PREFACE

This book’s focus is fundamental on health, normally and

wellness promotes an evidence-based interventional philosophy of care
rooted in the concept that in most women birth is not a disease, but a
natural event normally calling for little intervention. This book
addresses the pregnant women’s changing situations from conception
to during labor and birth, and through the early weeks after birth. This
discus various issues of obstetric management drawn from obstetrical
textbook, journals, and research detach chronologically order, as you
would encounter them.
When you understand what is happening in labor you will
recognize each stage as it comes and fell more confident about trying
different ways of coping. As you learn your own personal strength and
resources for labor and birth, you will learn to trust your body and the
enigma of the birth will be rediscovered.
Remember, birth is a powerful experience of the unknown. Not a
predetermined set of events. There is no right way to give birth. There
is the birth you have. There is no right method just the need to be
integrated into the physiological, psychological and emotional process
of the intensely private experience of birth. This experience that is
your own is an adventure in physical sensation and intense emotional
discerning of your own inner power and strength. Labor is an awesome
treadmill contracting incredible inner sensations. However difficult the
labor may be, you are in your own space and discover your self the
power to give birth with the same love and passion that created your
baby. As the power of swing contractions spreads through your body, if
the power of physicality of birth is respected, it allows you to use your
body to bring forth life with strength and confidence.
The care of the childbearing and childbearing family is a major
focus of nursing practice. To have healthy children, it is important to
promote the health of the childbearing woman her family from the time
before the children are born to the time until they reach adulthood.
Prenatal care and guidance are essential to the health of the woman
and fetus and of the family’s emotional preparation for childbearing.
Although the field of nursing typically divides all concerns for
families during childbearing and childbearing into to two separate
entities, maternity and child health, the full scope of nursing practice in
the area is not true separate entities but one: MATERNAL AND CHILD
NURSING BOOK.
 INTRODUCTION

Someone once said, “pregnancy begins at that unfelt, unknown

moment of time when a single, wiggling sperm penetrates a mature
ovum. Even though this momentous event of fertilization occurs
without notice, the changes, which take place within the mothers’ body
in the next nine months, are undeniable and amazing. Yeah, our
coming to earth is really magical and we should thank our mothers for
they sacrificed their lives just to give us our precious gift… our LIFE.
Childbirth is a good metaphor for life. It begins at time of conception,
when long gestation by hard labor to bring forth a new creation. Mixed
passion and discomfort strike before fulfillment.
For every person going through the process of birth, there is a
possibility of transformation at the individual and the family level.
That’s why everyone views birth as the most critical time, a hopeful
time.
In many ways, birth has become crucible in which modern
woman is around and burned; it is our testing place. But there’s value
in this work. True-births have often been difficult and painful, but pain
can be essential part of growth.
Maternal and child care is a philosophy based on the
consideration of a mother and child in relation to each other and
consideration of a whole family with each meaningful relationship as
well as its cultural and socio-economic environment of the client. The
overall trust of maternity care is to assist each mother throughout the
stage of pregnancy, labor and delivery and the puerperium in such a
way that minimal discomfort will be experienced and to ensure optimal
health and well being for the mother and her newborn. Sure care must
also meet the psychological needs of the mother and her partner and
their contribution to satisfactory infant- maternal bonding following
delivery.
 NURSING PROCESS
Nursing process is a systematic, rational method of planning and
providing individualized nursing care. Its purpose is to identify a
client’s health status, actual or potential health care problem or needs;
to establish plans to meet the identified needs; and to deliver specific
nursing intervention to meet those needs. The nursing process is
cyclical; that is, the components of the nursing process follow a logical
sequence, but more than one component may be involved at any one
time.

CHARACTERISTICS OF NURSING PROCESS

Cyclic and dynamic: nursing process is unique by properties that

enables it to respond t the changing health status of the client.
Client centered: the nurse organizes the plan of care according to
client problems rather than nursing goals. In the assessment phase,
the nurse collects data to determine the client’s habits, routines, and
needs, enabling the nurse to incorporate client routines into the care
plan as much as possible.
Interpersonal and collaborative: to ensure the delivery of quality
nursing care, the nurse must share concerns and problems and
problems and participate in continuous evaluation of the care plan.
This depends on open and meaningful communication and the
development of rapport between the client and the nurse. To carry out
the nursing process effectively and individualize approaches to each
client’s particular needs, the nurse must collaborate with each
individual, family, group, or community as required.
Universally applicable: it can be used with client with any age.
At any point of the wellness-illness continuum. Furthermore, it is useful
in a variety of settings and across specialty areas.
Problem - solving technique, It can be viewed as parallel to but
separate from the medical process.
Interpersonal skills: Nurses use a variety of interpersonal, technical,
and intellectual skills in applying the nursing process.
Technical skills: include using equipment and performing
procedure.
Intellectual skills: includes analyzing, problem solving, critical thinking,
and making nursing judgments.

COMPONENTS OF NURSING PROCESS

ASSESSING: is collecting, organizing, validating, and recording data
about a client’s health status. Data are obtained from a variety of
sources and are the basis for actions and decisions taken in
subsequent phases. No conclusions about the data are drawn in this
phase.

DIAGNOSIS: is a process, which results in a diagnostic statement or

nursing diagnosis. In this phase, the nurse sorts, clusters, and analyzes
the data and asks,” What are the actual and potential health problems
for which the client needs nursing assistance?” and “What factors
contributed to this problem? Responses to those questions establish
the nursing diagnosis.

PLANNING: involves series of steps in which the nurse and the client
set priorities and goals or expected outcomes to resolve or minimize
the identified problems of the client. In collaboration with the client,
the nurse develops specific interventions for each nursing diagnosis.
The product of the planning phase is a written care plan to coordinate
the care provided by all the health team members.

INTERVENTION: is putting the nursing care plan into action. During

the implementation phase, the nurse carries out the prescribed nursing
activities or delegates the care to an appropriate person, and validates
the nursing care plan. This phase ends when the nurse records the care
given and the client’s responses to care in the client record.

EVALUATION: is assessing the client’s response to nursing

interventions and then comparing the response to the goals or
outcome criteria written in the planning phase. The nurse determines
the extent to which the outcomes\goals of care phase been achieved.
The care plan is reassessed in this phase, which may involve changes
in any or all of the previous phases of the nursing process.

CONCEPT OF A FAMILY

No social group has the potential to provide the save level of

support and long - lasting emotional ties as one’s family. How well a
family works
The ability to provide for the physical, emotional, and spiritual
needs of family members.
The ability to be sensitive to the needs of family members.
The ability to communicate thoughts and feeling effectively.
The ability to provide support, security, and encouragement.
 The ability to initiate and maintain growth - producing
relationships.
The capacity to maintains and deals constructive and responsible
community relationships.
The ability to grow with and through children.
The ability to perform family roles flexibly.
The ability to help oneself and to accept help when appropriate.
The capacity for mutual respect for the individuality of family
members.
The ability to use a crisis experience as a means of growth.
A concern for family unity, loyalty, and inter - family cooperation.
Many types of families exist and a family type may change over
time as it is affected by birth, work, death, divorce, and the growth of
child health nursing, the following are the different types of families
according to:
Organization, structure or membership together and meets any
crisis depends on its structure and function and how well the family
can organize itself against potential threats.
A family is a group people waked by blood, marriage, or
adaptation. Spradly and Allender (1996) define the family in a much
broader context as “two or more people who live in the name
household (usually), share a common emotional bond, and perform
certain interrelated social tasks.” This is a better definition for health
care providers because it addresses the broad range of types of
Families health care providers encounter.
Like individuals, families manifest both wellness behavior and
------- behaviors. The following are lists of generally accepted behaviors
indicating a well or functioning family:
Nuclear. This is the primary or elementary type of family. It
composed of a husband, wife, and children. An advantage of a nuclear
family in its ability to provide support to family members because
people feel genuine affection for each other. Extended. Sometimes
called the multigenerational family, which includes not e stretched to
accommodate all members.
Single - Parent. This type increases today due to the high rate of
divorce and also to the increasing practice of raising children outside
marriage.
Place of residence
Patrilocal. The couple resides with the groom’s parents
Matrilocal. The couple resides with the bride’s parents.
Bilocal. The couple has the freedom to choose where to reside.
Neolocal. The couple lives away from both parents.
Awercolocal. The couple requires residing with the uncle of the
groom.
Authority

Patriarchal. In this type of family, the authority is vested on the

oldest male or father.
Matriarchal. In this fairly, authority is vested on the mother or
mother’s kin.
Equalitarian. In this family, there is an equal share of authority.
Matricentric. In this type, the mother answers the highest
authority while the father is away.

Terms of Marriage

Monogamy. It includes one husband and 1 wife

Polygamy. This also called plural marriage wherein there is two or
more wives or husbands.
Families tend to display characteristics of their culture and
community. The types of families that live in communities tend to be
culturally determined.
According to Friedman, the role of the family is to meet the needs of
its members while also meeting the needs of the society. A healthy
family provides food, shelter, clothing, and health care for its
members. And also prepares the children to live in community and
interact with people outside the family. Because families work as a
unit, unmet needs of any member can spread to become unmeet need
of all family members.

RESPONSIBLE PARENTHOOD

We affirm the principle of responsible parenthood. The family, in

its varying forms, constitutes the primary focus of love, acceptance,
and nurture, bringing fulfillment to parents and child. Healthful and
whole personhood develops, as one is loved, responds to love, and in
that relationship comes to wholeness as a child of God.
Each couple has the right and the duty prayerfully and
responsibly to control conception according to their circumstances.
They are, in our view, free to use those means of birth control
considered medically safe. As developing technologies have moved
conception and reproduction more and more out of the category of a
chance happening and more closely to the realm of responsible choice,
the decision whether or not to give birth to children must include
acceptance of the responsibility to provide for their mental, physical,
and spiritual growth, as well as consideration of the possible effect on
quality of life for family and society. To support the sacred dimensions
of personhood, all possible efforts should be made by parents and the
community to ensure that each child enters the world with a healthy
body and is born into an environment conducive to the realization of
his or her full potential.
When through contraceptive or human failure an unacceptable
pregnancy occurs, we believe that a profound regard for unborn human
life must be weighed alongside an equally profound regard for fully
developed personhood, particularly when the physical, mental, and
emotional health of the pregnant woman and her family show reason
to be seriously threatened by the new life just forming. We reject the
simplistic answers to the problem of abortion that, on the one hand,
regard all abortions as murders, or, on the other hand, regard
abortions as medical procedures without moral significance.
When an unacceptable pregnancy occurs, a family-and most of
all, the pregnant woman is confronted with the need to make a difficult
decision. We believe that continuance of a pregnancy that endangers
the life or health of the mother, or poses other serious problems
concerning the life, health, or mental capability of the child to be, is
not a moral necessity. In such cases, we believe the path of mature
Christian judgment may indicate the advisability of abortion. We
support the legal right to abortion as established by the 1973 Supreme
Court decision. We encourage women in counsel with husbands,
doctors, and pastors to make their own responsible decisions
concerning the personal and moral questions surrounding the issue of
abortion.
We therefore encourage our churches and common society to:
Provide to all education on human sexuality and family life in its
varying forms, including means of marriage enrichment, rights of
children, responsible and joyful expression of sexuality, and changing
attitudes toward male and female roles in the home and the
marketplace; provide counseling opportunities for married couples and
those approaching marriage on the principles of responsible
parenthood;
Build understanding of the problems posed to society by the
rapidly growing population of the world, and of the need to place
personal decisions concerning childbearing in a context of the well
being of the community; provide to each pregnant woman accessibility
to comprehensive health care and nutrition adequate to ensure healthy
children; make information and materials available so all can exercise
responsible choice in the area of conception controls. We support the
free flow of information about reputable, efficient, and safe
nonprescription contraceptive techniques through educational
programs and through periodicals, radio, television, and other
advertising media. We support adequate public funding and increased
participation in family planning services by public and private
agencies, including church-related institutions, with the goal of making
such services accessible to all, regardless of economic status or
geographic location; make provision in law and in practice for voluntary
sterilization as an appropriate means, for some, for conception control
and family planning; safeguard the legal option of abortion under
standards of sound medical practice; make abortions available to
women without regard to economic standards of sound medical
practice, and make abortions available to women without regard to
economic status; monitor carefully the growing genetic and biomedical
research, and be prepared to offer sound ethical counsel to those
facing birth-planning decisions affected by such research; assist the
states to make provisions in law and in practice for treating as adults
minors who have, or think they have, venereal diseases, or female
minors who are, or think they are, pregnant, thereby eliminating the
legal necessity for notifying parents or guardians prior to care and
treatment. Parental support is crucially important and most desirable
on such occasions, but needed treatment ought not be contingent on
such support; understand the family as encompassing a wider range of
options than that of the two-generational unit of parents and children
(the nuclear family); and promote the development of all socially
responsible and life-enhancing expressions of the extended family,
including families with adopted children, single parents, those with no
children, and those who choose to be single; view parenthood in the
widest possible framework, recognizing that many children of the world
today desperately need functioning parental figures, and also
understanding that adults can realize the choice and fulfillment of
parenthood through adoption or foster care; encourage men and
women to actively demonstrate their responsibility by creating a family
context of nurture and growth in which the children will have the
opportunity to share in the mutual love and concern of their parents;
be aware of the fears of many in poor and minority groups and in
developing nations about imposed birth-planning, oppose any coercive
use of such policies and services, and strive to see that family-planning
programs respect the dignity of each individual person as well as the
cultural diversities of groups.

ANATOMY AND PHYSIOLOGY

Ovary, in anatomy, organ of female animals, including humans, that
produces reproductive cells called eggs, or ova. In humans they are
oblong, flattened, ductless glands, about 3.8 cm (about 1.5 in) long, on
either side of the uterus, to which they are connected by the Fallopian
tubes. Each ovary is composed of two portions: an external, or cortical,
portion, and a deep, medullary portion. The cortical portion in the adult
contains an enormous number of follicles, or sacs, varying in size.
called Graafian follicles, they contain the ova, the female reproductive
cells. The interior of the ovary is distinctly divided into an outer cortex,
where the germ cells develop, and a central medulla occupied by the
major arteries and veins. Each egg cell develops in its own fluid-filled
follicle and is released by ovulation. The ovary is supplied with an
ovarian artery, ovarian veins, and ovarian nerves, which travel through
the suspensory ligament.
The ovary is held in place by the ovarian, suspensory, and broad
ligaments as well as a peritoneal fold called the mesovarium. The
ovary secretes hormones that, together with secretions from the
pituitary gland, contribute to secondary female sexual characteristics
and also regulate menstruation. The union of the male sperm cell with
the ovum results in fertilization. The ovary may be the site of several
disease conditions. It can be the site of acute and chronic
inflammation; this may arise from injuries during labor, operations in
the pelvic area, or gonorrheal infection spreading from the vagina. The
ovary also may be the site of neoplasms (tumors) of several varieties.
Some are fluidic enlargements of one or more Graafian follicles and
may attain an enormous size; these are known as ovarian cysts. Other
growths, of a solid nature, are known as dermoid cysts. These
enlargements, usually benign, occasionally prove to be cancerous.
Most species have male and female organisms. Each sex has its
own unique reproductive system. They are different in shape and
structure, but both are specifically designed to produce, nourish, and
transport either the egg or sperm. Unlike its male counterpart, the
female reproductive system is almost entirely hidden within the pelvis.
It consists of organs that enable a woman to produce eggs (ova), to
have sexual intercourse, to nourish and house the fertilized egg (ovum)
until it is fully developed, and to give birth.
Females also have external organs collectively called the vulva (which
means "covering"). Located between the legs, the outer parts of the
vulva cover the opening to a narrow canal called the vagina. The fleshy
area located just above the top of the vaginal opening is called the
mons pubis. A thin sheet of tissue called the hymen partially covers
the opening of the vagina. Two pairs of skin flaps, the labia (which
means "lips") surround the vaginal opening. The clitoris, which is
located toward the front of the vulva where the folds of the labia join, is
a small cylindrical structure similar to the male penis; it also contains
erectile tissue. Inside the labia are openings to the urethra (the canal
that carries urine from the bladder to the exterior of the body) and
vagina. The outer labia and the mons pubis are covered by pubic hair
in the sexually mature female.
The female internal organs are the vagina, uterus, fallopian tubes, and
ovaries. The vagina is a 3- to 6-inch-long tubular structure that extends
from the vaginal opening to the uterus. It has muscular walls lined with
mucous membrane, and it serves as the female organ of copulation
(sexual intercourse) as well as the birth canal. It connects with the
uterus, or womb, which houses the fetus during pregnancy. About 3
inches long and 2 inches wide and shaped like an inverted pear, the
uterus is a muscular, expandable organ with thick walls At the lower
part of the uterus is the cervix, which opens into the vagina. At the
upper part, the fallopian tubes connect the uterus with the ovaries,
two oval-shaped organs that lie to the right and left of the uterus. They
produce, store, and release eggs through the fallopian tubes into the
uterus. The ovaries also produce the hormones estrogen and
progesterone. Also part of the reproductive system is the breasts.
Mammary glands inside the breasts secrete milk after childbirth.

Normal Physiology
The organs of sexual reproduction are the gonads, which are the
ovaries in females and the testes in males. Females produce female
gametes, or eggs; males produce male gametes, or sperm. Sexual
reproduction is the fertilization of a female gamete by a male gamete.
When a female is born, each of her ovaries has hundreds of thousands
of eggs, but they remain dormant until her first menstrual cycle, which
occurs during puberty. At this time, during adolescence, the pituitary
gland secretes hormones that stimulate the ovaries to produce female
sex hormones, including estrogen, which helps the female develop into
a sexually mature woman. Also at this time, females begin releasing
eggs as part of a monthly period called the menstrual cycle.
Approximately once a month, during ovulation, an ovary discharges a
tiny egg that reaches the uterus through one of the fallopian tubes.
Unless fertilized by a sperm while in the fallopian tube, the egg dries
up and is expelled about 2 weeks later from the uterus during
menstruation. Blood and tissues from the inner lining of the uterus
combine to form the menstrual flow, which usually lasts from 3 to 5
days.
If a female and male have sexual intercourse within several days of
ovulation, fertilization can occur. When the male ejaculates, about one
tenth of an ounce of semen is deposited into the vagina. Between 200
and 300 million sperm are in this small amount of semen, and they
"swim" up from the vagina through the cervix and uterus to meet the
egg in the fallopian tube. It takes only one sperm to fertilize the egg.
About a week after the sperm fertilizes the egg, the fertilized egg has
become a multicelled blastocyst, a pinhead-sized hollow ball with fluid
inside, now housed in the uterus. The blastocyst burrows itself into the
lining of the uterus, called the endometrium. Estrogen causes the
endometrium to thicken and become rich with blood, and
progesterone, another hormone released by the ovaries, maintains the
thickness of the endometrium so that the blastocyst can attach to the
uterus and absorb nutrients from it. This process is called implantation.
As cells from the blastocyst take in nourishment, the embryonic
stage of development begins. The inner cells form a flattened circular
shape called the embryonic disk, which will develop into a baby. The
outer cells become thin membranes that form around the baby. The
embryonic cells multiply thousands of times, move to new positions,
and eventually become the embryo. After approximately 8 weeks, the
embryo is about the size of an adult's thumb, but all of its parts - the
brain and nerves, the heart and blood, the stomach and intestines, and
the muscles and skin - have formed. During the fetal stage, which
lasts from 9 weeks after fertilization to birth, development continues as
cells multiply, move, and differentiate. The fetus floats in amniotic fluid
inside the amniotic sac. Its oxygen and nourishment come from the
mother's blood via the placenta, a disk-like structure that adheres to
the inner lining of the uterus and is connected to the umbilical cord.
The umbilical cord attaches the embryo at its navel to the mother's
uterus. The umbilical arteries in the cord carry blood from the fetus to
the placenta, and an umbilical vein returns blood from the placenta to
the fetus. The amniotic fluid and membrane cushion the fetus against
bumps and jolts to the mother's body.
Pregnancy lasts an average of 266 days. When the baby is ready
for birth, its head presses on the cervix, which begins to relax and
widen to get ready for the baby to pass into and through the vagina,
which has enlarged to become the birth canal. The mucus that has
formed a plug in the cervix loosens, and with amniotic fluid, comes out
through the vagina when the mother's "water" breaks. When
contractions begin, the uterine walls contract as they are stimulated by
the pituitary hormone oxytocin. The contractions cause the cervix to
widen and begin to open. After several hours of this widening, the
cervix is dilated (opened) enough for the baby to come through. The
baby is pushed out of the uterus, through the cervix, and along the
birth canal. The baby's head usually comes first; the umbilical cord
comes out with the baby and is cut after the baby is delivered.
The last stage of the birth process involves the delivery of the
placenta, which is now called the afterbirth. It has separated from the
inner lining of the uterus, and through further contractions of the
uterus it is expelled with its membranes and fluids.

MENSTRUATION
A menstrual cycle (also termed a female reproductive cycle) can
be defined as episodic uterine bleeding in response to cyclic hormonal
changes. It is the process that allows for conception and implantation
of a new life. The purpose of a menstrual cycle is to bring an ovum to
maturity and renew a uterine tissue bed that will be responsible for its
growth should it be fertilized. Menarche, the first menstrual period in
girls, may occur as early as age 8- 9 or as late as 17 and still be within
normal limits. Because menarche may occur as early as age 9 years, it
is good to include health teaching information on menstruation to both
girls and their parents as early as 4th grade as part of routine care. It is
a poor introduction to sexuality and womanhood for a girl to begin
menstruation unwarned and unprepared for the important internal
function it represents.
The length of menstrual cycle differs from woman to woman, but
the accepted average length is 28 days (from the beginning of one
menstrual flow to the beginning of the next). However, it is not unusual
for cycles to be as short as 23 days or as long as 35 days. The length
of the average menstrual flow is (termed menses) is 2 to 7 days
although women may have periods as short as 1 day or as long as 9
days.
Because there is such variation in length, frequency, and amount
of menstrual flow and such variation in he onset of menarche, many
women have questions about what is considered normal. Contact with
health care personnel during the yearly health examination or pre-
natal visit is often the first opportunity some women have to ask
question they have had for sometime.

PHASES OF MENSTRUAL CYCLE

1. Proliferative Phase
Immediately after a menstrual flow (occurring the first 4 or 5
days of a cycle), the endometrium, or lining of the uterus, is very thin,
only approximately one cell layer in depth. As the ovary begins to
produce estrogen (in follicular fluid, under the direction of the pituitary
FSH), the endometrium begins to proliferate. This growth is very rapid
and increases the thickness of the endometrium approximately
eightfold. This increase continues for the first half of the menstrual
cycle (from approximately day 5 to 14). This half of menstrual cycle is
termed interchangeably the proliferative, estrogenic, follicular or
post menstrual phase.

2. Secretory Phase
After ovulation, the formation of progesterone in the corpus
luteum (under the direction of the LH) causes the glands of the uterine
endometrium to become corkscrew or twisted in appearance and
dilated with quantities of glycogen and mucin, an elementary sugar
and protein. The capillaries of the endometrium increase in amount
until the lining takes on the appearance of rich, spongy velvet. This
second phase of menstrual cycle is termed the progestational,
luteal, premenstrual, or secretary phase.
3. Ischemic Phase
If fertilization does not occur. The corpus luteum in the ovary
begins to regrets after 8 to 10 days. As it regresses, the production of
progesterone and estrogen decreases. With the withdrawal of
progesterone stimulation, the endometrium of the uterus begins to
degenerate (approximately day 24 or 25 of the cycle). The capillaries
rupture, with minute hemorrhages, and the endometrium sloughs off.

4. Menses: Final Phase of Menstrual Cycle

The following products are discharged from the uterus as the
menstrual flow or menses: blood from ruptured capillaries; mucin from
the glands, fragments of edometrial tissues, microscopic, atrophied
and unfertilized ovum.
Menses is actually the end of an arbitrarily defined menstrual cycle.
Because it is the only external marker of the cycle, however, the first
day of menstrual flow is used to mark the beginning day of a new
menstrual cycle. Contrary to common belief, menstrual flow contains
only approximately 30 to 80 ml of bloods, it may seem more because
of the accompanying mucus and endometrial shreds. The iron loss
during menstrual flow is approximately 11 mg, this is enough that
many woman need to take daily iron supplement to prevent iron
depletion during their menstruating years.
In women who are going through menopauses, menses may
typically be a few days of spotting before a heavy flow or heavy flow
followed by a few days of spotting, because progesterone withdrawal is
more sluggish or tends to “staircase” rather than withdraw.

TEACHING ABOUT MENSTRUAL HEALTH

Exercise
It’s good to continue moderate exercise during menses because
it increases abdominal tone. Sustained excessive exercise, such as
professional athletes maintain, can cause amenorrhea.

Sexual Relations
Not contraindicated during menses (the male should wear a
condom to prevent exposure to body fluid). Heightened or decrease
sexual arousal may be noticed during menses. Orgasm may increase
menstrual flow.

Activities of Daily Living

Nothing is contraindicated (many people believed incorrectly that
things like washing hair are harmful).

Pain Relief
 Any mild analgesic is helpful. Prostaglandin inhibitors such as
ibuprofen (Motrin) are specific for menstrual pain. Applying local heat
may also be helpful

Rest
More rest may be helpful if dysmenorrhea interferes with sleep at
night.

Nutrition.
Many women may need iron supplementation to replace iron lost
in menses. Eating pickles or cold food does not cause dysmenorrhea.

CHILD BEARING CYCLE

Conception is the penetration of one ovum by one sperm
resulting in a fertilized ovum called zygote. Sex of child is determined
at the moment of conception by male gamete. If X-bearing male
gamete unites with ovum, result is female child. If Y-bearing male
gamete fertilize the ovum, result is male child.
Nidation is the process of burrowing of the developing zygote
into the endometrial lining of uterus. Usually take place 7-10 days after
fertilization.
Chorionic villi appear on surface of trophoblast and secrete human
chorionic gonadotropin, which inhibit s ovulation during pregnancy by
stimulating continuous production of estrogen and progesterone.

SPECIAL STRUCTURES OF PREGNANCY

Fetal membranes
Arise from the zygote
Hold the developing fetus as well as the amniotic fluid
Amniotic fluid
Clear yellowish fluid surrounding the developing fetus
Average amount 1000 ml
Allows free movement
Maintains temperature
Provides oral fluid
Umbilical cord
Connecting link between fetus and placenta
Contains 2 arteries and 1 vein supported by mucoid
material(Wharton’s jelly) to prevent kinking and knotting
There are no pain receptors in the umbilical cord
Placenta
Transient organ allowing passage of nutrients and water
materials between mother and fetus
also acts as an endocrine organ and as a protective barrier
against some drugs and infectious agents
STAGES OF FETAL DEVELOPMENT

In just 38 weeks, a fertilized egg matures from a single cell

carrying all the necessary genetic material to a fully developed fetus
ready to born. Fetal growth and development is typically divided into
three periods. Pre- embryonic (First 2 weeks beginning with
fertilization); embryonic (from 3 weeks through 8), and fetal (from
week 8 through birth).

Ovum From ovulation to fertilization

Zygote From fertilization to implantation
Embryo From implantation to 5 - 8 weeks
Fetus From 5 - 8 weeks until term
Concept Developing embryo or fetus and
us placental structures throughout
pregnancy

MILESTONES OF FETAL GROWTH AND DEVELOPMENT

The life of the fetus is generally measured from the time of
ovulation or fertilization (ovulation age), but the length of pregnancy is
generally measured from the first day of the last menstrual period
(gestational age). Because ovulation and fertilization take place about
2 weeks after the last menstrual period, the ovulation age of the fetus
is always 2 weeks less than the length of the pregnancy or the
gestational age. Both ovulation and gestational age are also
sometimes measured in lunar months (4 - week periods) or in
trimesters (3- month-period) rather than in weeks. In lunar months, a
pregnancy is 10 months (40 weeks or 280 days) long; a fetus grows in
uteri 9.5 lunar months or three full trimesters (38 weeks or 266 days)

End of 4 Gestation Weeks

At the end of the 4th week gestation, the human embryo is
rapidly growing formation of cells but does not resemble a human
being yet.
Length: 0.75 to 1 cm.
Weight: 400 mg.
The spinal cord is formed and fused at the midpoint.
Lateral wings that will form the body are folded forward to fuse
at the midline.
Head folds forwards, becoming prominent, comprising about one
third of the entire structure.
The back is bend so the head almost touches the tip of the tail.
The rudimentary heart appears as a prominent budge on the anterior
surface.
Arms and legs are bud like structures.
Rudimentary eyes, ears and nose are discernible.

End of 8 Gestation Weeks

Length: 2.5 cm (1cm).
Weight: 20 g.
Organogenesis is complete.
The heart, with a septum and values, is beating rhythmically.
Facial features are definitely discernible.
Extremities have developed.
External genitalia are present, but sex is not distinguished by
simple observation.
Primitive tail regressing.
Abdomen appears large as the fetal intestine is growing rapidly.
Sonogram shows gestational sac, diagnostic of pregnancy.

End of 12 Gestation Weeks (First Trimester)

Length: 7 to 8 cm.
Weight: 45 g.
Nail beds are forming on fingers toes.
Spontaneous movements are possible, although usually too faint
to be felt by the mother.
Some reflexes, such as Babinski reflex are present.
Bone ossification centers are forming.
Tooth buds are present.
Sex is distinguishable by outward appearance.
Kidney secretion has begun, although urine may not be evident
in amniotic fluid.
Heartbeat is available by a Doppler

End of 16 Gestation Weeks

Length: 10 to 17 cm.
Weight: 55 to 120 g.
Fetal heart sounds are audible with an ordinary stethoscope.
Lanugo (fine, downy hair on the back and arms of newborns,
apparently serving as a source of insulation for body heart) is well
formed.
Liver and pancreas are functioning.
Fetus actively swallows amniotic fluid, demonstrating an intact
but uncoordinated swallowing reflex, urine is present in amniotic fluid.
Sex can be determined by ultrasound.

End of 20 Gestation weeks

Length: 25 cm.
Weight: 223 g.
The mother can sense spontaneous fetal movements.
 Antibody production is possible.
Hair forms, extending to include eyebrows and hair on the head.
Meconium is present in the upper intestine.
Brown fat, a special fat that will aid in temperature regulation at
birth, begins to be formed behind the kidneys, sternum and posterior
neck.
Fetal heart beat is strong - enough to be audible
Vernix caseosa, a cream cheese -like substance produced by the
sebaceous gland that serves as a protective skin covering intrauterine
life, begins to form.
Definite sleeping and activity patterns are distinguishable (the
fetus has developed biorhythms that will guide sleep /wake patterns
throughout life).

End of 24 Gestation Weeks (Second Trimester)

Length: 28- 36 cm.
Weight: 550 g.
Passive antibody transfer from mother to fetus probably begins
as early as 20thweek of gestation, certainly by the 24th week of
gestation. Infants born before antibody transfer has taken place have
natural immunity and need more than the usual protection against
infectious disease in the newborn period until the infant’s own store pf
immunoglobulins can build up.
Meconium is present as far as the rectum.
Active production of lung surfactant begins.
Eyebrows and eyelashes are well defined.
Eyelids, previously fused since the 12th week, are now open.
Pupils are capable of reacting to light.
When fetuses reach 24 weeks or 601 g, they have achieved a
practical low- end age of viability if they are cared for after birth in a
modern intensive care facility.
Hearing can be demonstrated by response to sudden sound.

End of 28 Gestation Weeks

Length: 35 to 38 cm.
Weight: 1,200 g.
Lung alveoli begin to mature, and surfactant can be
demonstrated in amniotic fluid.
Testes begin to descend into the scrotal sac from the lower
abdominal cavity.
The blood vessels of the retina are extremely susceptible to
damage from high oxygen concentrations (an important consideration
when caring for preterm infants who need oxygen).
The eyes open.

End of 32 Gestations Weeks

Length: 38-43 cm.
Weight: 1,600 g.
Subcutaneous fat begins to be deposited (the former is stringy “
Little old man” appearance is lost).
Fetus is aware of sounds outsides the mothers body.
Active Moro reflex is present.
Birth position (vertex or breech) may be assumed.
Iron stores that provide iron for the time during which the
neonate will ingest only milk after the birth are beginning to be
developed.
Finger nails grow to reach the end of the fingertips.

End of 36 Gestation Weeks

Length: 42 to 49 cm.
Weight: 1,900 to 2,700 g (5 - 6 lbs).
Body stores of glycogen, iron, carbohydrate and calcium are
augmented.
Additional amounts of subcutaneous fat are deposited.
Sole of the foot has only one or two crisscross crisscross creases
compared with the full crisscross pattern that will be evident at term.
Amount of lanugo begins to diminish.
Most b babies turn into vertex or head - down presentation
during this month.

End of 40 gestation Weeks (Third Trimester)

Length: 48 to 52 cm (crown to rump, 35 to 37 cm).
Weight: 3,000g (7 - 7.5 lbs).
Fetus kicks actively, hard enough to cause the mother
considerable discomfort.
Fetal hemoglobin begins its conversion to adult hemoglobin. The
conversion is so rapid that, at birth about 20% hemoglobin will be adult
in character.
Vernix caseosa is fully formed.
Fingernails extend over the fingertips.
Creases on the soles of the feet cover at least two thirds of the
surface.

PRENATAL CARE
Prenatal care, essential for ensuring the overall health of
newborns and their mothers, is a major strategy for helping to reduce
the number of low - birth - weight babies born yearly.
When a woman inspects the she is pregnant, a woman should
consult a physician to gain optimum care even during the early months
of pregnancy. Since women are not certain that they will become
pregnant and after gestation have elapsed, the earliest prenatal care is
always the responsibility of the woman herself. Her general health
habits and physical condition before a physician is ever consulted are
of considerable importance. When the diagnosis of pregnancy is
established, provision for regular medical supervision and suitable
plans for the baby’s arrival must be made.
The term prenatal care refers to the planned examination,
observation, and guidance of an expectant mother. It is well to
remember that the extension of prenatal care is probably the primary
factor in the improvement of maternal morbidity and mortality
statistics. Society needs to appreciate its importance. The goals are as
follows:
A pregnant with minimum mental and physical discomfort and a
maximum of gratification.
A delivery under the best circumstances possible
A normal, well baby
The establishment of good health habits benefiting all the family
A smooth, guided postpartum adjustment
At the first visit, an extensive health history, a complex physical
examination, including a pelvic examination, and blood and urine
specimen for laboratory work are obtained. The first prenatal
visit is a time to establish baseline data relevant to planning
health promotion strategies now and with subsequent visit.
A first prenatal visit not only cot only confirms a pregnancy but
provides at time to assess client needs and to educate about
pregnancy. Assessments consist of a health history, physical
examination, and laboratory tests. The physical examination
could include measurement of fundal weight and assessment of
fetal heart sounds of the pregnancy is beyond 12 weeks, a pelvic
examination (including pap smear test), and perhaps estimation
of pelvic size.
A first prenatal visit sets the tone for visits to follow. Maintaining
a supportive manner is helpful in establishing rapport and
allowing the woman to feel comfortable to return for future care.
Sufficient time should be reserved for a first prenatal visit so it
can be thorough, allowing enough time to set realistic goals and
outcome criteria with both the woman and her partner, if
desired. The purposes of prenatal care are to:
Establish a baseline of present health
Determine gestation age of the fetus
Monitor fetal development
Identify the woman at risk for complication
Minimize the risk of possible complications by anticipating and
preventing problems before they occur.
Provide time for education about pregnancy and possible
dangers.
The primary goal of maternal and child health nursing care can
be stated simply as the promotion and maintenance of optimal
family health to ensure cycles of optimal childbearing and
childrearing. Remember that a family, not a woman alone, is
having a baby and include family members in procedure and
health reaching as derived. Nurses can be instrumental in
helping achieve this goal by educating women and their families
about the importance of prenatal care and by making sites of
prenatal case receptive to women and families.
Then aimed with information, the pregnant woman may make an
appointment for her next visit. Before her return she can jot
down questions that came up about which she needs to be
reassured.
 GENERAL HEALTH TEACHING

1. Pre-natal care Visits

Blood pressure will be monitored each month. While low blood
pressure is rarely a reason for concern, an abnormal increase may be
sign of problems that can affect you and your baby.
Weight is normal for your body to gain weight or experience a
little ankle swelling due to water retention during pregnancy. Your
doctor will advice you about how much weight gain is good for you.
Urinalysis, bodily functions will be determined through this test.
It will also detect diabetes, kidney and bladder infections, and early
signs of many problems in pregnancy.
Blood test, samples will be taken to determine blood type and Rh
factor to check for anemia and other blood diseases, and to screen for
potential birth defects.
Ultrasound or sonograms, will be done to check for twins, baby’s
position, and due date accuracy. Breast exam, may be done on your
first pre-natal visit. Advice will be given on breastfeeding as well as
nipple and breast preparation.
Abdominal exam, the doctor will measure the size of your uterus,
which shows the growth of you baby, as well as check the baby’s
position.
Pelvic exam, on your first prenatal visit, your doctor will perform
a vaginal exam to evaluate the size of your birth canal. Unless
absolutely necessary, this exam will not be repeated until just before
the baby is due, when changes such as dilation and effacement of the
cervix will be measured.
1st visit: 32 weeks: visit must be every 4 weeks
2nd visit: 32-36 weeks: visit must be every 2 weeks
3rd visit: 36-40 weeks: visit must be once every week

2. Work
You can go to work, but take care not to strain yourself or subject
yourself to stress.
Avoid prolonged standing or sitting.
Provide deep breathing, foot circling and relaxation.

3. Sleep
Get plenty of bed rest. In the last months of your term, you may
have some difficulty sleeping. Try to nap when you have the chance.

4. Exercise
Moderate exercise, such as relaxed swimming, is allowed. Take
care not to overheat.
 Kegel’s exercise is recommended to strengthen the muscles
around the reproductive organs and improve muscle tone.

5. Travel
Routine travel, such as daily commute, is allowable. Airplane
flights are possible usually until the last trimester of your pregnancy.
Proper use of seatbelt and headrest and lap belts must be done.
Avoid long trips especially on the 1st and 3rd trimester but can
travel in 2nd trimester.
Periods of activity and rest must be done fro 15 minutes. Every 2
hours for emptying of bladder.
In high altitudes regions, lowered O2 mav cause hypoxia or fetal
brain damage, it may be pressurized.

6. Nutrition
Quality of your diet is essential. Your doctor may give you advice
on a particular set of foods you can eat, given your condition. He may
also prescribe vitamin and mineral supplements. Avoid salty, too-
sweet, and fatty foods.
Drink 8-12 glasses of liquid a day, Juices may be included to
lower the pH of urinary tract.
Increase caloric intake to prevent maternal underweight.
Eat variety of foods and maintain small, frequent feeding.

7. Hygiene
Keep yourself clean always. Bathe regularly to keep your body
cool. Do not use feminine washes or douches unless advised by your
doctor.
Do not use bathtub it can alter balance
Do not bath if there is vaginal bleeding and rupture of
membranes.
Warm showers can be therapeutic, relax tensed tired muscles,
helps counter insomnia, makes us feel fresh.
Can swim but no diving to prevent traumatic injury.

8. Sexual activity
Contrary to what some people say, sexual intercourse is not
harmful to the baby. However, take care not to put too much weight on
the abdomen. Try other position instead. If you have been exposed to
any sexually transmitted disease, report it to your doctor immediately.
Provide a safe, open, non-judgmental atmosphere,
Provide comfortable environment, offer alternatives and show
illustrations.
Avoid sexual intercourse during the 1st and 3rd trimester.

9. Smoking
 Stop! Smoking depletes much- needed oxygen and may cause
birth defects.

10. Drinking
Alcohol can harm your baby and should not be ingested during
pregnancy.
Avoid alcoholic beverages to prevent growth retardation and
musculoskeletal deformities.

11. Caffeine
Limit your intake or cut it altogether, it hinders the body
absorption of certain nutrients like iron.
12. Medications/Drugs
Self-treatment must be discouraged.
All drugs, including aspirin should be limited and careful record of
therapeutic agents used should be used.
Consult your physician who undergone medications to reduce the
cause of possible teratogenecity or fetal drug toxicity.

13. Immunizations
Tetanus toxoid must be given to pregnant woman.
Do not give medications such as measles, mumps and polio
vaccine due to potential teratogenecity.

14. Dental care

Adequate calcium and phosphorus in the teeth must be included
on the diet.
Dental tooth extraction is prohibited during pregnancy.

EXERCISES DURING PREGNANCY

KEGEL EXERCISES
Are exercises designed to strengthen the pubococcygeal
muscles? They should be done about 3 times a day. Exercises are as
follows:
Squeeze the muscles surrounding the vagina as if stopping the
flow of urine. Hold for 3 seconds. Relax repeat 10 times.
Contract and relax the muscles surrounding the vagina as rapidly
as possible 10 to 25 times.
Imagine that you are sitting in a bathtub of water and squeeze
muscles as if sucking water into the vagina. Hold for 3 seconds.
Relax Repeat 10 times.
Push out with the vagina as if expelling something from it. Hold
for 3 seconds. Relax Repeat 10 times.
It may take as long as 6 weeks of exercise before, pubococcygeal
muscles are strengthened. In addition to strengthening urinary
 control and preventing stress incontinence, exercises can lead to
increased sexual enjoyment because of the tightened vaginal
muscles.

PERINEAL AND ABDOMINAL EXERCISES

1. Tailor sitting - strengthens the things and stretches perineal
muscles to make them suppler. A woman could use this position for
TV watching, telephone conversations, or playing with an older child. It
is good to plan on sitting in this position for at least 15 minutes. Should
also practice this position for 15 minutes a day.
2. Squatting - stretches the perineal muscles. Should also practice
this position for 15 minutes a day. For the pelvic muscles to stretch, the
woman most keeps her feet flat on the floor.
3. Pelvic Floor Contractions - done during the course of daily
activities as well. Perineal muscle - strengthening exercise will be
helpful in the postpartum period as well as to promote perinea healing,
to increase sexual responsiveness, and to help to prevent stress
incontinence.
4. Abdominal muscles contractions - help strengthen abdominal
muscles during pregnancy. Strong abdominal muscles can also
contribute to effective second - stage pushing during labor and help to
prevent constipation. Abdominal contractions can be done in standing
or lying position along the pelvic floor contractions. The woman merely
tightens here abdominal muscles, and then relaxes; she can repeat the
exercise as often as she wished during the day.
Another way to do the same thing is to practice blowing out a candle”.
The women take a fairly deep inspiration, and then exhale normally.
Holding her finger about 6 inches infront of herself, as if were a candle,
she than exhales forcibly, pushing out residual air from her lungs.
5. Pelvic Rocking - helps relieve backache during pregnancy and
early labor by making the lumbar spine more flexible. It can be done in
a variety of positions. hand on knees, lying down, sitting or standing.
The woman arches her back, trying lengthening or stretching her
spine. She holds the position for I minutes, and then hallows her back.
A woman can do this at the end of the day about five times to relieve
back pain and make herself more comfortable for the night.

LEOPOLD’S MANEUVER
First Maneuver (Upper uterine segment or the uterine fundus)
a. Nurse faces woman's head
b. Palpate uterine fundus
c. Determine the height the uterine fundus
d. Determine what fetal part is in the uterine fundus
 e. Palpation of the Uterine Fundus Will usually indicates the fetal
part situated in the fundus; usually a fetal head; infrequently a
fetal breech. Place hands on either side of the fundal area so that
the fingers of both hands almost tough each other (face the
woman's head). A somewhat hard and roundish shape, which
when moved back and forth between the finger pads, also moves
the entire fetus usually indicates a fetal breech. Press gently and
firmly with finger pads. A very hard round well defined shape
which can be moved back and forth (balloted) usually indicates a
fetal head.

Second Maneuver (Determines small parts and back of fetus along

the sides of maternal abdomen)
a. Examiner faces woman's head
b. Palpate with one hand on each side of abdomen
c. Palpate fetus between two hands
d. Assess on which side is the fetal back or spine and which side
has small parts or extremities

Third Maneuver (Lower uterine segment or uterine pole)

a. Face the woman's head and spread your hands widely apart
b. Grasp the uterine contents just above the symphysis pubis
(firmly but gently)
c. Hold presenting part between index finger and thumb
d. Assess for cephalic versus Breech Presentation
e. Move the fetal presenting part gently back and forth in your hand
Fetal head will shift more easily back and forth Fetal breech will
move the whole body

Fourth Maneuver (pelvic palpation of the uterus - assess the

presenting part)
a. Provides information about the presenting part: breech or head,
attitude (flexion or extension), and station (level of descent of
the presenting part).
b. Examiner faces woman's feet
c. Place hands on either side of the lower abdomen with finger pads
at the lower uterine pole (bikini line) and thumbs directed toward
the umbilicus.
d. Carefully move fingers of each hand towards each other in a
downward and inward manner using gentle pressure. The nurse's
thumbs should point towards the woman's umbilicus. If there is a
head palpated in the pelvis, the fetal presentation is referred to
as a cephalic or vertex presentation.
e. Assess if a prominence on one side of the abdomen can be
palpated higher than a prominence on the other side. The first
prominence felt indicates the occiput (forehead) of the infant and is
on the same side as the fetal small parts. Therefore, the occiput is
on the side opposite the fetal back. The prominence felt further
down the pelvis is the fetal occiput back of the head) and is on the
same side as the fetal back. This maneuver provides information
related to fetal descent into the pelvis. How much of the fetal head
can be palpated above the pelvic brim? Is the head fixed into
pelvis? Can the head be easily moved from side to side? When
moved from side to side does the presenting part move by itself
back and forth (balloted)? Does the whole fetal body move when
palpating the presenting part side to side?
Findings from Leopold's Maneuver

Movement of the fetal part in the fundus moves the entire fetus.
This part is firm and roundish (the 1st Leopold's maneuver).
There is a long firm smooth area which covers most of one side
of the maternal far right abdomen. The flat smooth surface is felt
deep on the right lateral side (the 2nd Leopold's maneuver).
"Walking the fingers" across the uterus finds many large and
small dips and contours on the maternal left lateral margin.
The lower uterine pole contains a round small, hard object. This
object can be moved slightly from side to side (the 3rd Leopold's
maneuver).
In the pelvis, the prominence which is higher is found on the
maternal left side (the 4th Leopold's maneuver)

Estimate Fetal Growth

Nagele’s Rule
To calculate the date of birth by this rule, count backward 3 calendar
months from the first day of the last menstrual period and add seven
days.
Eq: 06 - 22 - 03
-03 +7 + 01
03 - 29- 04

Mc Donald’s Rule:
Measurement of the height of the fundus using a tape measure. The
distance from the symphisis pubis to the level xyphoid process. Used
to calculate the AOG.

Eq: Fundic height (cm) x 2/7 = AOG in lunar months

Fundic height (cm) x 8/7 = AOG in weeks.
Bartolomew’s Rule:
Height of fundus is used to determine the AOG. Fundic height is used
to determined by palpation and by relating it to the different landmark
in the abdomen: umbilicus: symphisis pubis and xiphoid process.

12 wks - level of syphisis pubis

16 wks - halfway between umbilicus and symphisis pubis
20 wks - level of umbilicus
24 wks - 2 finger breaths above umbilicus
30 wks - midway between umbilicus and xiphoid process
34 wks - just below xiphoid process
36 wks - at the level of xiphoid process
40 wks - at 34 wks level due to lightening
Johnson’s Rule:
Used to calculate the fetal weight in grams.
Fundic height in (cm) - N x K = weight of the fetus
K= 155 (constant) N- 12 (engaged) 11 (not engaged)
Eq: 30 - 12 x 155 = 18 x 155 = 2790 gms.

Haase’s Rule: Is used to determine length of fetus

A. During the first half of pregnancy, square the number of months
B. During the second half of pregnancy, multiply the number of months
by five.

Beliefs and Practices

Belief and Practices Rationale Clinical Significance

Prenatal
Do not eat twin So that the mother No scientific basis
banana will not give birth to a
twin baby
Do not eat dark foods The baby’s skin will No scientific basis
have dark complexion
Avoid hiding of foods So that the baby will No scientific basis
came out naturally
Always have a garlic Protection from No scientific basis
on your pocket “aswang”
Do not see a dying The baby will come No scientific basis but
person out grasping from may affect the mother
breath and may die emotionally.
Intrapartal
Nobody should stay For easy delivery Doorsteps or stairs
on the door or near has no connection
the stair. with the progress of
labor.
Member of the family ‘Atang’ are the ones Has nothing to do with
should give ‘atang’ to they offer to the the progress of labor
the anitos to help the spirits to help the
woman in labor people who are kind
to them
Let the mother eat To make the mother’s No scientific basis
soft boiled egg and birth canal slippery because the birth
drink lard thus facilitate easy canal will surely give
delivery of the baby way to the baby to be
delivered
Kick every corner of To facilitate easy No scientific basis
the house during labor delivery
Post Partal
Mother should not To prevent post partal Taking a bath is very
take a bath for 9 days complications important to promote
after delivery good hygiene
Mother should wear So that mother will Mother should have
thick clothes and not get sick exercise and can work
confine to bed after as long as she can for
delivery early wound healing
and peristalsis
Keep the baby’s first To make the baby No Scientific basis
cut hair and finger intelligent
nails
LABOR AND DELIVERY
Labor is the series of events by which uterine contractions and
abdominal pressure expel the fetus and placenta from the woman’s
body. Regular contractions cause progressive dilatation of the cervix
and sufficient muscular force to allow the baby to be pushed to the
outside. It is a time of change, both an ending and beginning, for the
woman, the fetus, and the family.
Labor and birth require the woman to use all the psychological
and physical coping methods she has available. Labor and birth are
enormous emotional and physiologic accomplishments not only for a
woman but her support person as well. For this reason, support
persons should be treated with respect and be included in all phases of
the process, wherever possible.
Labor normally begins when a fetus is sufficiently mature to cope
with extra uterine life, yet not too large to cause mechanical difficulties
why labor begins, it is believed that labor is influenced by a
combination of factors form the mother and fetus. These factors
include:
Uterine muscle stretching
Pressure on cervix
Oxytocin stimulation
Change in ratio of estrogen and progesterone
Placental age
Rising fetal Cortisol level
Fetal membrane production of prostaglandin
Seasonal and time influences
Assessment of a woman in labor must be done quickly yet
thoroughly and gently. Before labor, woman after experiences
subtle signs that can signal the onset of labor. All pregnant
women should be taught how to recognize the preliminary signs
and true signs of labor.

The following are the preliminary signs of labor:

Lightening
In primiparas, it is the descent of the fetal presenting part into
the pelvis, occurs approximately 10 to 14 days before the labor begins.
This changes the woman’s abdominal contour as the uterus becomes
lower and more anterior. Lightening gives the woman relief from
diaphragmatic pressure and shortness of breath however abdominal
pressure increases.

Increase in Level of Activity

This increase in activity is due to an increase in epinephrine
release that is initiated by a decrease in progesterone produced by the
placenta.

Braxton Hicks Contraction

This is sometimes called the false labor contractions, which
begins and remain irregular. Contraction is felt first abdominally and
remain confined to the abdomen and grown which do not increase in
duration, frequency, or intensity.

Ripening of the Cervix

Ripening of the cervix is an internal sign seen only on pelvic
examination. At term, the cervix becomes till softer, until can be
described as “butler - soft,” (Goodells’ sign) and tips forward. This
ripening, and internal announcement that labor is chose at hand.
Signs of true labor involve uterine and cervical changes. The
more women know about true labor signs, the better. This is helpful
both in preventing preterm birth and being able to feel secure during
labor.

TRUE SIGNS OF LABOR

Uterine Contraction
The surest sign that labor has begun is the initiation of effective,
productive, involuntary uterine contractions. This is felt in lower back
and sweep amount to the abdomen in a wave.

Show
As the cervix softens and ripens, the mucus plug that filled the
cervix canal during pregnancy is expelled. The blood, mixed with
mucus, takes on a pink tinge and is referred to as “show” or “bloody
show.”

Rupture of the Membane

Labor may begin with rupture of the membranes, experienced as
either as sudden gush or scanty, slow seeping of clear fluid from the
vagina. The two main risks associated with ruptured membranes
include intrauterine infection and possible prolapsed of the umbilical
cord, which can cut off the oxygen supply to the fetus.
A successful labor depends on three integrated concepts:
The woman’s pelvis (passage) is of adequate size and contour.
The passage refers to the route the fetus must traverse from the
uterus through the cervix and vagina to the external perineum. In most
instances, if a disproportion between the fetus and pelvis occurs, the
pelvis is the structure at fault.
The fetus (passenger) is a appropriate size and in an
advantageous position and presentation. The body parts of a fetus that
has the widest diameter is the head, it is important to understand fetal
presentation and position. Complete flexion is the normal fetal position,
which is advantageous for birth because it helps \ the fetus presents
the smallest antercoposterior diameter of the skull to the pelvis.
Cephalic presentation means that the head is the part that first
contacts the cervix. It is the most common type of presentation.
The uterine factors (powers of labor) are adequate. The powers
of labor, supplied by the fundus of the uterus, are implemented by
then expulsion of the fetus from the uterus. After full dilation of the
cervix, the primary power is supplemented by the use of the abdominal
muscles. It is important for women to understand they should not bear
down with their abdominal muscles until the cervix is fully dilated.
Doing so will impede the primary force or could cause fetal or cervical
damage.
The fourth “P” (Psyche) refers tot eh psychological scale of
feelings that women bring into labor with them. For many women, this
is a feeling of apprehension or fright. For almost everyone, it includes a
sense of excitements or awe. Women who manage best in labor
typically are those who have a strong sense of self - esteem and a
meaningful support person.

In nursing literature, labor is traditionally divided into three

stages: a first stage of dilatation, beginning with true labor contraction
an ending when the cervix is fully dilated; a second stage, from the
time of full dilatation until the infant is born; and a third or placental
stag, from the time the infant is born until after the delivery of the
placenta. The fist 1 to 4 hours after birth of the placenta are
sometimes termed the “fourth stage” to emphasize the importance of
the close observation needed at this time.
The table below (Table 1.1) shows the average length of labor
both in primipara and multipara. This varies depending upon the
individual.

(1.1) AVERAGE LENGTH OF LABOR

STAGE PRIMIPARA MULTIPARA
Stage 1 Stage 2 Stage 12 - 13 hours 1 hour 8 hours 20 minutes 4
3 Stage 4 3 - 4 minutes 1 - 2 - 5 minutes 1 - 2
hours hours

Length of labor depends on the following:

Effectiveness/consistency of contraction
Amount of resistance: baby must overcome to adapt to the pelvis
Stretching ability of soft tissue
Preparation and relaxation client
 STAGES OF LABOR
FIRST STAGE OF LABOR
The first stage of labor is divided into three phases: the latent,
the actives, and the transition phases.

Latent Phase
The latent or preparatory phase begins of the onset of regularly
perceive uterine contractions and ends when rapid cervical dilatation
begins. Contractions during this phase are mild and short, lasting 20 -
40 seconds. Cervical effacement occurs, and the cervix dilates from 0
to 3 cm. This phase may be prolonged if a cephalopelvic disproportion
(CPD) exists.

Active Phase
During the active phase of labor, cervical dilatation occurs more
rapidly, going form 4 cm to 7 cm. Contractions are stronger, lasting 40
to 60 seconds and occurring approximately every 3 to 5 minutes. Show
and perhaps spontaneous rupture of the membrane may occur.

Transition Phase
During this phase, maximum dilatation of 8 to 10 cm occurs, and
contractions reach their pear of intensity, occurring every 2 to 3
minutes with duration of 60 to 90 seconds. Dilatation continues at a
rapid rate. If the membranes have not previously ruptured or been
ruptured by amniotomy, they will rupture as a rule at full dilatation (10
cm).

SECOND STAGE OF LABOR

The second stage of labor is the period from full dilatation and
cervical effacement to birth of the infant. Contractions change form the
characteristics crescendo - decrescendo pattern to an overwhelming,
uncontrollable urge to push or bear down with contractions as if she
were moving her bowels. As the fetal head touches the internal side of
the perineum, the perineum begins to bulge and appear tense. The
anus of the woman may appear averted. As the fetal head is pushed
still tighter against the perineum, the vaginal introitus opens and the
fetal scalp becomes visible at the opening to the vagina. At first, this is
a slit like opening, which then becomes oval, then circular. The circle
enlarges from the size of a dinel to that of a quarter to that of a half
dollor. This is called crowning. As the woman pushes, using her
abdominal muscles and the involuntary uterine contractions, the fetus
is pushed out of the birth canal.

THIRD STAGE OF LABOR

 The third stage of labor, or the placental stage, begins with the
birth of the infant and ends with the delivery of the placenta.

CARDINAL MOVEMENTS OF LABOR

Passage of the fetus through the birth canal involves a number of
different position changes to keep the smallest diameter of the fetal
head (in cephalic presentation) always presenting to the smallest
diameter of the birth canal. These positions are termed the
mechanisms or cardinal movements of labor. The following are the
mechanisms of labor:

Decent
This is the downward movement of the biparietal diameter of the
fetal head to within the pelvic inlet. Full descent occurs when the fetal
head extrudes beyond the dilated cervix and touches the posterior
vaginal floor. The pressure of the fetus on the social nerves causes the
mother to experience a pushing sensation. Descent occurs because of
the pressure on the fetus by the uterine fundus. Full descent may be
aided by abdominal muscle contraction.

Flexion
As descent occurs, pressure from the pelvic floor causes the fetal
head to bend forward onto the chest. The smallest anteroposterior
diameter the suboccipitobugnatic diameter) is the one presented to
the birth canal in this flexed position.

Internal Rotation
The head flexes as it touches the pelvic floor, and the occupant
intake until it is superior, or just below the symphisis pubis, bringing
the head into the best diameter for the outlet coming next, into the
optimum position to enter the inlet or puts the widest diameter of the
shoulders in line with the wide transverse diameter of the inlet.

Extension
As the occiput is born, the back of the neck stops beneath the
pubic arch and acts as a pivot for the rest of the head. The head thus
extends, and the foremost parts of the head, the face and chin, are
born.

External Rotation
In external rotation, almost immediately after the head of the
infant is born, the head rotates back to the diagonal shoulders are thus
brought into an anteroposterior position, which is best for entering the
outlet. The anterior shoulder is delivered first, assisted perhaps by
downward flexion of the infant’s head.
Expulsion
Once the shoulders are delivered, the rest of the baby is
delivered easily and smoothly because of its smaller size. This is
expulsion and is the end of the pelvic division of labor.

THE DELIVER OF THE PLACENTA

After birth of the infant, the uterus can be palpated as a firm,
round mass just inferior to the level of the umbilicus. After a few
minutes shape, It retains this new shape until the placenta, ahs
separated, approximately 5 minutes after birth of the infants. The two
separate phase involved in the delivery of the placenta are:
Placental Separation
Placental separation occurs automatically as the uterus resumes
contractions. As the uterus contracts down on an almost empty
interior, there is such ad disproportion between the placenta and the
contracting wall of the uterus that folding and separation of the
placenta occurs. Active bleeding on the maternal surface of the
placenta begins with separation; the bleeding helps to separate the
placenta still further by pushing it away form its attachment site. As
separation is completed the placenta sinks to the lower uterine
segment or the upper vagina.
The following signs indicate that the placenta has loosened and
is ready to deliver:
a. Lengthening of the umbilical cord
b. Sudden gush of vaginal blood, or
c. Change in the shape of the uterine
If the placenta separates first at its center and last at its edges, it
tends to fold on itself like an umbrella and will present at the vaginal
opening with the fetal surface evident. Appearing shiny and glistering
from the fetal membranes, it is called a Schultze’s Placenta. If,
however, the placenta separates first at its edges, it slides along the
uterine surface and presents at the vagina with the maternal surface
evident. It looks raw, red, and irregular with the ridges or cotyledons
that separate blood collection spaces showing, and is a Duncan
Placenta.
Bleeding occurs as part of the normal consequence of placental
separation, before the uterine contracts sufficiently to seal maternal
sinuses. The normal blood loss is 300 to 500 ml.

Placental Expulsion
The placenta is delivered either by the natural braving - down effort of
the mother or by gentle pressure on the contracted uterine fundus by
the physician or nurse midwife. Pressure must never be applied to a
uterus in a noncontracted station the uterus may event and
hemorrhage. This is a grave complication of birth, because the
maternal blood sinuses are open and gross hemorrhage occurs.
If the placenta does not deliver spontaneously, it can be removed
morally. With the delivery of the placenta, the third stage of labor is
over.
The placenta is carefully inspected to be sewing that it is whole. If
pieces remain within the uterus, it cannot clamp down completely, and
serious hemorrhage may result.

CARE OF NEWBORN
What is newborn care?
Caring for a brand new baby can be overwhelming and tiring. It
includes adjusting to round-the-clock diaper changes and feedings.
Ideally, new mothers should receive significant support from partners,
other family members, and friends. The new mother's partner can and
should participate in most aspects of newborn care. Even during
breastfeeding, partners can help to ensure that the mother is
comfortable and receiving adequate nourishment.
Some basics of newborn care include:
1. Infants need breastmilk or formula only.
Breastfeeding offers many advantages to both infants and
their mothers, and breastmilk is the best source of food for your baby's
health and development. However, a major brand of formula is
sufficient if the mother chooses not to breastfeed. Newborn babies do
not need any other food.
2. Infants need to be warm and comfortable.
Babies should be dressed appropriately for the weather. If
parents are wearing shorts, then baby can wear shorts too. Babies
should not be overdressed, since this can cause irritability and
elevated body temperature.
3. Diapers should be changed as soon as they are wet or
soiled.
Failure to change diapers when wet or soiled can lead to
discomfort and skin irritation. Cloth diapers are better than plastic
ones, and diapers should be free of chemicals and fragrances. Should a
rash occur, exposing the affected skin to air is excellent treatment?
4. Infants need to be clean.
Babies twice weekly shampoo with a product like Sebulex.
5. The umbilical cord should be cleaned every 4-6 hours with
rubbing alcohol and cotton.
6. Infants need sleep.
Babies sleep many hours throughout the day, and sleep
patterns differ from one baby to the next. During the first few weeks,
babies should sleep in the parents' room. Babies should be placed on
their backs. Sleeping on the abdomen has been related to SIDS
(sudden infant death syndrome).
7. Infants need stimulation.
 Appropriate stimulation includes talking to, singing to, and
holding the baby.
8. Infants cry.
Crying is how babies "talk" to their parents, and babies
often cry up to several hours each day. Babies cry when they are
hungry, sick, angry, in pain, or have a wet diaper. Whenever a baby
cries, the caretaker should consider these reasons first. Sometime,
babies also cry for no apparent reason, except that they may be
irritable. Babies who cry during most of their waking hours are called
"colicky." Colic usually disappears after a few months. If this occurs,
you can try:
Holding the baby closely
Holding the baby more often during periods when s/he is not
crying
Gently rubbing the abdomen
Burping the baby more often during feedings
Changing the diet (avoiding cow milk formula)
Gently rocking or swinging the baby
9. Infants need regular preventive medical visits.
A good time to find a pediatrician is before the baby is
born. During "well-baby visits" with a health care provider, infant
growth and development will be monitored. In addition, providers will
screen for common childhood conditions and provide immunizations

APGAR
The APGAR scoring provides a valuable index for assessing the
newborn’s condition at birth. The APGAR Score standardizes infant
evaluation and serves as a baseline for future evaluations. Using the
APGAR system, the infant is assessed at one minute and 5 minutes
after birth. An infant whose total score is under 4 is in serious danger
and needs resuscitation. A score of 4 to 6 means that the condition is
guarded and the baby may need clearing of the airway and
supplementary oxygen. A score of 7 to 10 is considered good. The
highest score is 10.

Sign 0 1 2 Score
Heart Rate Absent Slow <100 >100 2
Respiratory Absent Slow, Good strong 2
Effort irregular, cry
weak cry
Muscle Flaccid Some Well flexed 2
Tone flexion of
extremities
Reflex No Grimace Cry and 2
Irritability Response withdrawal
 of foot
Color Blue pale Body pink, Completely 2
extremities pink
blue
10

Implication: The baby had a total score of 10. She was in good
condition.

PUERPERIUM
Postnatal Care and Puerperium
Introduction:
Throughout pregnancy, you were center stage: your partner,
your family, your doctor and you yourself were concentrating on
various aspects of your health and care in pregnancy and labour. The
foetus growing inside you was a secondary patient. Now that you have
delivered, the focus of everybody’s attention, including your own
seems to have shifted suddenly from you to the little bundle of joys
(well, most of the time joy, sometimes trouble!) next to you. This is but
natural, and we are sure you will take it in your stride. However, there
are many things about your body that are still going to change. This
post delivery period is extremely important, and to recover to your pre-
pregnancy health (if not better) you need to pay attention to yourself
too.
Phases of Puerperium:
Taking - In Phase
The taking -in phase, the first phase experienced, is a time of
reflection for a woman. During this period, the woman is largely
passive. She prefers having a nurse minister to her to get her a bath
towel or a clean night gown, and make decisions for her rather than
doing these things herself. This dependence is due partly to her
physical discomfort from possible perineal stitches, afterpains, or
hemorrhoids; partly to her uncertainty in caring for newborn; and
partly from the extreme exhaustion that follows childbirth.
Taking - Hold Phase
After the time of passive dependence, a woman begins to initiate
action. She prefers to get her own washcloth and to make her own
decisions. Women who give birth without anesthesia may reach this
second phase in a mater of hours after birth. During the taking - in
period, a woman may have expressed little interest in caring for her
child. Now, she begins to take a strong interest, as a rule therefore, it is
always best to give the woman brief demonstration of baby care and
then allow her to care for the child herself with watchful guidance.
Although a woman’s action suggest strong independence during this
time, she often stills feels insecure about her ability to care for her new
child. She needs praise for the things she does well to give her
confidence. Do not rush a woman through the phase of taking - in or
prevent her from taking hold when she reaches that point. For many
young mothers, learning to make decisions about their child’s welfare
is one of the most difficult phases of motherhood. It helps if the woman
has practice in making such decisions in a sheltered setting rather than
first taking on that level of responsibility when she is on her own.
Letting - Go Phase
In this 3rd phase, called letting go, the woman finally refines her new
role. She gives up fantasize image of her child and accept that real
one; she gives up her old role of being childless or the mother of only
one or two. This process requires some grief work and adjustment of
relationships similar to what occurred during pregnancy. It is extended,
and continues during the child’s growing years. A woman who has
reached this phase is well into her new role.

Immediate Puerperium:
The first 24 hours after birth, or the immediate puerperium, is a
critical stage. This is the time when your uterus has to contract well, in
order to stop the bleeding from the site of placental attachment. It is
also the initiation of breastfeeding and bonding. Occasionally, this is
the time that most life threatening complications of delivery manifest.
These include postpartum excessive bleeding, collapse of the
circulation, cardiac failure, etc. These are not common, but even with
normal vaginal birth there is a risk of death of about 1 in 10,000
women. This risk may be more in women with pre-existing medical
conditions like anaemia, hypertension or heart diseases. It is also more
with operative deliveries. Hence you will be advised to stay in hospital
for at least 24 hours following childbirth.

Early Puerperium:
This refers to the 2<sup>nd to 7<sup>th day post delivery
where major changes start in your genital tract. This is probably also
the time of maximum adjustment when you come to terms with your
new role as ‘mother’. You will also be going home with your baby in this
period. There are many relatively minor, yet significant bodily changes
you should be aware of.
These include:
Lochia / Vaginal discharge:
This term refers to the discharge from the vagina, coming mainly
from shedding of the inner lining of the uterus. For the first 4 days,
there is fresh bleeding, like a heavy menstrual flow (Lochia rubra). You
may need to use 2 pads at a time, changing 3 - 4 times a day.
However, if you find it very heavy, or large clots keep coming out, you
must inform your doctor. Usually by the 5<sup>th day the flow
becomes much less, and may now be more of a blood stained
yellowish-brown discharge. You may still require sanitary protection,
about 2 - 3 pads a day. This discharge called ‘lochia serosa’ usually
stops by the end of the second week after which it becomes a plain
white discharge. Good hygiene and care of episiotomy will prevent
infection. Any foul smell in the discharge should be reported to your
doctor.
Urination:
The first day you must pass urine at least 2 - 3 hourly, despite
pain in the stitches. This is because the bladder may become overfull
without you realize it, which can cause problems, especially infections
later. During the first week, you may notice that you seem to be
passing a lot of urine. This is because your body is removing some of
the excess water and salt that was retained in pregnancy.
Stools:
You may not have a good bowel motion for the first 2 days
following delivery, for various reasons. One is that you have not eaten
much during labor, you are exhausted and sleepy. Secondly you may
be having pain in the stitches of the episiotomy It is important to take
a high fiber diet and plenty of liquids to prevent hard stools. You may
need a mild laxative for a few days.
Breast:
The first day you will have only a watery, yellowish discharge,
not looking like ‘real’ milk coming from the breasts. This is called
colostrum and it is rich in many nutritive factors that are needed by
your baby. You must feed your baby at this time. By the third day, the
milk flow increases a lot, due to hormonal changes in your body.
Regular feeding is important to prevent engorgement. Link to engorged
breast in Breastfeeding.

After - Pains:
The delivery is over. You have borne with labor pains. So now you
may be worried that you are still getting a cramping lower abdominal
pain off and on. Don’t worry, there is nothing left inside! This is a
normal phenomenon, which occurs due to the uterus contracting in
response to oxytocin, a natural body hormone. This is more marked
when you are breastfeeding. Link to letdown reflex in breastfeeding. It
is nature’s way of getting your uterus back to the normal size. If the
pain is severe, or you are having other symptoms like fever or excess
bleeding, you need to inform your doctor.

POST PARTAL EXERCISES

MUSCLE STRENGTHENING EXERCISE
1. Abdominal Breathing - abdominal breathing maybe started on the
first day postpartum, because it is a relatively easy exercise. Lying flat
on her back on sitting, a woman should breath slowly and deeply in
and out 5 minds, using her abdominal muscles.
2. Chin - to chest - chin to chest exercise is excellent for the second
day. Lying on chin forward on her chest without moving any other part
of her body while exhaling. She should start this gradually, repeating
it no more than 5 times the first time and then increasing it to 10-15
times in succeeding. The exercises can be done 3 to 4 times a day.
She will feel the abdominal muscles pull and tighten if she is doing it
correctly.
3. Perineal Contraction - If a woman is not already if she is doing it
correctly. Of alleviating perineal discomfort, it is a good one to add on
the third day. She would tighten and relax her perineal muscles 10-15
times in succession as if the trying to stop voiding. She will feel her
perineal muscles working if she is doing it correctly.
4. Arm Raising. Arm raising helps both the breasts and the abdomen
return to good time is a good exercise to add on the fourth day. Lying
on back, arms at her sides, a woman moves arms out from her sides
until they are perpendicular to her body. She time raises them over her
body until they are perpendicular to her body. She then raises them
over her body until her hands touch and lowers them slowly to her
sides. She should rest a moment, then repeat the exercise 5 times.
5.Abdominal Crunches. It s advisable to wait until to 10th and 12th
day after delivery before attempting abdominal crunches. Lying flat on
her back with knees bent a woman folds her arms across her chest and
raises herself to a sitting position. This exercise expenses a great deal
foe effort and tires a postpartum woman easily. She should be
cautioned to begin it very gradually and work up slowly to doing it 10
times in a row.

Post Partum Blues:

There are many changes, which have happened to you in the
past 9 months, and even more are happening now. You may be feeling
a little left out or dissociated from your surroundings. Link to
introduction of puerperium the swings in your hormone levels are
maximum in the first week. Your baby may be keeping you awake all
the time, your breasts feel sore, and your stitches are hurting. Many
things add up to make you feel down. Many women feel low or
depressed soon after delivery - in fact, it is so common that there is a
medical team for it, called ‘fifth day blues’! Talk to your partner, your
friends, an older relative or your health care persons. Ask for help with
the baby if you are tired. Have a good cry. Take a break, sleep for a
while and you will feel better. If this feeling of depression does not
settle in a few days, then perhaps you should see your doctor for help,
Sometimes an underlying hormonal problem like low thyroid function
may be causing these feelings. Remember that these feelings are not
uncommon. You are not the only mother who is not feeling ‘100%
maternal love’ all the time, particularly soon after delivery. Be good to
yourself, pamper yourself also, and talk about what you feel. Soon, you
too will feel on ‘top of the world’!

Resuming Activities:
As discussed earlier, it takes up to 6 weeks for your body to
recover from the changes of pregnancy. So, be patient with you. Listen
to your body and do as much as you feel up to, Different women have
different abilities to deal with their health changes. However, in most
cases, after a normal vaginal delivery, you will be able to resume your
daily personal care activities within a day, and your household routine
within a week, don’t overexert yourself - This is the time you need to
devote to yourself and your baby. Take help; involve your partner, Link
to Father’s role, and others available to make your life easier. After a
complicated childbirth, or after a caesarean delivery your recovery
may take twice as much time, so be patient.
Postnatal Exercises:.
Sexual Activity is best avoided in the early post delivery period.
This is because your stitches may be raw or painful, and your genital
tract is prone to infection, particularly in the 1<sup>st week. Complete
restoration of the lining of the uterus, including the placental site, is
not complete. Hence traditionally some advise abstinence till 6 weeks
following delivery. However, if you have had an uncomplicated birth,
and are not having any problems, you could resume your sexual life
earlier. You and your partner may have been deprived of each other,
particularly in the last month of pregnancy. Hence, it is not unusual to
feel the need to renew your sex - life. Until you feel comfortable for
actual penetrative sexual intercourse, other displays of caring and
affection can suffice. Hugging, kissing, petting or touching is not
forbidden at anytime during pregnancy or post-delivery.

Lactational Amenorrhoea:
Link to lactation amenorrhoea in preventing pregnancy. While
you are exclusively breastfeeding, Link to exclusive breastfeeding in
Breastfeeding, the hormonal changes is your body act on the genital
tract to suppress ovulation and menstruation. Link to female
reproductive, tract, ovulation, and menstruation. You may not get your
periods for a few months. Some women do not start menstruating for
up to a year, depending on the pattern and frequency of breastfeeding.

Timing No lactation If lactation established Menstruation 6 - 12 weeks

36 weeks (average) Earliest ovulation 4 weeks 12 weeks Average
time for ovulation. 8 - 10 weeks 17 weeks (variable)

Does this mean you cannot get pregnant? The answer is NO.
About 5% of women get pregnant before they start menstruating, post-
delivery. Lactation amenorrhoea (absence of periods) does protect you
from pregnancy to some extent. However, you can rely completely on
Lactational amenorrhoea as a method of preventing pregnancy ONLY IF
ALL 3 preconditions listed below are satisfied:

Contraception:
If you are relying on lactational amenorrhoea. If not, that brings
us to the important question: Are you ready for another pregnancy?
You need to give your body time to recover; your baby time to grow up
and yourself time to adjust to the new role of ‘mother’. Of course, it is
a question of personal choice but a minimum gap of 2 years is
recommended between successive pregnancies. So, how can you
prevent pregnancy during the post-delivery period?
There are many methods available. During the post partum period,
however, certain factors need to be kept in mind:
Others:
Condoms
Condoms are a good, locally acting method, which are reliable if
used correctly and consistently. They have no side effects and are
useful for couples with less frequent sexual intercourse.

IUCDs or ‘loops’:
These are a very reliable method, requiring one visit to the
doctor for insertion, which can be done easily without anaesthesia.
They are effective for average 3 - 5 years (depends on the device) and
are independent of the sexual act, unlike condoms. This is a very
popular method for women with one or more children. Infact, can be
used as an option to permanent procedure. The IUCD can be inserted
at the first postnatal visit. Link (6 weeks from childbirth) or later, even
if you do not have periods, provided your internal checking is normal.

Oral Contraception pills:

These are a type of hormonal contraception. During the period of
exclusive breastfeeding the combined Oral Contraception pills
(containing Estrogen + Progesterone) may reduce the breast milk flow.
Hence are not popularly recommended. Once weaning is begun, there
can be used safely.

Sterilization:
This is a permanent method, which can be opted for after you
have completed your family. This is a procedure which can be done
easily immediately post-delivery (puerperial sterilization) or at the time
of caesarean section. For both these options, you need to discuss the
pros and cons with your doctor and spouse before delivery, ideally in
one early antenatal period. Some prefer to wait until the youngest child
is older, preferably above 1 year old, before doing this permanent
procedure. As an interval procedure, 6 weeks or more after delivery, it
is usually done by laparoscopy.

First Postnatal Visit:

You and your baby have been through a lot. After you go home,
and you recover from childbirth, your doctor will need to see you at
least once to confirm that your recovery is complete. The first check up
is usually 6 weeks from delivery. It may be earlier, about 3 weeks, if
you have needed special care or had any problem in delivery. At the
first visit, your doctor will check

You may need to do some tests. You need to discuss the

following issues with your doctor
ESTABLISH SUCCESSFUL LACTATION
In most of the hospital they require the mothers who delivered
there to breast reed as soon as possible because the baby will receive
colostrums that contains gamma globulins. Advantages of breath
feeding to the mother are: It is economical in terms of money and
effort, more rapid involution, loss incidence of cancer of the breast. For
the baby: closer mother infant relationship, contains antibodies that
protect against common illness, less incidence of gastrointestinal
diseases and always available at the right temperatures.

BREASTFEEDING
Breast milk is preferred method of feeding a newborn because it
provides numerous health benefits to both the mother and the infant. It
remains the ideal nutritional source for infants through the first year of
life.
Nurses can play a major role in teaching women about the
benefits of breastfeeding and providing anticipatory guidance for
problems that may occur by implementing steps such as:
Educating all pregnant woman about the benefits and management
of breastfeeding.
Helping women initiate breastfeeding within half an hour of birth.
Assisting mothers to breast-feed and maintain lactation even if they
should be separated from their infant.
Not giving newborns food or drink other than breast milk unless
medically indicated.
Not giving pacifies to breastfeeding infant.
Practicing rooming- in (allow mothers and infants to remain
together) 24 hours a day.
Encouraging breastfeeding on demand.
Fostering the establishment of breastfeeding support groups and
referring mothers to them on discharge from the birthing center or
hospital.

The mother gains several physiologic benefits from breast

feedings, such as: breastfeeding may serve as a protective function in
preventing breast cancer, the released of oxytocin from the posterior
pituitary aids uterine involution and successful breastfeeding can have
an empowering effect because it is a skill only woman can master.
Breastfeeding also reduces the cost of feeding and preparation
time. Many women feel that breastfeeding enhances the formation of a
true symbiotic bond with their child.
Breastfeeding has major physiologic advantages for the baby.
Breast milk contains secretary immunoglobulin A, which binds large
molecules of foreign proteins, including viruses and bacteria and keeps
them from being absences to the GIT into the infant.
Prolactin
An anterior pituitary hormone, acts on the acinar cells of the
mammary gland to stimulate the production of milk. In addition, when
infant’s sucks at the breast, nerve impulses travel from the nipple to
the hypothalamus to stimulate the production of prolactin releasing
factor.

Colustrum
The acinar breast cells starting in the 4th month of preganancy
secrete a thin watery, yellow fluid composed of protein, sugar, fat,
water, minerals, vitamins, and maternal antibodies.

Lactoferin
Is an iron binding protein in breast milk that interferes with
growth of pathogenic bacteria?

Lysozyme
In breast milk apparently actively destroys bacteria by lying their
cell membranes, possibly increasing the effectiveness of antibodies.

Leukocytes
In breast milk provide protection against common respiratory
infections invaders.

L bifidus
Interferes with the colonization of pathogenic bacteria, in GIT. the
incidence of diarrhea. Breast milk also contains ideal electrolyte and
mineral composition for human infant growth.

Advantage of breastfeeding

Little controversy exist about breastfeeding as the best nutrition

for human infants, but the decisions to breastfeed depends on what
would please the woman the most and make and make her most
comfortable. If she is comfortable and pleased with what she is doing,
her infant will be comfortable and pleased, will enjoy being fed, and
will thrive.

Breastfeeding is contraindicated in only a few

circumstances, such as:
 An infant with galactosemia (such infant cannot digest the
lactose in milk
Herpes lesions on the mother’s nipples
Mother is on restricted nutrient diet that prevents quality milk
production
Mother is receiving medications that are inappropriate for
breastfeeding, such as lithum or methotrexate.
Maternal exposure to radioactive compounds, as could happen
during thyroid testing

Advantage for the mother

A woman gains several physiologic benefits from breastfeeding,

including:
Breastfeeding may serve a protective function in preventing breast
cancer
The release of oxytocin from the posterior pituitary gland aids in
uterine involution
Successful breastfeeding can have an empowering effect
because it is a skill only woman can master.
Breastfeeding also reduces the cost of feeding and preparation
time. Many women feel that breastfeeding provides the best
opportunity to enhance the formation of a true symbiotic bond with
their child. Although this does occur readily with breastfeeding, a
woman who holds her baby to bottle- feed can form this bond equally
well. Some woman believes that breastfeeding is a foolproof
contraceptive technique. Some feel breastfeeding will help them lose
their weight gained during pregnancy. This also is not true, and women
who arebreastfeeding need to concentrate on eating a well balance
diet to ensure that her milk is rich in nutrients. Some woman are
reluctant to breastfeed because they fear that having to be available to
feed the baby every 3 or 4 hours will tie them down.

Advantage for the Baby

Breastfeeding has many physiologic advantages for the baby.

Breast milk contains contains immunoglobulin A (IgA), which binds
large molecules of foreign proteins, including bacteria and viruses.
Thus keeping them from being absorbed through the gastrointestinal
tract into the infant. Lactoferin is an iron binding protein in breast
milk that interferes with growth of pathogenic bacteria. Lysozyme in
breast milk apparently actively destroys bacteria by lying their cell
membranes, possibly increasing the effectiveness of antibodies.
Leukocytes in breast milk provide protection against common
respiratory infections invaders. L bifidus interferes with the
colonization of pathogenic bacteria, in GIT. the incidence of diarrhea.
Breast milk also contains ideal electrolyte and mineral composition for
human infant growth.
Breast milk contains more linoleic acid, an essential amino acid
for skin integrity, and less sodium, potassium, calcium and
phosphorous than do many formulas. Breast milk also has a better
balance of trace elements, such as zinc, than formulas do. These levels
of nutrients are enough to supply the infants needs, yet they spare the
infant’s kidneys from having to process a high renal solute load of
unused nutrients.
One disadvantage of breast milk is that it may carry
microorganisms such as hepatitis B and cytomegalovirus, although the
risk to infant is small. HIV is carried at a high enough level in breast
milk that women who are HIV positive are advised not to breast-feed.

Preparing for Breastfeeding

Ask all women during pregnancy whether they plan to breast-

feed or formula feed their newborn. Thinking about feeding in advance
allows couples to make informed choices. Some fathers experience
jealousy at the thought of breastfeeding.
Physical preparation such as nipple rolling, advised in the past as
a way of making the nipple more protuberant is no longer advised. This
is unnecessary because few women have inverted or non-protuberant
nipples, plus oxytocin, released by this maneuver, could lead to pre-
term labor (nipple rolling is used to create uterine contractions for
stress test). Practicing breast massage to move the milk forward in the
milk ducts (manual expression of milks) maybe helpful.
This can help a woman who feels hesitant about handling her breast to
grow accustomed to doing so, allowing her to assist with milk
production in the first few days after birth. Manual expressions consists
of supporting the breast firmly, then placing the thumbs and forefinger
on the opposite sides of the breast just behind the areolar margin, first
pushing backward toward the chest wall and then downward until
secretion begins to flow.
Teach woman not to used soap on their breasts during pregnancy
because soap tends to dry and crack nipples. The occasional woman
who has inverted nipples may need to wear a nipple cup (a plastic
shell) to help the nipples become more protuberant.

BEGINNING BREASTFEEDING
 Breastfeeding should begin as soon as possible, ideally while the
woman is still in the delivery or birthing room and while the infant is in
the first reactivity period. This practice has several advantages infant
suckling stimulates release of oxytocin which in turns stimulates
uterine contracts to prevent hemorrhage, promotes closer maternal
and infant relationship, prevents breast engorgement:
If it is not possible to start breastfeeding right after delivery, initiate
breastfeeding, then, after 4 to 8 hours when the mother has already
rested on her condition and stable.

HOW TO FEED

1. Instruct mother to relax first before feeding, anxiety and fatigue

interferes with the let down reflex
2. Wash hands and assumes a comfortable position. The mothers can
breastfeed lying down or sitting, which ever is comfortable for her and
her baby.
3. If the baby is asleep or sleepy talking or rubbing baby’s soles will
gently wake him or wake up breastfeeding is more effective if the baby
is awake.
4. Guide baby to the breast by stimulating rooting reflex, touch the
cheek nearest the breast. The baby will respond by turning his head
and opening his mouth.
5. Press the breast away from the nose with a finger if the breast
blocks the baby’s nose.
6. Let the baby’s mouth grasp both the nipple and areola.
7. Feed the baby for only 2 to 3 minutes during the first time, then,
increase feeding time by one minute each day until the infant is fad for
ten minutes on each breast
8. When removing the baby from the breasts, pull the chin down or
place a finger in the corner of the mouth to break the suction. Pulling
the baby from the breasts is painful and can cause sore nipple.
9. On the next feeding, place infant on the breast where she or he last
fed during the previous feeding.
10. Instruct mother to burp infant after feeding by placing baby on her
lap on a prone position or positioning him or her in sitting upright.
11. Signs of proper feeding:
the baby’s mouth group both nipple and areola.
the other breast flows with milk. Infant sucking stimulates release of
oxytocin, which in form stimulates milk let down reflex.
the mother feels after pains or uterine cramping while
breastfeeding, this is due to release of oxytocin.
 12. It is not unusual to haves scanty milk supply during the first few
days after delivery. There is no need to offer milk formula to the
infant. Placing infant regularly on the breasts will stimulate milk
production. Maintenance of successful lactation requires that breasts
are completely emptied at each feeding so that they will completely fill
again. The more the baby suckles, the more milk is produced.
13. Instruct the mother to avoid:
Smoking
Oral contraceptives because they decrease milk supply
Drugs passed to infant via breast milk.

Problems of breastfeeding:

1. Breast Engorgement

Breast engorgement usually occurs during the 3rd to 4th day after
delivery. The mother complains of pain and tenderness, the breast are
reddish, tense, shiny, hot to touch and feels firm and nodular. Breast
engorgement is not cause by milk or infection but by lymphatic and
venous congestion. When the breast are engorged, the infant will not
be able to grasp the nipple effectively and pain can cause the mother
to avoid or refused breastfeeding.

Management:
Give analgesics before feeding to provide pain relief
Give breast more often to empty breast with milk and prevent
further engorgement
Initiate breastfeeding as soon as possible after delivery to prevent
engorgement.
Let warm water run over the breast or apply warm compress to
improve circulation and promote comfort if the mother plans
breastfeed. If the mother does not plan to breastfeed, apply ice packs.
Reassure mother that engorgement is temporary and it will subside
after 24 hours.

2. Sore and Crack Nipples

Causes:
Forceful pulling of the infant after feeding
Improper sucking - infant grasping only the nipple during feeding
Breastfeeding too long
Nipple remaining moist for a long time due to leakage of milk
 Management:
Expose to air after feeding to let nipples dry
Use of loose fitting clothing and leaving bra unsnapped to let air
circulate in the breast for a few
minutes
Limit amount of time of feeding to allow nipple to healed
Use of nipple shield
Express milk usually or by breast pump if breastfeeding causes too
much pain to maintain milk supply
Sore nipples are not contraindication to breastfeeding unless the
mother cannot tolerate the discomfort caused by infant suckling. She
can express milk from her breasts and give it to infant using feeding
bottle.

ACKNOWLEDGEMENT

The author acknowledges with profound gratitude and

appreciation to all those were behind her in the pursuit of her work for
without them she should not have succeeded.

Special mention to:

Ms. Maria Elena Figuerroa RN, for her suggestion and guidance in
accomplishment of this study.
Kathleen and numerous true friends for their voluntary services,
support and care;
Her parents, brothers for the prayer and encouragement and
who are always at her price.
Above all to God for countless blessings showered to the writer.
 DEDICATION

To my parents who gave me the unconditional love from the time

I saw the light and for what I am now;
To my brothers who added inspiration though their assistance
and moral support,
To my ever loyal and closest friend and relatives.

This humble work is heartily dedicated