in the pelvis and other
C. TERATOGENIC FOODS, ADDITIVES AND DRUGS according to US
discomforts
food and drug act
8. Solitary and mutual masturbation and oral genital intercourse
1. Nitosamines (N-nitroso compounds)
maybe used by couple as alternatives to penile-vaginal
- These compounds are patent carcinogens in all tested
intercourse
species, including amphibians, birds, fish and mammals
9. The side by side position is often preferred, especially during third
e.g sodium nitrate and sodium nitrite are added to
trimester because it requires less energy and places less pressure
most smoke and cured meat and fish to act as an
on the pregnant abdomen
antioxidant to ensure preserving the foodstuff
10. Intercourse is contraindicated for medical reasons such as:
2. Alatoxins
 Multiple pregnancy
- Related to mycotoxins and are produced by fungal
 Threatened abortion
growths on a wide range of food stuffs. For instance,
 Incompetent cervix
the mycotoxin ergotism of rye can induce abortion as
 Partner with std
well as gangrene and other ills of the vascular system
 Maternal history of miscarriage
3. US certified food colorings
 Membranes are ruptured
- These are the “azo” dyes which include red #2
 History of preterm labor
(amaranth) red #4, yellow #6 (tartrazine). Green
 Abdominal pain
(ferrous gluconate) and some other
 Vaginal bleeding
4. Artificial sweeteners
 Uterine contractions
- Researchers have found that mothers who had taken
11. Sexual activity styles are:
cyclamates during pregnancy had children who
 Spoon – both bodies fit closer together in this position,
suffered from hypersensitivity and leaning disabilities
making it very intimate, relaxing and optimal for slow
5. Caffeine
and sensual love-making. Spooning is a great
- The substance is of concern because of its chemical
introduction to rear-entry sex, and also is very
structure, purine, one of the constituent groups of
comfortable during late pregnancy because there is
DNA. Moreover, it crosses placenta and is known to
very little pressure on the woman’s stomach
penetrate the preimplantation blastocytes in mammals
 Scissors – the woman is lying side by side so that the
6. Trace elements and metallic and chemical contaminants
man is facing the woman’s back then sliding his body
- Such trace elements and metallic contaminants as
so that his body is perpendicular to the woman’s body.
lead, selenium, arsenic, cadmium, mercury and
The end result is a little like the doggy-style position
methylmercury occur in the gorund; in fish and
laid on the side
crustaceans, especially when they came from
 Penguine – a sexual position where the male partner is
contaminated waters
lying down, while the pregnant woman partner is
7. Oral analgesics (NSAID): aspirin; Oral hypoglycemic:
sitting on top him enough to secure the abdomen or
orinase; Antithyroid: methimazole Anticoagulant: coumarin;
the fetus against harm
antibiotics: sulfonamides, tetracycline;ACE inhibitors:
capotene, vasotec; Tranquilizers: diazepam; Vitamin A
IMMUNIZATIONS
derivatives: Isotretinoin, etretinate; Nicotine; alcohol:
whisky, wine Immunity is the resistance that an individual has against disease. As a
general rule, immunizations are best avoided during pregnancy

1. Immunizations with attenuated live viruses (including mumps and

rubella vaccines should not be given during pregnancy because of
their teratogenic effect on the developing embryo)
SEXUAL ACTIVITY DURING PREGNANCY
2. Vaccinations with killed viruses (including varicella, hepatitis,
1. The result of physiologic, anatomic, and emotional changes of influenza, tetanus and diphtheria vaccines) may be given during
pregnancy makes the couples usually ask questions and concerns pregnancy
about sexual activity during pregnancy  Schedule of tetanus toxoid immunization for women
as per DOH
 Maternal and Child Nursing
TT1 – as early as possible during pregnancy  Recommend the woman to lie on her left side in
TT2 – at least 4 weeks later bed to enhance glomerular filtration rate of the
TT3- at least 6 months later kidneys
TT4 – at 1 year later  Encourage woman to avoid wearing tight,
TT5 – at least 1 year later constrictive clothing
 Benefits of tetanus toxoid  Suggest her to get up and move about every 1-2
1. Infants – protection from neonatal tetanus hours when sitting for long periods
2. Mother – protection from tetanus for 3,5,10 and c. Varicose veins: from weakening walls of veins or faulty
lifetime valves. Same management with ankle edema
d. Hemorrhoids: from increased venous pressure or
constipation.
 Increase bulk and fluid in diet
COMMON DISCOMFORTS IN PREGNANCY  Caution the woman against prolonged standing
and wearing constrictive clothes
1. FIRST TRIMESTER  Encourage the use of witch hazel compresses
a. Nausea and vomiting (morning sickness) due to elevated  Teach the woman how to perform sitz bath or
HCG levels and changes in carbohydrate metabolism apply warm soaks
 Teach client to take small frequent meals with  Encourage the woman to lie on her left side with
dry crackers; drink liquids between meals; her feet slightly elevated
instruct patient to avoid greasy, highly seasoned e. Constipation: from sluggish bowl from progesterone and
food steroid metabolism, displaced intestines and iron
 Suggest intake of complex carbohydrates with supplements
the onset of nausea.  Increase bulk and fluid in diet; maintain regular
b. Fatigue exercise regimen
 Get plenty of rest  Caution the woman to avoid the use of mineral
c. Urinary urgency and frequency because of pressure of oil, which deplete her level of fat soluble vitamins
fundus on bladder f. Backache: from exaggerated lumbosacral nerve from
 Do not limit fluid intake; decreases in 2nd enlarged uterus
trimester  Maintain good body mechanics and posture;
d. breast tenderness from increase levels of estrogen and wear low-heeled shoes;sit in chair with proper
progesterone back support
e. increased vaginal discharge from hyperplasia of mucosa and  Advise woman to apply local heat to the back if
increased mucus production necessary
f. nasal stiffness and epistaxis from elevated estrogen level  Suggest sleeping on firmer mattress or using
causing edema of nasal mucosa board under the current mattress to add firmness
 encourage the use of cool-moist humidifier  Teach the woman to do pelvic rocking or tilting
 suggest the use of normal saline nose drops or exercise
nasal spray g. Leg cramps: from pressure on nerves
 advise patient to apply cool compress to the  Stretch and exercise legs; maintain good posture
nasal area and body mechanics
g. palmar erythema (palmar pruritis) probably caused by  Encourage frequent rest periods with the legs
increased estrogen level. The woman may believe that she slightly elevated
has developed an allergy  Encourage to wear warm clothing
 tell the woman that this is normal h. Faintness: a result from orthostatic changes
 advise her to apply calamine lotion on the  Change position slowly; sit up for several minutes
affected side before rising
h. hypotension: symptoms that occur when a woman lies on i. Shortness of breath: from pressure on diaphragm
her back and the uterus presses on the vena cava impairing  Sleep in reclining position
blood return to the heart. j. Braxton hicks: contractions beginning as early as the 8th to
 Turn the woman to her side to remove pressure 12th weeks of pregnancy. The uterus periodically contracts
from the vena cava, blood flow will be restored and then relaxes again. A rhythmic pattern of very light
contractions can be a beginning sign of labor
2. SECOND AND THIRD TRIMESTER  Advise woman to telephone or e-mail their
a. Heartburn: from esophageal reflux primary caregiver
 Avoid caffeine and spicy foods; sit up after meal
b. Ankle edema: from venous stasis; normal because of the DANGER SIGNS IN PREGNANCY
pressure of the enlarging uterus
 Elevate legs when sitting and do not cross legs  Teach woman to report immediately these
 Avoid prolonged standing and wear support danger signs: recall FRESHAC/PADS
stockings Fever indicates infection
Rush of water from vagina indicates premature
rupture of membranes (PROM)
 Maternal and Child Nursing
Epigastric pain (pain in abdomen) indicates 3.DRUGS, ALCOHOL, TOBACCO
preeclampsia, ischemia in the pancreas
Swelling of the face, hands and feet, spots before  Drugs cross placenta (teratogen)
eyes: hypertension, preeclampsia  No drugs unless prescribed by physician
Hard fall  No over the counter medications e.g aspirin, herbal
Absence of baby movement indicates fetal death remedies
Continuous headache;convulsions indicates  No illegal drugs
hypertension, preeclampsia, eclampsia  Category D drugs are those that have clear health risks
Persistent vomiting; abdominal pain: abruption for fetus, include alcohol, lithium and phenytoin
placenta placenta previa, premature labor (dilantin)
Dimness/blurring of vision: decreased urine  Category X drugs are those that have been shown to
output (oliguria) indicates hypertension, cause birth defects and should never be taken during
preeclampsia, renal impairment pregnancy
Seizures of muscular irritability indicates  Alcohol during pregnancies may lead to fetal alcohol syndrome,
preeclampsia, eclampsia physical abnormalities, congenital anomalies, growth deficits or
jitteriness
ENVIRONMENTAL RISK FACTORS IN PREGNANCY  Cigarette smoking
 Leads to low birth weights and higher incidence of
1. GERMAN MEASLES birth defects and stillbirth
a. Can cause major defects in fetus between 2nd and 6th weeks  Research indicates that even second hand smoke is
after conception harmful
b. Measles titer should be given before pregnancy to  Nicotine cigarettes causes vasoconstriction; alters
determine risks maternal and FHR
2. SEXUALLY TRANSMITTED DISEASE
A. Chlamydial infection 4.RADIATION EXPOSURE
1. Most common STD especially in teenagers
2. Transmission to neonates of infected mothers during  Women should always be asked about the possibility of
passage through birth canal pregnancy before radiography are taken
3. Must be careful with timing of treatment because  Increased risk of abortion and physical deformities
tetracycline used can interfere with tooth enamel
formation 5.OTHER RISK FACTORS
B. Syphilis
Passed to fetus usually leads to spontaneous  Stress causes increased activity in fetus in response to increased
abortions epinephrine
Treated with penicillin up to last trimester;  Women over age 35 years have greater risk of genetic
important to prevent congenital syphilis, abnormalities
increased incidence of mental sub abnormality  Girls under 15 years have greater risk of stillbirth, spontaneous
and physical deformities abortion and premature birth
C. Herpes
ADOLESCENT PREGNANCY AND PARENTHOOD
Contamination of fetus after membranes rupture
or with vaginal delivery
A. GENERAL INFORMATION
Generalized herpes results in 100% mortality; CS
1. Pregnancy in a female under 17 years of age. Pregnancy is a
indicated if labor occurs during an episode
condition of both physical and psychologic risk. Adolescent
D. Gonorrhea
pregnancy is considered high risk because of frequency of
Fetus contaminated during vaginal delivery serious complications, iron deficiency, preterm birth and low
Risk to neonate: ophthalmia neonatorum, birth weight infants
pneumonia and sepsis 2. Incidence – one million teenage pregnancies per year
Problems avoided if treatment given before worldwide
delivery a. Earlier onset of menarche
E. Human immunodeficiency virus b. Changing sexual behaviors
Risk of transmission to fetus estimated from 30% c. Poor family relationship
to as high as 75% d. Poverty
Newborn maybe asymptomatic at birth, but signs 3. Prognosis
and symptoms usually develop during first year a. For pregnant girls under 15 years, a high risk of
of life stillbirth, low birth weight infants, neonatal mortality
No effective treatment or prevention if mother and cephalopelvic disproportion (CPD)
HIV positive b. Increased maternal risk of pregnancy induced
F. Group B streptococcus infection hypertension, prolonged labor, iron deficiency anemia
Most common cause of neonatal sepsis in the US; and UTI
can lead to post-partal infections in mother B. NURSING PROCESS
Treatment in last semester with ampicillin can a. Assessment/Analysis
prevent transmission to neonate during labor 1. Nutrition status
 Maternal and Child Nursing
2. Knowledge of physiology of pregnancy 2. Bones of skull are joined by membranous sutures, which
3. Emotional status allow for overlapping or molding of cranial bones during
4. Support system birth process
b. Plan, Implementation and Evaluation 3. Anterior and posterior fontanels are the points of
Goal: the pregnant woman will maintain good health; will intersection for the sutures and are important landmarks
eat a balance diet with adequate protein; will prepare for a. Anterior fontanel is larger, diamond shaped and closes
birth and care of newborn, will achieve developmental taks about 18 months of age
of adolescence and pregnancy; fetus will develop b. Posterior fontanel is smaller, triangular, and usually
appropriately for gestation closes about 3 months of age
Plan/Implementation 4. Fontanels are used as landmark for internal examinations
1. Assist the pregnant woman to achieve developmental during labor to determine the position of fetus
tasks of adolescence in addition to the role of  FETAL SHOULDERS: maybe manipulated during delivery to allow
pregnancy passage of one shoulder at a time
- Develop sense of identity  PRESENTATION: the part of the fetus which enter in the pelvis in
- Accept changing body image the birth process
- Develop close, mature relations with peers TYPES OF PRESENTATION
- Socialize into appropriate gender role 1. CEPHALIC: head is presenting part; usually vertex (occiput),
- Establish an independent and satisfying lifestyle which is most favorable and ideal for vaginal birth. Head is
2. Provide dietary counseling regarding importance of flexed with chin on chest
well balance meals and increase protein, calcium and Types of cephalic are: vetex, brow, face, mentum
iron intake. Adolescent is frequently undernourished 2. BREECH: buttock or lower extremities present first. Most
and not yet completely matured physically or managed through CS birth.
psychosocially Types of breech presentation are:
3. Prepare for childbirth: arrange for coaching assistance a. Frank breech: thigh flexed, leg extended on anterior
4. Refer to social service for career and educational body surface ; buttocks presenting
counseling; options regarding child care/adoption; b. Complete of full breech: thighs and leg flexed.
support services in community; parenting classes and Buttocks and feet presenting(baby in squatting
supplemental food programs position)
5. Instruct in child care and teach in family planning c. Footling breech: one (single footling) or both (double
footling) feet presenting
Evaluation 3. SHOULDER: presenting part of the scapula and baby is on
horizontal or transverse position CS birth is indicated
- Client is free from preventable complications; has  FETAL POSITION: relationship of the fetal presenting part to a
positive birth experience;delivers a healthy specific quadrant of a woman’s/ maternal bony pelvis
newborn;cares safely for newborn or arranges for 1. Maternal bony pelvis divided into four quadrants (right and
alternate placement; achieves appropriate left anterior;right and left posterior). Relationship is
developmental tasks expressed in three-letters abbreviation; first the maternal
side (R or L), next the fetal presentation and last the
NURSING CARE DURING LABOR maternal quadrant (A or P). Most common positions are:
a. LOA (LEFT OCCIPUT ANTERIOR) fetal occiput is on
FIVE ESSENTIAL FACTORS IN LABOR (5P’S)
maternal left side and toward front, face down. This is
a favorable delivery position
1. Passenger
b. ROA (RIGHT OCCIPUT ANTERIOR) fetal occiput on
2. Passageway
maternal right side and toward front, face down. This
3. Power
is a favorable delivery position
4. Placenta
c. LOP (LEFT OCCIPUT POSTERIOR) fetal occiput is on
5. Psychological response
maternal left side and toward back face is up. Mother
experiences much back discomfort during labor, labor
LABOR
may be slowed; rotation usually occurs before labor to
 A series of events by which abdominal pressure and uterine anterior position or health care provider may rotate at
contraction expels the fetus and placenta outside the woman’s time of delivery. Occiput positions are managed
body through forceps and CS.
 The process of fetal expulsion along with the products of d. ROP (RIGHT OCCIPUT POSTERIOR) fetal occiput is on
conception secondary to regular, progressive and frequently maternal right side and toward back, face is up.
occurring uterine contractions Presents problem similar to LOP
e. LOT (LEFT OCCIPUT TRANSVERSE) fetal occiput is
I. PASSENGER transverse the maternal left side; ROT (RIGHT OCCIPUT
The size, presentation, position of the fetus, fetal attitude and TRANSVERSE) fetal occiput is transverse the maternal
fetal lie right side
 FETAL HEAD f. LSA (LEFT SACRUM ANTERIOR) fetal sacrum is on
1. Usually the largest part of the baby; it has profound effect maternal left side and toward front; RSA (RIGHT
on the birthing process
 Maternal and Child Nursing
SACRUM ATERIOR) fetal sacrum is on maternal right Forces of labor, acting in concert, to expel fetus and
side and toward front placenta. Major forces are:
g. LSP (LEFT SACRUM POSTERIOR) fetal sacrum is on A. Uterine contraction (involuntary)
maternal left side and toward back; RSP (RIGHT 1. Frequency: timed from the beginning of one contraction to the
SACRUM POSTERIOR) fetal sacrum is on maternal right beginning of the next
side and toward back 2. Regularity: discernible pattern; better established as pregnancy
progresses
Assessment of fetal position can be made by 3. Intensity: strength of contraction; a relative assessment without a
use of a monitor. May be determined by the depressibility of the
a. Leopold’s maneuvers; external palpations(4 steps) of maternal uterus during a contraction
abdomen to determine fetal contours or outlines 4. Duration: length of contraction. Contraction lasting more than 90
b. Vaginal examination location of sutures and fontanels and seconds without a subsequent period of uterine relaxation may
determination of relationship to maternal bony pelvis have severe implications for the fetus and should be reported
c. Rectal examination now virtually completely replaced by vaginal B. Voluntary bearing-down efforts
examination 1. After full dilation of the cervix, the mother can use her abdominal
d. Auscultation of fetal heart tones and determination of quadrant muscle to help expel the fetus
of maternal abdomen where best heard. Correlate with leopolds 2. These efforts are similar to those for defecation, but the mother
maneuver pushing out the fetus from birth canal
3. Contraction of levator ani muscles
 FETAL ATTITUDE: the degree of flexion a fetus assumes during
labor; the relationship of fetal parts to each another. Normal or IV. PLACENTA
good attitude are spinal column is bowed forward; moderate A. As the placenta usually forms in the fundus of the uterus, it
flexion of the head; flexion of the arms onto the chest; and the seldom interferes with the progress of labor
flexion of the legs/thighs unto abdomen. Deviations in these B. A low-lying maginal partial or complete placenta previa may
attitudes will cause difficult, prolonged labor require medical interventions to complete birth process
 FETAL LIE: the relationship between the long (cephalocaudal) axis,
spinal column of the fetus and the long (cephalocaudal) axis of the V. PSYCHOLOGICAL RESPONSE
mother/woman’s body. A longitudinal lie occurs when A woman who is relaxed, aware and participating in the
cephalocaudal axis of the fetus is parallel to he woman’s spin e.g birth process usually has shorter, less intense labor. A
vertex (cephalic), breech. A transverse lie occurs when woman who is fearful has high level of adrenaline
cephalocaudal axis of the fetal spine is at right angles to the (epinephrine) and norepinephrine, these are hormone
woman’s spine e.g shoulder presentation cathecholamines from the nerve endings, brain, and adrenal
glands which later slow uterine contraction
II. PASSAGEWAY
Shape and measurement of maternal pelvis and THE LABOR PROCESS
distensibility of birth canal
CAUSES
A. ENGAGEMENT: settling of the fetal presenting part far enough
into the pelvis (inlet) to be at the level of the ischial spine. May
Actual cause unknown. Factors involved include:
occur two week before labor In primipara; usually occurs at
beginning of labor in multipara a. Progressive uterine distention
B. STATION: relationship of the fetal presenting has descended into b. Increase intrauterine pressure
the pelvis. Referrant is ischial spines, palpated through lateral c. Aging of the placenta
vaginal wall d. Changes in levels of estrogen (increased) progesterone (dropped)
1. When presenting part is at ischial spine, station is 0, and prostaglandins (increased)
meaning it is engaged e. Increasing myometrial irritability
2. If presenting part is above ischial spine, station expressed as
negative number e.g(-1, -2, -3) -4 means presenting part is PRELIMINARY SIGNS OF LABOR
still high or floating
3. High or floating terms used to demote unengaged a. Lightening: settling or descent of the fetal presenting part into the
presenting part. Soft tissue (cervix, vagina); stretches and pelvic brim (2) weeks before delivery in primigravida
dilates under the force of contraction to accommodate that b. Increased level of activity: increase in activity is due to an
passage of the fetus. increase in epinephrine release initiated by the decrease
4. If presenting part is below ischial spine, station is expressed progesterone by the placenta
as a positive number e.g (+1,+2,+3 and +4) means presenting c. Braxton hick’s contraction: a contraction which may be
part is at the perineum and can be seen at the vulva e.g interpreted as true labor contractions
crowning as the stage when fetal head has negotiated the d. Ripening of the cervix: an integral or sure sign seen only in pelvic
pelvic outlet and the largest diameter of the head is examination
encircled by the external opening of the vagina e. Bloody show: (pinkish vaginal discharge) the mucus plug that
filled the cervical canal during pregnancy is expelled
III. POWERS f. Rupture of membrane: experience as either a sudden gush or
scanty. Slow seeping of clear fluid from vagina
 Maternal and Child Nursing
g. Uterine contraction: the surest sign that labor has begun with the the diagonal or transverse position of the arly part of labor. The
initiation of effective, productive, involuntary uterine contraction head rotates to full alignment with back and shoulders for
shoulder delivery mechanisms. To accommodate the shoulder,
FIVE THEORIES OF LABOR ONSET the head goes back to its original position
G. EXPULSION: once the shoulders are born, the rest of the body is
1. Uterine stretch theory: any hollow organ stretch to its maximum born spontaneously because of its smaller size. When entire body
potential will always expel its contents. Stretching of uterine of the baby has emerged from mother’s body, birth is complete.
muscles causes prostaglandin release This time is recorded as the time of birth.
2. Prostaglandin theory: archidonic acid stored from amnion,
chorion, and deciduas stimulates contraction STAGES OF LABOR
3. Progesterone deprivation theory: sudden drop in progesterone
levels will initiate contractions 1. FIRST STAGE/DILATATION STAGE
4. The theory of aging placenta: the placenta begins to degenerates 2. SECOND STAGE/EXPULSION STAGE
at 36 weeks and the body perceives it as a foreign objects 3. THIRS DTAGE/PLACENTAL STAGE
5. stimulation theory: this production of the posterior pituitary 4. FOURTH STAGE/RECOVERY STAGE
gland of this substance will cause uterine contractions
FIRST STAGE OF LABOR. FIRST CERVICAL DILATATION STAGE
DIFFERENCE BETWEEN FLASE AND TRUE LABOR
 From onset of labor until full dilation of cervix
FALSE:  Guide summary recall LAT
Latent phase
 contractions – irregular, no increase in frequency and intensity Active phase
 intervals of contraction – no longer between contractions Transition phase
 pain/discomfort – lower abdomen, walking has no effect
decreases LATENT PHASE – from 0-3 cm (4.5 hours in multipara; 6 hours in nullipara)
 no bloody show
 no dilatation and effacement Assessment

TRUE: a. Contractions: frequency (every 20 minutes decreasing to every 5

minutes) intensity (mild to moderate); duration (20-40 seconds)
 contractions – regular, increase in frequency, intensity and b. Membranes – intact or ruptured
duration Normal color of amniotic fluid is color water
 intervals of contraction –shorter between contractions Nitrazine paper test (ruptured membranes): either blue green (pH
 pain/discomfort – back then radiates to the abdomen, not 6.5) blue gray (pH 7.0) deep blue (pH7.5)
relieved by walking Nitrazine paper test (intact membranes) either color in yellow (pH
 bloody show – present 5.0) olive yelloe (pH 5.5) olive green (6.0)
 with effacement and dilatation; fetal descent progresses c. Bloody show present
d. Time of onset
MECHANISM OF LABOR (VERTEX PRESENTATION) e. Cervical change
f. Time of last ingestion of food
A. ENGAGEMENT g. FHR every 1 minutes: immediately after rupture of membranes
1. The biparietal diameter of the head passes the pelvic inlet h. Maternal vital sign:
2. The head is fixed in the pelvis 1. Temperature every 2 hrs if membrane ruptured, every 4 hrs
B. DESCENT: downward movement of the biparietal diameter of the if intact
fetal head to within the pelvic inlet; progress of the presenting 2. Pulse and respiratory every hour or prn as indicated
part through the pelvis 3. Blood pressure every half hour or prn as indicated
C. FLEXION: as descent occurs, the head bends forward onto the i. Client’s knowledge of labor process: prolonged latent phase is
chest, the smallest anteroposterior diameter (the caused by cephalopelvic disproportion (CPD)
suboccipitobregmatic diameter) the one presented to the birth j. Client’s affect: woman is sociable and excited
canal. Chin flexed more firmly onto chest by pressure on fetal k. Client’s birth plan
head from maternal soft tissue (cervix, vaginal walls, pelvic floor)
D. INTERNAL ROTATION: during descent, the head enters the pelvis Analysis
with the fetal anteroposterior head diameter in a diagonal or
transverse position Nursing diagnoses for the latent phase of first stage of labor may include
1. Fetal skull rotates along axis from transverse to
anteroposterior at pelvic outlet a. Anxiety
2. Head passes the midpelvis b. Ineffective breathing pattern
E. EXTENSION: as occiput is born, the back of the neck stops c. Pain
beneath the pubic arch and acts as a pivot for the rest of the d. Knowledge deficit
head. Fetal head passes under the symphysis pubis and is
delivered, occiput first, followed by chest and chin Planning and Implementation
F. EXTERNAL ROTATION: almost after the head, head rotates from
anteroposterior position, it assumes to enter the outlet back to Goals
 Maternal and Child Nursing
1. Complete all admission procedures 9. With posterior position, apply sacral counter-pressure, or have
2. Labor will progress normally father to do so
3. Mother/fetus will tolerate latent phase successfully
Evaluation
Interventions
a. Labor progressing thru active phase
1. Administer perineal prep/enema if ordered appropriate b. Mother/fetus tolerating labors appropriately
2. Assess VS, BP, FHR, contraction bloody show, cervical changes, c. No complication observed
and descent of fetus as scheduled
3. Maintain bed-rest if indicated/required TRANSITION PHASE - 8-10cm (30 minutes -2 hrs)
4. Reinforce/teach breathing techniques as needed
5. Support laboring woman/couple based on their needs Assessment
6. Have a client attempt to void every 1-2 hrs
7. Appky external fetal monitoring prn a. Contractions: frequency (every 2-3 mins) intensity (firm) duration
(60-90 sec)
Evaluation b. Membranes ruptured: bloody show increases, cervical dilation
completed
1. Admission procedures complete c. Maternal mood change: irritable or aggressive and loss of control,
2. Progress latent stage normal, cervix dilated may be tiring or unable to cope
3. Mother/fetus before latent phase well, mother as comfortable as d. Signs if nausea and vomiting, trembling, crying, irritability
possible. VS normal, FHR maintained in response to contraction e. Maternal/fetal VS
f. Breathing pattern may be hyperventilating
ACTIVE PHASE – 4-7 cm (2 hrs in multipara; 3-6 hrs nullipara) g. Feeling the urge to push/ bear down with contraction
h. Loss of control in common
Assessment
Analysis
a. Contractions: frequency (3-5 mins apart) intensity (moderate to
firm) duration (40-60sec) Nursing diagnoses for the transition phase of first stage of labor may include:
b. Cervical changes: effacement of cervix completed
c. Membranes may be ruptured a. Ineffective breathing pattern
d. Progress of descent: fetus descends in pelvis and internal rotation b. Powerlessness
begins c. Ineffective individual coping
e. Maternal//fetal vital signs
f. Client’s affect: more anxious and may feel helpless Planning and Implementation

Analysis Goals

Nursing diagnosis for the active phase of first stage of labor may include: a. Labor will continue and progress through transition
b. Mother/fetus will tolerate process well
1. Ineffective individual coping c. Complications will be avoided
2. Alteration in orla mucous membranes
3. Knowledge deficit Interventions
4. Pain
5. Altered tissue perfusion 1. Continue observation of labor progress, maternal/fetal VS
6. High risk for injury 2. Give another positive support if tired or discouraged
3. Accept behavioral changes of mother
Planning and Implementation 4. Promote appropriate breathing pattern to prevent
hyperventilation
Goals 5. If hyperventilation present, have another rebreath CO2 to revert
respiratory alkalosis
a. Progress will be normal for active phase 6. Discourage pushing effort until cervix is completely dilated, then
b. Mother/fetus will successfully complete active phase assist with pushing
7. Observe for signs of delivery
Interventions
Evaluation
1. Continue to observe labor progress
2. Reinforce/teach breathing techniques as needed a. Mother/fetus progressed through transition
3. Position client for maximum comfort b. No complication observed
4. Support client/couple as mother becomes more involved in labor c. Mother/fetus ready for second stage of labor
5. Administer analgesia prn
6. Assist with anesthesia if given and monitor maternal/fetus VS CERVICAL CHANGES IN THE FIRST STAGE OF LABOR
7. Provide ice chips or clear fluids for mother to drink if
allowed/desired 1. Effacement
8. Keep client/couple informed as labor progresses a. Shortening and thinning of cervix
 Maternal and Child Nursing
b. In primipara, effacement is usually well advanced before Assessment
dilation begin in a multipara, effacement and dilaton
progress together 1. Signs of placental separation
2. Dilation a. Callein’s sign – earliest sign of placental separation; change
a. Enlargement or widening of the cervical os and canal in shape of uterus (discoid uterine shape to regular)
b. Full dilation is considered 10cm b. Sudden gush of vaginal blood
c. Lengthening of umbilical cord
SECOND STAGE OF LABOR/2ND EXPLUSION STAGE
Types of Placental Delivery
 From full dilation of cervix to birth of baby
 Schultz – placenta separates from the center to edge
Assessment  Duncan – placenta separates from the edge to the center

a. Signs of imminent delivery Nursing interventions

b. Progress of descent
c. Maternal/fetal VS  Trap and rotate the cord slowly so that no fragments of placenta
d. Maternal pushing effort is left in the unterus
e. Vaginal distention  Palpate the uterus. If boggy
f. Bulging of perineum - Put ice pack to stimulate vasoconstriction
g. Crowning - Immediately massaging the uterus
h. Birth of baby - Nipple stimulation
- VS every hour, then every 4 hrs
Analysis - Assist the physician in episiorraphy (repair of lacerated
vulva)repair of episiotomy
Nursing diagnoses for the second stage of labor may include 2. Completeness of placenta
3. Status of mother/baby contact for first critical 1-2 hrs
1. High risk of injury a. APGAR Score
2. Noncompliance related to exhaustion b. BP, pulse and respiration rate, lochia, fundal status of
3. Knowledge deficit mother

Planning and Implementation Analysis

Goals: Nursing diagnoses for the third stage of labor

a. Safe delivery of living, uninjured fetus a. Pain

b. Mother will be comfortable after tolerating delivery b. Potential fluid volume deficit

Interventions Planning and Implementation

1. If necessary, transfer mother carefully to delivery table or birthing Goals:

chair; support legs equally to prevent strain on ligaments or
prevent popliteal vein pressure a. Placenta will be delivered without complication
2. Help mother use handles or legs to pull on as she bears down with b. Maternal blood loss will be minimized
contractions c. Mother will tolerate procedures well
3. Clean vulva and perineum to prepare for delivery
4. Continue observation of maternal/fetal VS Interventions
5. Encourage the mother in sustained(5-7 sec)pushes with each
contraction 1. Palpate fundus immediately after delivery of placenta; massage
6. Support father’s participation if in a delivery area gently if not firm
7. Catheterized mother’s bladder if indicated 2. Palpate fundus ate least every 1 mins for first 1-2 hrs
8. Keep mother informed of delivery progress 3. Observe lochia for color and amount
9. Note time of delivery of baby 4. Inspect perinem
5. Assist with maternal hygiene as needed
Evaluation 6. Offer fluid as indicated
7. Promote beginning relationship with baby and parents through
a. Delivery of healthy viable fetus touch and privacy
b. Mother comfortable after procedure 8. Administer medication as ordered/needed (pitocin added to IV
c. No complication during procedure present)

Evaluation

THIRD STAGE OF LABOR/3RD PLACENTAL STAGE a. Placenta delivered without complication

b. Minimal maternal blood loss
 From birth of baby to expulsion of placenta c. Mother tolerated procedure well
 Maternal and Child Nursing
FOURTH STAGE/4TH RECOVERY STAGE Multipara
Stage 1: 8 hrs
 Time after birth if immediate recovery; critical period of 1-2 hrs Stage 2: 20 mins
Stage 3: 4-5 mins
Assessment Stage 4: 1-2 hrs

a. Fundal firmness, position

b. Lochia: color, amount ASSESSMENT DURING LABOR
c. Perineum
d. VS FETAL ASSESSMENT
e. IV if running
f. Infant’s heart rate, airways, color, muscle tone, reflexes, warmth, o Auscultation – FHR at least every 15-30 mins during first stage
activity state and 5-15 mins during second stage (depend on risk status of
g. Bonding/family integration client)
A. Normal range 120-160 bpm
Analysis B. Best recorded during 30 sec immediately following a
contraction
Nursing diagnoses for the fourth stage of labor o Palpation – assess intensity of contraction by manual palpation of
uterine fundus
a. Pain
a. Mild – tense fundus, difficult to indent with fingertips
b. High risk for fluid volume deficit
b. Moderate – firm fundus, difficult to indent with fingertips
c. High risk for altered family process
c. Strong – very frim fundus cannot be indent with fingertips

Planning and Implementation

Electronic Fetal Monitoring (EFM)

Goals: critical first hour(s) after delivery will pass without complications for
A. Placement of ultrasound transducer and tocotransducer to record
mother
FHR and uterine contractions and display them on special graph
for comparison and identification of normal and abnormal pattern
Interventions
B. Can be applied externally to other’s abdomen or internally within
the uterus
1. Palpate fundus every 15 mins for first 1-2 hrs; massage gently if
C. External application (External Electronic Monitoring)
not firm
a. Less precise information collected
2. Check mother’s BP, pulse and respiratory rate every 15 mins for
b. May be affected by maternal movements
first 1-2 hrs or until stable
c. Non-invasive: rupture of membranes not required, can be
a. Check lochia for color and amount for every 15 mins for 1-2
widely used
hrs
d. Little danger associated with use
b. Inspect perineum every 15 mins for first 1-2 hrs
D. Internal Apllication
c. Apply ice to perineum if swollen or episiotomy
a. More precise information collected
d. Encourage mother to void, particularly if fundus is not firm
b. Cervix must be dilated 3cm and membranes ruptured to be
or if displaced
utilized
1. Use nursing techniques to encourage voiding
c. Physician applies fetal scalp electrode and uterine catheter
2. If client is unable to void, get order for catheterization
attached to the pressure recorder
3. Measure first voiding
d. Sterile technique must be maintained during application to
e. Encourage early bonding, through breastfeeding if desired
reduce risk of intrauterine infection
Evaluation e. Can yield specific short-term variability
E. Patterns Recognition
a. Mother’s VS stable, fundus and lochia within normal limits 1. Nurse is responsible for assessing FHR patterns,
b. Evidence of bonding; parents cuddle, touch, talk to baby implementing appropriate nursing interventions. And
c. No complication observed for mother or baby during crucial time reporting suspicious patterns to physician
2. Baseline/normal FHR: 120-160, when uterus is not
DURATION OF LABOR contracting. FHR variability is normal, indicative of intact
fetal nervous system or reliable fetal well being. Variability is
A. Depends on result of interaction of sympathetic and parasympathetic
1. Regular, progressive uterine contraction nervous system. Two types of variability are:
2. Progressive effacement and dilation of cervix a. Short-term (beat to beat) refers to the difference
3. Progressive descend of presenting part successive heartbeats. Assessed as present or absent
B. Average Length or decreased. FHR: average 3-5bpm
Primipara b. Long term (rhythmic fluctuations) refers to the broad
Stage 1: 12-13 hrs view of the recording and from fluctuations in the FHR.
Stage 2: 1 hr Classified according to number of cycles per minute.
Stage 3: 5-30 mins FHR: average is 6-10 bpm
Stage 4: 1-2 hrs 3. Tachycardia
a. FHR more than 160-180 bpm lasting 10 mins
 Maternal and Child Nursing
b. FHR >180 bpm i. Sever variable decelerations indicate fetal distress
Causes: maternal – fever, dehydration, severe nemia,
hyperthyroidism, bronchodilators, decongestant and DANGER SIGNS OF LABOR
stimulant drugs; maternal/fetal hypoxia or
hypovolemia; fetal- arrhythmia Fetal Danger Signs
c. Oxygen may be administered
4. Bradycardia 1. High or low FHR: FHR >160 bpm (tachycardia) and <100 bpm
a. FHR less than 120bpm lasting 10 mins (bradycardia) both signs of possible fetal distress as shows in the
b. FHR 100-119 bpm (moderate bradycarida) is not fetal monitor with variable deceleration pattern
serious due to fetal heart compression during labor 2. Meconium staining (green color in the amniotic fluid results in
c. FHR <100 bpm is marked bradycardia and dangerous the loss of sphincter control, fetus is experiencing hypoxia
Causes: umbilical cord compression; fetal hypoxia and (deficient in the blood or tissue)
heart block, maternal seizures, epidural and spinal 3. Fetal hyperactivity a sign of hypoxia
anesthesia 4. Fetal acidosis (sign of compromised fetal well being, blood pH
d. Oxygen may be administered lower than 7.2)
5. Early deceleration
Maternal Danger Signs
a. Periodic decreases in FHR from pressureon the fetal
head brought about by parasympathetic stimulation in
1. Rising or falling of BP
response to vagal nerve compression
2. Abnormal pulse
b. FHR between 120-160 bpm a mirror image of
3. Inadequate prolonged contractions (less frequent and shorter
contraction
duration indicates inertia
c. Deceleration of FHR begins in early or which the peak
4. Abnormal lower abdominal contour indicates full bladder
of uterine contraction, stops within normal range
5. Increasing apprehension (sign of oxygen deprivation and internal
(reassuring pattern) and returns to baseline by the end
hemorrhage)
of contraction
d. Believe to be the result of compression of fetal head PREPARATION FOR LABOR
against cervix
e. Not an ominous pattern, no nursing intervention Prepared Childbirth
required
6. Late deceleration a. Natural childbirth was used to describe one approach to giving
a. Deceleration of FHR begins 30-40 sec after the onset birth
uterine contraction depth varies within strength of b. To some, natural childbirth means delivery without analgesic or
contractions; does not return to baseline by the end of anesthesia or being prepared for childbirth through prenatal
contraction. Lowest peak of FHR is 110-120 bpm education and training
b. May be occasional or consistent. Gradual increase in c. This preparation gave the woman a method of coping with the
number is always suspicious and must be reported discomforts of labor and delivery
c. Believer to be the result of uteroplacental insufficiency d. To avoid the suggestion that analgesia or anesthesia are available
d. Nurse should change maternal position, administer to the woman during labor and delivery should she need it, the
oxygen, discontinue any oxytocin infusions, assess term “prepared childbirth” is now used instead of natural
variability and prepare for immediate delivery if childbirth
patterns remain uncorrected. An ominous pattern
7. Variable deceleration
I. Method of Grantly Dick-Read
a. Onset of deceleration not related to uterine
a. This method is used on the idea that fear and anticipation of pain
contraction; occurs at unpredictable times seen in U, V
arouse natural protective tension in the body, both psychic and
or W shaped waves
muscular (fear-tension-pain mechanism)
b. Lowest FHR 55-85 bpm
b. Fear stimulates sympathetic nervous system and causes the
c. Believed to be the result of compression of the
circular muscle of the cervix to contract
umbilical cord
c. the longitudinal muscles of the uterus then have to act against
d. Although not an ominous pattern, continued nursing
increased cervical resistance, causing tension and pain.
assessment required
d. Tension and pain aggravate fear which produces and vicious cycle
e. Nurse should change maternal position from supine to
of tension, pain and fear
trendelenburg to relieved pressure on cord: if no
e. A minor degree of pain, magnified by fear, becomes unbearable
improvement seen, administer oxygen, discontinue
f. According to Dick-Read, prenatal courses and training reduce fear,
oxytocin if infusing. Rationale: with ach uterine
overcome, ignorance and build a woman self-confidence
contraction being stimulated by ocytocin bloodflow
from the mother to the baby initially ceases as the
Included in this method are:
uterine myometrial veins are compressed
f. Prepare client for vaginal examination to assess for 1. Explanation of fetal development and childbirth
prolapsed cord 2. Description of methods available to relieve pain
g. If cord is proplapsed, relived pressure on cord, do tno 3. Exercise that strengthen certain muscle and relax others
attempt to replace cord
h. CS will be needed
 Maternal and Child Nursing
4. Breathing technique that will enable the woman to relax in the c. He is also to explore his feelings and role as a parent and to
first stage of labor and work effectively with muscle used during prepare psychologically for fatherhood
delivery
5. Explanations of the value of improved physical health and V.Home Delivery
emotional stability for childbirth
6. The woman is not told that labor and delivery will be painless;  Home delivery although controversial, has won in increasing
analgesia and anesthesia are available If needed support in recent years
7. The woman is empathetic understanding and support during labor  Motivation of home delivery:
by her partner, the nurse and the physician a. Belief that home birth has significant advantages for the
family and the newborn infant
II. Psychoprophylactic or Lamaze Method b. Objection to the impersonal and authoritarian atmosphere
of the hospital environment with enforced separation of
1. Psychoprophylactic childbirth has a rationale based on Pavlov’s woman and family
concept of perception and his theory of conditioned reflexes (the c. Desire to avoid such practice as routine CS delivery for
substitution of favorable conditioned reflexes for unfavorable one breech presentation, episiotomy, forceps delivery, oxytocin
2. The woman is taught to replace responses of restlessness, fear, stimulation, routine monitoring of FHR and other practices
and the loss of control with more useful activity. A high level of associated with hospitals
activity can excite the cerebral cortex efficiently to inhibit other d. Risk of hospital infections; belief that infant is immune to
stimuli such as pain in labor own home bacteria
3. The mother taught exercises that strengthen the abdominal e. Rising cost of hospitalization
muscles and relax perineum  Contraindications
4. Breathing techniques to help the process of labor are predicted a. High risk indications for infants or mother
5. The woman is conditioned to respond with respiratory activity b. Patient with history of premature or postdate delivery in
and disassociation or relaxation of the uninvolved muscles, while previous pregnancy
controlling her perception of the stimuli associated with labor c. Woman with medical and emotional complications
6. One method of control consists of breathing normally while d. Patients who cannot be quickly transported to a hospital
silently mouthing the words to a song and simultaneously tapping  Alternatives
the rhythm with fingers a. Alteration of hospital setting to a family centered
7. Similarity between Dick-Read and Lamaze methods: approached
a. Fear, which enhances the perception of pain, may diminish b. Birthing centers for low risk women with adequate facilities
or disappear when the woman understand the physiology of for emergency care
labor c. Properly educated and motivated support personnel
b. Since psychic tension enhances perception of pain,
relaxation is achieved more easily in a calm, agreeable
atmosphere with supportive persons nearby
c. Muscular relaxations and specific type of breathing diminish
or abolish the pains of labor

III.The Laboyer Method of Delivery

a. It is based on the premise that the infant suffers psychological

shock at the time of delivery
b. As effort is made to remove the contrast between the intrauterine
environment and the outside world
c. Gentle, controlled delivery – prenatal education, support from
family and personnel to decrease anxiety, fear and tension
d. Emphasis on providing protection to the craniosacral axis by
gently supporting the newborn infant head, neck and sacrum. The
craniosacral axis is completely relaxed and lost body heat restored
in a hot water bath
e. Avoiding overstimulation of the newborn sensorium- the infant is
allowed to breath spontaneously; cutting the cord is delayed to
permit the placental blood transfusion for improved respiration
f. Importance of maternal infant bond-skin to skin contact with
mother is provided and infant is fondled and stroked

IV. Father Involvement

a. Prepared childbirth programs include the father as an active

participant in helping the woman with labor
b. The father is made to feel involved and useful and through
learning the psychological and emotional processes of pregnancy,
be may gain an appreciation of the woman’s experience