Maternal and Child Health Care

PSYCHOLOGIC/EMOTIONAL
ADAPTATIONS TO PREGNANCY
 ACCEPTANCE OF PREGNANCY
 “ I am Pregnant.” (First Trimester)
 At this stage, the unborn child is incorporated as part of the
woman’s body image or as part of herself.
  ACCEPTANCE OF THE FETUS AS A
SEPARATE INDIVIDUAL
 “I am going to have a baby.” (Second Trimester)
 As the woman realizes of her unborn child, she
begins to fantasize about the child’s sex and
appearance.
  The woman becomes more introspective during
this stage because she is preoccupied with
fantasies about her unborn child.

 THE WOMAN PREPARES FOR THE

BIRTH OF THE BABY AND HER ROLE
AS A MOTHER
 “I am going to be a mother” (Third
Trimester)
 The woman begins to plan about the birth of

the baby
EMOTIONAL REACTIONS EXPERIENCED
BY A NEWLY PREGNANT WOMEN
 AMBIVALENCE: refers to the simultaneous negative
and positive response of the woman to pregnancy.
 FEAR AND ANXIETY: Fear and anxiety is related to the
woman’s concern about her own health and the health of
her baby.
 INTROVERSION OR NARCISSISM: During pregnancy,
the woman may become concerned for her welfare and
the effects of pregnancy on her health and lifestyle.
: she may be
preoccupied with her own thoughts and feelings.
 UNCERTAINTY
CHARACTERISTICS OF THE PREGNANT WOMAN
AT DIFFERENT STAGES OF PREGNANCY
 
 FIRST TRIMESTER:
 Displays a sense of ambivalence to the
pregnancy.
 Fantasize about the pregnancy
 Role playing
 Increased concern for financial and social
problems
 Decreased interest in sex due to bodily changes
 SECOND TRIMESTER:
 The patient develops a sense of well being as her
body becomes adjusted to the changes
associated with pregnancy.
 Quickening is experienced.
 The fetus heartbeat is heard.
 Both parents develop an interest in fetal growth
and development.
 The interest is processes of labor and delivery is
expressed.
 The patient may have wide mood swings.
 Tendency to introversion and to focus on herself
as the center of attention.
  Changes in sexuality characterized by increased
interest in sex and increased sexual fantasies and
dreams, and an increase in vaginal lubrication.
 THIRD TRIMESTER:
 Altered self-image: the patient is vacillating,
going from being special, beautiful, and pretty
to being ugly, awkward, unsexy, and feels fat.
 Fear: she dreams about the infant and what
the future holds for the new baby. She is
concerned for the health and well-being of her
baby. She is also concerned for her own
safety and “performance” during labor and
delivery.
 Aggravation: the patient is aggravated over
things she can’t do for herself due to her size.
 Fatigue
 Obsession: she is concerned and
preoccupied by the events of labor and
delivery.
 Wondering: the patient wonders what kind of
parent she will be.
PSYCHOLOGICAL CHANGES
DURING PREGNANCY
TERMS
Maternal Tasks of Pregnancy
 Acceptance of pregnancy
 This task focuses on the woman’s adaptive
responses to the changes
that occur related to pregnancy growth and
development
These responses include:
 Responding to mood changes
Responding to ambivalent feelings
 Responding to nausea, fatigue, and

other physical discomforts

of the early months of pregnancy

 Responding to financial concerns

 Responding to increased dependency

needs
 Identification with the motherhood role
 Accomplishment of this task is influenced by the
woman’s acceptance of pregnancy and the
relationship the woman has with her own mother.
 Women who have accepted their pregnancy and
who have a positive relationship with their own
mothers have an easier time accomplishing this
task
 Accomplishment of this task is also influenced
by the woman’s degree of fears about labor
related to helplessness, pain, loss of control,
and loss of self-esteem
 Vivid dreams are common during
pregnancy, which allows the woman to
envision herself as a mother in various
situations.
 A woman often rehearses or pictures

herself in her new role indifferent scenarios

 The motherhood role is strengthened as the

woman attaches to her fetus.

 Fetal attachment influences the woman’s

sense of her child and her sense of being

competent as a mother.
 Relationship to her mother
 Four components important to the woman’s
relationship with her own mother are:
 Availability of the woman’s mother to her in
the past and in the present
 The mother’s reaction to her daughter’s
pregnancy
 The mother’s relationship to her daughter
 The mother’s willingness to reminisce with her
daughter about her own childbirth and
childrearing experiences
 Unresolved mother–daughter conflicts reemerge
and confront the woman during pregnancy
 Reordering relationship with her
husband or partner
 Pregnancy has a dramatic effect on the couple’s
relationship.
 Somecouples view pregnancy and childbirth as a
growth experience and as an expression of deep
commitment to their bond, while others view it as
an added stressor to a relationship already in
conflict.
 The partner’s support during pregnancy
enhances the woman’s feelings of well-being
during pregnancy and is associated with earlier
and continuous prenatal care
 Assessment of the relationship between the
couple includes:
 The partner’s concern for the woman’s needs
during pregnancy
 The woman’s concerns for her partner’s needs
during pregnancy
 The varying desires for sexual activity among
pregnant women
 The effect pregnancy has on the relationship
(e.g., does it bring them closer together or cause
conflict?)
 The partner’s adjustment to his or her new role
 Preparation for labor

 Preparation for labor means preparation

for the physiological processes of labor
as well as the psychological processes
of separating from the fetus and
becoming a mother to the child.
 Preparation for labor and birth occur by

taking classes, reading, fantasizing, and

dreaming about labor and birth
The degree of preparation for labor and
birth has an effect on the woman’s level
of anxiety and fear. The more prepared
a woman feels, the lower the level of
anxiety and fear.
 Feeling loved and valued and having

her child accepted by her partner are

two major contributors to positive
adaptation
 Prenatal fear of loss of control in
labor
 Loss of control includes two factors:
 Loss of control over the body
 Loss of control over emotions

 The degree of fear is related to:

 The woman’s degree of trust with the medical
and nursing staff, her partner, and other
support persons
The woman’s attitude regarding the use
of medication and anesthesia for labor
pain management
 Expected findings:

 The woman perceives individual attention

from medical staff.
 Woman perceives that she is being treated as
an adult and her questions and concerns are
addressed by the medical staff.
 The woman perceives that the nursing staff is
compassionate, understanding, and available.
 Prenatal fear of loss of self-esteem
in labor
 Some women have fears that they will lose
self-esteem in labor and “fail” during labor
 When a woman feels a threat to her self-
esteem it is important to assess the following
areas :
 The source of the threat
 The response to the threat
 The intensity of the reaction to the threat
 Expected findings:
 Able to develop realistic expectations of self
during labor and birth and an awareness of
risks and potential complications
 Able to identify and respect her own feelings
 Able to assert herself in acquiring information
needed to make decisions
 Able to recognize own needs and limitations
 Able to adjust to the unexpected and
unknown
 Able to recover from threats quickly
Variables that Influence Maternal
Adaptation
Parity
 Multigravidas

 they may need time to process and

develop strategies for integrating a new
member into the family.
 Pregnancy tasks may be more complex.

Giving adequate attention to all of her

children and supporting sibling adaptation are
unique challenges faced by them
Maternal Age
 Adolescent mothers
 The major developmental task of
adolescence is to form and become
comfortable with a sense of self.
 Achieving a maternal identity is very diff
icult for an adolescent who is in the
throes of evolving her own identity as an
adult capable of psychosocial
independence from her family.
Although she may achieve the maternal role,
research indicates that she functions at a
lower level of competence than do older
women.
 The younger she is, the more difficulties the

adolescent woman has with body image

changes, acknowledging the pregnancy,
seeking health care, and planning for the
changes that pregnancy and parenting will
bring. Delayed entry into prenatal care is
common. There is also a higher rate of
abuse among pregnant adolescents
 Successful adaptation to pregnancy
and parenthood may greatly depend
on the age of the adolescent .
 Early adolescence – 11-15 yrs. Old
- Adolescents in this phase of life
are selfcentered and oriented toward the
present.
- Moving into the maternal role is
a difficult challenge for this age group
 Middle adolescence – 14-16 years old
- During this time, the adolescent
is more capable of abstract thinking and
understanding consequences of current
behaviors.
 Late adolescence – 17-20 years old

- The older pregnant adolescent is

more likely to be a capable and active
participant in health care decisions
 Higher levels of support and higher
self-esteem are associated with a
more positive adaptation to mothering
for adolescents
 Older mothers
 Evidence indicates that older mothers
are also more likely to have
miscarriages, fetal chromosomal
abnormalities, low birth weight infants,
premature births, and multiple births.
 In women older than 40, the risk
increases for placenta previa, placenta
abruption,caesarean, deliveries, and
gestational diabetes
 The more mature woman is better
equipped psychosocially to assume the
maternal role. She also might have
increased difficulty with the changing
roles in her life, experiencing heightened
ambivalence.
 Pregnant women in this age group are
highly motivated to seek information
about childbirth and parenting from
books, friends, and electronic resources
 Single Parenting
 The literature reports a higher degree of
stress for pregnant single women (e.g.,
greater anxiety; less tangible, reliable
support from family and friends).
 Single mothers may live at or below the

poverty level, facing greater financial

challenges, resulting in a higher risk of
depression
 Single women engage in the maternal tasks

of pregnancy and face more complex tasks

and a variety of challenges.
 Multifetal Pregnancy
 Socioeconomic Factors
 The resources of the family to meet the needs
for food, shelter, and health care play a crucial
role in how a family responds to pregnancy.
 Financial barriers have been identified as the
most important factor contributing to maternal
inability to receive adequate prenatal care.
 The nature of immigrant women’s work must
also be carefully assessed.
PATERNAL ADAPTATION
DURING PREGNANCY
 ANNOUNCEMENT PHASE
 Begins when the news of the pregnancy is

revealed.
 It may last from a few hours to several

weeks.
 Men react to the news of pregnancy with

joy, distress, or a combination of emotions,

depending on whether the pregnancy is
planned or unwanted.
 It is very common during this phase for
men to feel ambivalence.
 The main developmental task is to

accept the biological fact of pregnancy.

 Men will begin to attempt to take on the

expectant father role.

 MORATORIUM PHASE

During this phase, many men appear to
put conscious thought of the pregnancy
aside for some time, even as their
partners are undergoing dramatic
physical and emotional changes right
before their eyes. This can cause
potential conflict when women attempt to
communicate with their partners about
the pregnancy.
 Sexual adaptation will be necessary; men
may fear hurting the fetus during intercourse.
 Feelings of rivalry may surface as the fetus
grows larger and the woman becomes more
preoccupied with her own thoughts of
impending motherhood.
 Men’s main developmental task during this
phase is to accept the pregnancy. This
includes accepting the changing body and
emotional state of his partner, as well as
accepting the reality of the fetus, especially
when fetal movement is felt.
 FOCUSING PHASE
 The focusing phase begins in the last
trimester.
 Men will be actively involved in the pregnancy
and relationship with the child.
 Men begin to think of themselves as fathers.
 Men participate in planning for labor and
delivery, and the newborn.
 Men’s main developmental task is to negotiate
with their partner the role they will play in lab0r
and to prepare for parenthood.
FAMILY ADAPTATION
DURING PREGNANCY
 Types of Family:
■ The nuclear family: A father, mother, and
child living together but apart from both sets
of grandparents.
■ The extended family: Three generations,
including married brothers and sisters and
their families.
 The single-parent family: Divorced, never

married, separated,or widowed man or

woman and at least one child
■ Three-generational families: Any combination
of first, second,and third generation members
living within a household
 Dyad family: Couple living alone without

children
■ Stepparent family: One or both spouses have
been divorced or widowed and have remarried
into a family with at least one child
■ Blended or reconstituted family: A combination
of two families with children from one or both
families and sometimes children
of the newly married couple
■ Cohabiting family: An unmarried couple living
together
■ Gay or lesbian family: A homosexual couple
living together with or without children; children
may be adopted, from previous relationships,
or conceived via artificial insemination.
■ Adoptive family: Single persons or couples
who have at least one child who is not
biologically related to them and to whom
they have legally become parents
Eight Stages in the Life Cycle of a
Family
■ Beginning families
■ Childbearing families
■ Families with preschool children
■ Families with school-aged children
■ Families with teenagers
■ Middle-aged parents
■ Family in retirement
Developmental Tasks
■ The events of pregnancy and childbirth are
considered a developmental (maturational)
crisis in the life of a family (i.e., those changes
associated with normal growth and
development).
■ All family members are significantly affected.
■ Previous life patterns may be disturbed and
there may be a sense of disorganization.
■ Certain developmental tasks have been
identified which a family must face and
 master to successfully incorporate a new
member into the family unit and allow the family
to be ready for further growth and development.
The developmental tasks for
the childbearing family are:
 Acquiring knowledge and plans for the specific

needs of pregnancy, childbirth, and early

parenthood
 Preparing to provide for the physical care of

the newborn
 Adapting financial patterns to meet increasing

needs
 Realigning tasks and responsibilities
 Adjusting patterns of sexual expression to
accommodate pregnancy
 Expanding communication to meet emotional
needs. Reorienting of relationships with
relatives
 Adapting relationships with friends and
community to take
 account of the realities of pregnancy and the
anticipated newborn
PRENATAL CARE
 Prenatal Care or antenatal care refers
to the health care given to a woman
and her family during pregnancy.

 Primary goal: to provide maximum

health to expectant mothers and their
babies.
 DEFINITION OF TERMS:
 Gravida – refers to a pregnant woman. The
number of pregnancies a woman has had
irregardless of the outcome of pregnancy.

 Nulligravida – a woman who has never been

pregnant.

 Primigravida – a woman pregnant for the

first time.
 Multigravida – a woman who has had two or
more pregnancies.
 Para – the number of pregnancies that
reached viability (20 wks. Or more), or
number of fetus delivered with birth weight of
500g or more.
 Nullipara – a woman who has never
delivered a fetus that reached the age of
viability. Such woman may or may not have
been pregnant before.
 Primipara – a woman who has completed
one pregnancy to viability.
 Multipara – a woman who has completed
two or more pregnancies to the viability.
 Term Infant – an infant born between 37 and
42 weeks gestation.
 Postterm Infant – an infant born after 42
weeks gestation.
 Preterm Infant – an infant born before 37
weeks gestation.
 Parturient – a woman in labor
 Puerpera – a woman who has just delivered
(within 6 weeks after delivery)
 Livebirth – recorded when the infant born
shows signs of life: breathing, spontaneous
movement of voluntary muscles and heartbeat.
 Stillbirth – an infant born without signs of life.
 Early Neonatal Death – death of newborn
within 7 days after birth.
 Late Neonatal Death – An infant who died
between 7-29 days after birth.
 Low Birth Weight/Small for Gestational Age
(SGA) - an infant with a birthweight below the
10th percentile rank.
 L arge for Gestational Age (LGA) – an infant
with birthweight above the 90th percentile
rank.
COMPONENTS OF PRENATAL
CARE AT THE BHS AND RHU
 HISTORY TAKING
 Home Base Mother’s Record – used when
rendering prenatal care in pregnancy,
childbirth and postpartum period, identifying
risk factors, danger signs, health education
and referrals.
 BHW performs regular home visits in areas
without licensed health personnel using the
HBMR and makes referral when necessary
COMPONENTS OF PRENATAL
CLINIC VISITS
 FIRST CLINIC VISIT
 Time to obtain baseline data through interview,
laboratory tests and complete physical
examination.
 Activities:
 History Taking
 Complete Physical Examination
 Laboratory Tests
 Fetal assessment
 Health Teachings
LABOR AND DELIVERY

 LABOR – series of events by which

uterine contractions and abdominal
pressure expel a fetus and placenta
from a woman’s body
 Theories of Labor Onset
 Fetal Adrenal Response Theory
 Oxytocin Stimulation Theory – as

pregnancy nears term, oxytocin

production by the posterior pituitary
gland increases while the production of
oxytocinase by the placenta decreases. 
 Progesterone Deprivation Theory
 Prostaglandin Theory – when the fetus
has reached maturity, the fetal
membranes produce large amounts of
arachidonic acid which is converted by
maternal decidua into prostaglandin, a
hormone that initiates uterine
contractions.
 Theory of the Aging Placenta – as the

placenta ages, it becomes less efficient,

producing decreasing amount of
progesterone.
Signs of Labor
 INCREASED BRAXTON-HICKS
CONTRACTIONS
 LIGHTENING “THE BABY DROPPED”
 the settling of the presenting part to the pelvic
brim or inlet
 Occurs about 2 weeks before labor onset in
primiparas and just before or during labor in
multis.
 Lightening results in:
 Relief of dyspnea
 Increased frequency of urination
  Leg pains
 Increased vaginal discharge
 Decreased fundal height
 Floating – when the head is still movable above the
pelvic inlet on palpation
 Engagement – the descent of the biparietal planeof
the fetal head to a level below that of the inlet. In
cephalic presentation, the suboccipitobregmatic
diameter is fixed into the inlet and in breech
presentation, the intertrochanteric diameter is fixed
into the inlet
 Fixation – the descent of the fetal head to the inlet to
a level that it can no longer be moved.
 
 RIPENING OF THE CERVIX
 It becomes buttersoft when labor is near at hand.
 INCREASED LEVEL OF ACTIVITY
 Initiated by low progesterone level, the adrenal
gland secretes large amounts of epinephrine or
adrenalin starting about 2 weeks prior to labor to
provide the woman with energy for the strenuous
work of delivering a baby.
 WEIGHT LOSS
 About 2 weeks before labor, the woman
experiences sudden weight loss amounting to 2-3
pounds. This is due to the decline in progesterone
level.
 SHOW
 Blood tinged mucus dislodged from the
cervical canal
 RUPTURE OF MEMBRANES
 Signified by a gush or steady trickle of clear
fluid from the vagina.
 Caused by the pressure of uterine
contractions and dilatation of the cervix.
FALSE LABOR AND TRUE LABOR
False labor
No increase in intensity,
duration, and frequency of
uterine contractions
Contractions disappear with
ambulation
Discomfort remains in the
abdomen
Contraction stops when
woman is sedated
True Labor
Uterine contractions increase
in intensity, frequency and
duration
Ambulation increases
contractions
Discomfort radiates to the
lowerback or lumbosacral
area
Contraction persists even if
woman is sedated
FALSE LABOR TRUE LABOR

Absence of cervical Progressive cervical

dilation dilation
Absence of show Presence of show
DURATION OF LABOR
Stage of Labor Primis Multi

Ist Stage 10-12 hours 6-8 hours

2nd Stage 30 mins-2 hours 20-90 mins

Ave: 50 minus Ave: 20 mins
3rd Stage 5-20 mins 5-20 mins

4th Stage 2-4 hours 2-4 hours

Uterine Phases of Parturition
 Phase 0 – this extends from the time before
implantation until late in pregnancy when the
uterus is relaxed and the cervix is firm and
rigid.
 Phase 1 – This is the time when the uterus
and cervix undergo several changes in
preparation for labor.
 This phase occurs late in pregnancy and is
characterized by the uterus becoming more
irritable as shown by more frequent and
 intense Braxton-Hicks contractions
 The lower uterine segment is formed and the cervix
softens in preparation for labor.
 Phase 2 – the time of active labor when the
contents of the uterus are expelled.
 Divided into 3 stages: cervical stage, expulsive
stage, and placental stage.
Phase 3 – the time when the newly delivered
mother recovers from the effects of pregnancy and
childbirth.
 Begins from the birth of the baby and ends with the
first ovulation after delivery.
STAGES OF LABOR
 FIRST STAGE: CERVICAL STAGE – period
from the onset of true labor contractions until full
cervical dilation and effacement is achieved.
 Cervical effacement/Obliteration/Taking up
refers to the shortening of the cervical canal from
a length of about 1-2 cm until it is paper thin.
 In primis, dilatation begins when the cervix is

completely effaced.
 In Multis, dilatation and effacement takes place

at the same time

100% effaced cervix – fully effaced cervix
(paper thin or already absent)
75% - cervix has become ¼ of its original
length
50% effaced – cervix has become ½ of its
original length
25% - cervix is still ¾ of its original length.
 Cervical Dilatation – refers to the
enlargement or widening of the cervical
canal.
 Uterine contraction causes dilatation by pulling
the cervix over the presenting part, called
Ferguson Reflex. The BOW and the fetal head
also act as a wedge in dilating the cervix.
 It will be noted that there is increased amount of
show as dilatation is completed since the last of
blood tinged operculum is dislodged.
 Dilatation is expressed in centimeters.
 SECOND STAGE: EXPULSIVE STAGE
 Occurs from full cervical dilatation until the
birth of the baby. The main event of this period
is the birth of the baby.
 THIRD STAGE: PLACENTAL STAGE – this is
the period from delivery of the baby to the
expulsion of the placenta. The main event in
this period is the delivery of the placenta.
 FOURTH STAGE: IMMEDIATE
POSTPARTUM PERIOD
 The period from delivery of placenta until the
condition of the woman has stabilized.
ESSENTIAL FACTORS OF
LABOR (THE FIVE P’S)
 Passages
 Hard passages: Bony pelvis
 Soft Passages: lower uterine segment,
cervix, vagina, pelvic floor and perineum
 Power
 Primary force: involuntary uterine
contractions
 Secondary force: voluntary use of the
 thoracic, diaphragm and abdominal
muscles when the mother “bears
down”
 Passenger: fetal positions,

presentation and attitude

 Person: Maternal attitude during

labor
 Position: Maternal position during

labor and delivery

The Passages of Labor
 PASSAGE
- refers to the route a fetus must
travel from the uterus through the
cervix and vagina to the external
perineum
Functions of the Pelvis
 It provides protection to the organs
found within the pelvic cavity.
 It provides attachment to muscles,
fascia, and ligaments
 It supports the uterus during
pregnancy
 It serves as birth canal