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Antepartum Care cont…

ASSESSMENT OF FETAL WELL-BEING

Fetal Movement

 Can be felt by mother as quickening which begins approx. 18–20 weeks of pregnancy and peaks at 28-38 weeks
 Healthy fetus moves at least 10x a day
A. Sandovsky method
 Mother lying in left recumbent position after meal and record how many fetal movements she feels
over the next hour
 Normal is twice every 10 minutes or average of 10-12x/hr
B. Cardiff method
 “Count to ten”
 Mother records the time interval it takes for her to feel ten fetal movements, usually occurs within
60minutes

Fetal Heart Rate

 Can be heard and counted as early as the 10-11 th week of pregnancy by the use of ultrasonic doppler; normal is
120-160 beats/minute

Ultrasound

 Diagnose pregnancy as early as 7 weeks AOG

 Confirm presence, size and location of placental and amniotic fluid
 Establish presentation and position of the fetus
 Predict maturity by measurement of the biparietal diameter

Electrocardiography (ECG)

 Recorded as early as 11th week of pregnancy

Magnetic Resonance Imaging (MRI)

Maternal Serum Alpha-Fetoprotein

 Substance produced by the fetal liver that is present in amniotic fluid and maternal serum
 Increase in maternal serum AF indicates open spinal or abdominal defects and determine chromosomal defects
(down syndrome/trisomy 21)

Triple Screening

 Analysis of three indicators (serum alpha fetoprotein, unconjugated estriol and HCG)
 Together they increase the detection of trisomy 18 and 21
 Performed between 15 and 22 weeks and considered positive if all markers are low

Chorionic Villi Sampling

 Biopsy and analysis of chorionic villi for chromosomal analysis done at 10-12 weeks AOG to determine the fetus’
chromosomal condition

Amniocentesis

 Aspiration of AF from the pregnant uterus for examination at 14-16 weeks AOG
 To test for fetal maturity
  Informed consent, empty bladder, encourage expression of fears and concerns

Amnioscopy

 Inspection of the AF through cervix and membranes with an amnioscope to detect meconium staining

Percutaneous Umbilical Blood Sampling (Cordocentesis or Funicentesis)

 Aspiration of blood from umbilical vein for analysis

Fetoscopy

 Visualizing the fetus by inspection through a fetoscope

 Helps in assessing fetal well-being

Biophysical Profile

 Combines 4-6 parameters into one assessment

1. Amniotic fluid 3. Fetal breathing movements

2. Placental grading and fetal heart activity 4. Fetal movement and fetal tone

OB Classification

1. Gravida – number of pregnancies

2. Para – number of viable deliveries (20 weeks)

TPALM

3. Full term – number of full-term infants born (infants born at 37 weeks or after)
4. Preterm – number of preterm infants before 37 weeks
5. Abortion – number of spontaneous miscarriages or therapeutic abortions
6. Living – number of living children
7. Multiple – number of multiple pregnancies

Diagnostic Tests

Laboratory Tests

Detecting the presence of human chorionic gonadotropin (HCG), a hormone created by the chorionic villi of the
placenta, in the uterine or blood serum of the pregnant women

 Accuracy: 95-98%
 Tests are performed by radioimmunoassay (RIA), enzyme-linked immunosorbent assay (ELISA), radio-receptor
assay (RRA)

Home Pregnancy Test

 Accuracy: 97%
 Not accurate for those who take psychotic drugs like anti-anxiety agents, also those with oral contraception
 Oral contraception should be discontinued 6 days before the test

Roll-Over Test (ROT)

 Performed to pregnant mother suspected to develop Pregnancy Induced Hypertension (PIH) between
28th and 32ndweeks of gestation
 A comparison of blood pressure is made with the woman lying on her left side and on her back; an excessive
increase in blood pressure when she rolls to the supine position indicates increased risk of toxemia
 To determine the onset of hypertension and proteinuria
  Mother is positive if diastolic blood pressure increases to 20 mm/hg at 5-minute interval

VERIFYING PREGNANCY
Trimester Presumptive signs Probably Signs Positive Signs
First  Amenorrhea  Chardwick’s sign  UTZ evidence (10 – 12
 Morning sickness  Goodell’s sign weeks)
 Breast changes  Hegar’s sign
 Fatigue  +HCG or pregnancy test
 Urinary frequency
 Enlarging uterus
Second  Quickening  Enlarged abdomen  +FHT
 ^ skin pigmentation  Braxton Hick’s  + fetal movement felt by
 Chloasma  Ballottement the examiner
 Linea nigra  ^ body temperature
 Striae gravidarum

Physiologic Changes in Pregnancy

System Changes Description

 Enlarges and thickens
 Increases in fibro elastic tissue
Uterus  Change in shape = pear-like to ovoid
 Blood vessels increase in size
Reproductive  HEGAR’S SIGN = lower segment softens
System Cervix  Vascular and edematous
 GOODELL’S SIGN = softening of the cervix
Vagina  CHADWICK’S SIGN = bluish discoloration
 LEUKORRHEA = increase secretion/discharges
Abdominal Wall  Striae Gravidarum
 Melasma/Chloasma/Mask of Pregnancy
 Feeling of fullness
 Hyperplasia
Breasts  Darkening of areola
 Secretion of colostrum by 4th month
 Nipples are erected
 Circulating volume increases 30-50%
 Physiologic anemia & easily fatigability
 Increase cardiac output
Circulation  Decrease circulation to lower extremities, edema, varicosities
 Palpitation may occur
 Lightheaded- due to compression of inferior vena cava
(rolled towel under the woman’s right hip)
 Striae gravidarum
 Linea negra
 Melasma
Skin Color  Vascular spiders on the thigh (varicose
 veins)
 Increased perspiration
Respiration  Displaced diaphragm
 Lung expands laterally to compensate for shortness of breath
  Stomach & intestines are displaced Management
 Slow stomach peristalsis Heartburn/Pyrosis:
 Delayed stomach emptying  Avoid fried and fatty foods
 HEARTBURN/ PYROSIS: regurgitation of acidic  Sips of milk at frequent intervals
stomach contents through the cardiac  Small frequent meals taken slowly
Digestive System sphincter into the esophagus  Bend at the knees not at waist
 Constipation/flatulence
 Nausea & Vomiting Nausea & Vomiting
 HYPEREMESIS GRAVIDARUM  Eat dry toast, cereal before getting up
 Hemorrhoids out of bed
 Appetite increases after first 3 months
Urinary System  Increases output
 Increases in frequency occurs first 3 months
 Lordotic position – due to backache/fatigue Management
 Waddling gait/ Duck walk – low heeled/flat  Increase calcium intake
Musculoskeletal shoes  Dorsiflex the foot and press the knees
 Leg cramps due to:  Frequent period of rest
Pressure of the gravid uterus  Do not massage
Low calcium, Fatigue/Muscle tense
 First trimester allowed: 1.5 – 3lbs
 2nd and 3rd allowed: 10-11lbs./trimester
 Total allowable weight gain: 20-25lbs / 10-12kg
Distribution of Weight Gain
Fetus 7 lbs.
Placenta 1 lb.
Weight Amniotic Fluid 1.5 lbs.
Uterine weight 2 lbs.
Blood Volume 1 lb.
Weight of breast 1.5 – 3lbs.
Additional Fluid 2 lbs.
Fat and Fluid Accumulation 4 – 6lbs.
Total 20-25lbs
 MANAGING DISCOMFORTS OF PREGNANCY

First Trimester

a. Nausea and vomiting (morning sickness)

b. Palmar erythema – Calamine lotion
c. Urinary frequency – Kegel’s exercise
d. Breast tenderness
e. Fatigue
f. Leukorrhea (increased vaginal discharge that is white in color)
g. Headache

Second and Third Trimester

a. Heartburn / heart palpitations f. Backache

b. Ankle edema g. Leg cramps
c. Varicose veins h. Abdominal pain
d. Hemorrhoids i. Shortness of breath
e. Constipation

Danger Signs in Pregnancy

1. Vaginal bleeding no matter how slight

2. Swelling of the face and fingers
3. Severe, continuous headache
4. Flashes of light before the eyes
5. Plain in the abdomen
6. Persistent vomiting
7. Chills and fever
8. Sudden escape or fluid from the vagina

Prenatal Self Care Needs

 Bathing – daily tub or showers due to sweating that tends to increase in pregnancy
 Breast care – wearing firm supportive bra with wide straps to spread weight across the shoulders. Wash breast
with clear tap water (no soap) to remove or minimize infections
 Dental care – good tooth brushing habits
 Perineal care – douching is contraindicated due to force of the irrigation that can cause it to enter the cervix and
lead to infection; also alters pH of vagina leading to increased risk of bacterial growth
 Emotional – “Couvade syndrome”
 Dressing – avoid garters, and knee-high stocking that can impede lower extremity circulation
 Sexual activity – no sexual restrictions
 Exercise – important to prevent circulatory stasis in lower extremities
 Sleep
 Employment
 Travel
 Nutrition – weight gain 9-11.5kg (20-25lbs)
Folic Acid Intake – to reduce incidence of neural tube defects in newborn
Iron intake – WOF constipation
 Immunization
 TETANUS TOXOID IMMUNIZATION SCHEDULE FOR WOMEN

Vaccine Minimum Age/Interval % Protected Duration of Protection

Tetanus Toxoid 1 (TT1) As early as possible
Tetanus Toxoid 2 (TT2) At least 4 weeks later 80% 3 years
Tetanus Toxoid 3 (TT3) At least 6 months later 90% 5 years
Tetanus Toxoid 4 (TT4) At least 1 year later 99% 10 years
Tetanus Toxoid 5 (TT5) At least 1 year later 99% Lifetime

Foods to Avoid

 Food with caffeine

 Artificial sweeteners
 Weight loss diet

Components of Prenatal Visit

1. Health history 6. Past medical history

2. Chief concern 7. Gynecological history
3. Any exposure to disease 8. Ob history
4. Ingestion of drugs 9. Birthing Plan
5. Family & social profile

Frequency of Prenatal Visit

1st and 2nd Trimester Once a month up to 32 weeks

32-36 weeks Twice a month (every 2 weeks)
36 weeks Four times a month (every week)
80% of pregnant women in the Philippines should have at least 5 prenatal visits (DOH Goal)

Emotional and Psychological Tasks of Pregnancy

 Circumstance to pregnancy – Couvade syndrome
 Meaning of pregnancy to the couple
 Responsibilities associated with parenthood
 Resources available to family

Psychological Tasks of Pregnancy

Trimester Task Description
First Trimester Accepting the Woman and partner both stent time recovering from shock of learning
Pregnancy they are pregnant and concentrate on what it feels like to be pregnant;
a common reaction is ambivalence, or feeling both pleased and not
pleased at the pregnancy
Second Trimester Accepting the Baby Woman and partner move through emotions such as narcissism and
introversions as they concentrate on what it will feel like to be a parent;
role playing and increased dreaming are common
Third Trimester Preparing for the Woman and partner grow impatient with pregnancy as they ready
Baby and End of themselves for birth
Pregnancy
Emotional Responses
1. Self-concept related to body image
2. Mood swings related to biophysical and social changes
3. Ambivalence related to fear and anxiety
4. Sexual concerns related to biophysical changes

Laboratory and Diagnostic Examinations (According to DOH standards)

1. CBC
2. Urinalysis – hPL (insulin)
3. Random Blood Sugar (RBS)
4. Blood typing
5. Venereal Disease Research Laboratory (VDRL)
6. Hepatitis B Screening
7. Ultrasonography

Preparation for Labor and Delivery

1. Child birth education

2. Preconception classes
3. Expectant parenting classes
4. Childbirth plan – hospital, type of delivery, etc
5. Childhood classes
6. Responsible parenthood – contraceptives like LAM (4-6 months), use of condom, knowledge on fertility (cycle,
spinnbarkeit/mucus), etc.
 INTRAPARTAL CARE ASSESSMENT

Labor

The series of events by which uterine contractions and abdominal pressures expel the fetus and placenta from the
woman’s body

Theories of Labor Onset

Factors that influence Labor Onset

 Uterine muscle stretching which results in prostaglandin release

 Pressure on the cervix, which stimulates the release of oxytocin
 Oxytocin stimulation which works together with prostaglandin
 Change in ratio of estrogen to progesterone
 Placental age (once reaches maturity blood supply decreases)
 Rising fetal cortisol level
 Fetal membrane production of prostaglandin
 Seasonal and time influences

Signs of Labor
Preliminary Signs of Labor
 Lightening
 Increase level of activity
 Braxton hicks’ contraction
 Ripening of the cervix
Labor Contractions
True False
 Result in progressive cervical dilation x Do not result in progressive cervical dilation
 Occur at regular intervals x Occur at irregular intervals
 Interval between contractions decreases x Interval between contractions remains the same or
increases
 Frequency, duration, and intensity increase x Intensity decreases or remains the same
 Located mainly in back and abdomen x Located mainly in lower abdomen and groin
 Generally intensified by walking x Generally unaffected by walking
 Not easily disrupted by medications x Generally relieved by mild sedation

Signs of True Labor

1. Uterine contraction’s phases – initiation of effective, productive, involuntary uterine contractions

Phase:
 Increment/crescendo – intensity of contraction increases
 Acme/Apex – contraction reaches its height or peak
 Decrement/Decrescendo – intensity of contraction decreases
 Observation of Contraction

 Duration – from the beginning of one contraction to the end of same contraction
 Early stage of labor – 20 to 30 seconds
 Late stage of labor – 60 to 70 seconds
 Intervals – from the end of one contraction to the beginning of the next
 Early labor – 40 – 45 minutes
 Late labor – 2 to 3 minutes
 Frequency – from the beginning of one contraction to the beginning of the next contraction
 Intensity – strength of contraction
 Mild, moderate, strong

2. Show – blood and mucus

3. Rupture of the membranes
 Two risks associate with Rupture of Membrane
 Intrauterine infection
 Prolapse of umbilical cord

Components of Labor (5Ps)

1. Passage – uterus, cervix, vagina, external perineum

2. Passenger – fetus
3. Power – uterine factors
4. Psyche
5. Placenta

Leopold’s Maneuver

Systemic method of observation and palpation to determine fetal presentation and position

First Maneuver (Fundal Grip)

• Face the patient and warm your hands

• Place your hands on the patient’s abdomen
• Determine what fetal part is at uterine fundus
• Curl your fingers around the fundus
• When the fetus is in the vertex position (head first) buttocks should feel irregular shape and firm
• When the fetus is in breech position, the head should feel hard, round and movable
Second Maneuver (Umbilical grip)

• Move your hands down the side of the abdomen

• Applying gentle pressure
• If the fetus is in vertex position, you’ll feel a smooth, hard surface on one side – the fetal back
• Opposite, you’ll feel lumps and knobs – the knees, hands, feet, and elbow
• If the fetus is in the breech position, you may not feel the back at all
• Identifies and describes the fetal parts contained on each side of the uterus
• Locates for the position of the fetal back and auscultate for the fetal heart beat

Third Maneuver (Pawlick’s Grip)

• Spread apart your thumb and fingers of one hand

• Place them just above the patient’s symphysis pubis
• Bring your hand together
• If the fetus is in the vertex and has descended, you’ll feel a less distinct mass
• If the fetus is in the breech position, you’ll also feel a less distinct mass, which could be the feet or knees.
• Identifies the presenting part to determine the presentation and it’s mobility to determine engagement.

Fourth Maneuver (Pelvic Grip)

• The fourth maneuver can determine flexion or extension of the fetal head and neck
• Place your hands on both sides of the lower abdomen
• Apply gentle pressure with your fingers as you slide your hands downward, toward the symphysis pubis
• If the head is in the presenting fetal part (rather than the feet or a shoulder), one of your hands is stopped by
the cephalic prominence.
• The other hand descends unobstructed more deeply
• If the fetus is in the vertex position, you’ll feel the cephalic prominence on the same side as the small parts; if it’s
in the face position the same side as back
• If the fetus is engaged, you won’t be able to feel the cephalic prominence.
• Determines the fetal attitude

Station

• Fetal station is the position of the fetal presenting part and its descent into the pelvis, how far the fetus
descended, the ischial spines of the maternal pelvis are used to describe station 0

Fetal Lie

• Described by the relationship of the long axis of the fetus to the long axis of the mother
• This is a vertical lie
• Most common fetal lie

Transverse

• A problem with a term baby and labor approaching

Oblique

• A problem in a term pregnancy

Fetal Presentation

• Denotes the body part that will first contact the cervix or deliver first
Types of Fetal Presentation

1. Cephalic – head is the presenting part

 Vertex – parietal bone (full flexion)
 Brow – head is moderately flexed (military)
 Face – extension of head, face
 Mentum – hyperextension of the head (chin)
2. Breech presentation
 A fetus is said to be in a breech position when the buttocks of the baby are presenting first at the
bottom of the uterus, and the head is in the upper part, or fundus of the uterus
 Three types of breech presentations:
1. Frank breech – legs are flexed at the hips and extended at the knees so the feet are up by the head
2. Complete breech – one or both legs are extended
3. Incomplete breech – one or both hips are not flexed and the feet and knees are often below the
buttocks
3. Shoulder (Transverse)
 Fetus is lying horizontally in the pelvis and the presenting part can be the shoulder, iliac crest, hand or
elbow
 Causes:
 Relaxed abdominal walls from grand multiparity
 Pelvic contraction in which horizontal space is greater than the vertical space
 Placenta previa (placenta located low in the uterus)

Fetal Position

The relationship of the presenting part to a specific quadrant of the woman’s pelvis

Four Quadrants

1. Right anterior
2. Left anterior
3. Right posterior
4. Left posterior

Landmarks

1. Occiput
2. Breech – sacrum
3. Face – chin (mentum)
4. Shoulder – scapula or acromion process

Middle letter

Denotes the fetal landmark: O (occiput), S (sacrum), M (mentum), A (acronium)

First Letter

Landmark is pointing to the mother’s right or left

Last letter

Landmark points anteriorly (A), posteriorly (P), transverse (T)

Four Methods Used to Determine Fetal Position, Presentation, and Lie

• Combined abdominal inspection and palpation

• Vaginal examination
• Auscultation of FHT
• Sonography

Cardinal Movements (Mechanisms of Labor)

Engagement 0 station
Descent Head within the pelvic inlet
Flexion Fetal head flexed against the chest
Internal rotation Fetal head rotates from transverse to anterior
Extension Head extends with crowning
External rotation (restitution) Head returns to its transverse orientation
Expulsion Shoulders and torso of the baby are delivered

Cervical Changes

• Dilatation – how far has the cervix opened (in cm)

• Effacement – how thin is the cervix (in cm or %)

Stages of Labor

Cervical Dilatation

• Begins with true labor contraction and ends

Management of Early Labor

• Ambulation OK with intact membranes

• If in bed, lie on one side or the other, not flat on back
• Check vital signs every 4 hours
• NPO except ice chips or small sips of water

Three Phases of Cervical Dilatation

1. Latent Phase
 0 to 3 cm dilatation
 May lasts approximately 6 hours in nullipara and 4 to 5 hours in multipara
 Signs include: backache, cramping, bloody show, mother in talkative, cheerful, anxious

Nursing Care

 Diversional activities
 Time contractions
 Assess maternal-fetal status
 Promote hydration
 Utilize breathing pattern – slow, chest breathing
 Evaluate labor progress
2. Active Phase
 4 – 7 cm
 Contractions:
 3 – 5 minutes apart
 40 – 60 seconds long
 Stronger and more intense
 This phase lasts approximately 3 hours in nullipara and 2 hours in multipara

Nursing Care

 Assess maternal and fetal status

 Instruct the client pant-blow
 Backrubs, comfort measures
 Provide encouragement
 Provide analgesia if requested and if appropriate
 Promote hydration and elimination
 Keep perineum clean
 Promote rest between contractions
 Evaluate labor progress

Monitor the Fetal Heart

 During early labor, for low-risk patients, note the fetal heart every 1 – 2 hours
 During active labor, evaluate the fetal heart every 30 minutes
 Normal FHR is 120 – 160 bpm
 Persistent tachycardia (>160) or bradycardia (<120, particularly <100) is of concern

Electronical Fetal Monitors

 Continuously records the instantaneous fetal heart rate and uterine contractions
 Patterns are of clinical significance
 Use in high-risk patients
 Use in low-risk patients (optional)
3. Transition Phase
 8 0 19 cm dilatation
 Contractions:
 2 – 3 minutes apart
 40 – 90 seconds long
 Signs include: leg cramps, perspiration on forehead and upper lip, with dark profuse bloody
show, irritable, anxious and self-oriented

Nursing Care

 Assess maternal-fetal status

 Provide comfort measures
 Pant-blow with pushing urges
 Be supportive and help mother maintain control with breathing
 Evaluate labor progress
Delivery Stage of Labor

• From time of full dilatation until the infant is born; mother has urged to push

Nursing Care

 Assess maternal-fetal status

 Coach pushing
 Provide comfort
 Record time of delivery, episiotomy/lacerations, medications/anesthesia
 Evaluate labor progress
 Promote bonding

Anesthesia/Analgesia for Labor and Delivery

1. Narcotics
 Meperidine HCI (Demerol), after mixed with Promethazine (Phenergan) to potentiate
 Do not give if within two hours of delivery, infant may be depressed
2. Paracervical
 Numbs cervix, good for first stage of labor
 Should not be given after 8cm as it can cause fetal bradycardia
3. Pudendal
 Numbs vagina and perineum
 Good for second stage of labor
4. Epidural
 Numbs from the waist down

Nursing Interventions

 Take BP every 15 minutes until stable

 Assess bladder
 Assist in turning and pushing
 Hydrate client
 Assess FHR
 Complications: hypotension, fetal distress
5. Saddle (spinal) anesthesia
 Numbs waist down
 Complications: Headache
 Nursing interventions: Flat on bed, 4 – 6 hours

Episiotomy

• Avoid lacerations
• Provides more room for obstetrical maneuvers
• Shortens the second stage labor
• Midline associated with greater risk of rectal lacerations but heals faster
• Many women do not need them
• If there are lacerations, vaginal episiorrhaphy (repair) is done
Gauze

Gauze is compacted into the vagina to absorb the blood and apply pressure on the arteries of the uterus; vaginal packing
can slow bleeding

• Packing must be done to maintain pressure on the suture line, and must be removed after 6 – 8 hours
• If child is experienced by the patient during the procedure, cover with additional blankets

Clamp and Cut the Cord

• Cutting of the cord is postponed until the pulsations of the cord have stopped in order to allow additional blood
to flow into the newborn
• Clamp about an inch from the baby’s abdomen
• Use any available sterile instruments or usable material
• Check the cod for 3-vessels, two small arteries and one larger vein (AVA)

Placental Stage

• From time the infant is born until after the delivery of the placenta
• 2 phases: placental separation and placental expulsion
• Signs of placental separation:
 Lengthening of the umbilical cord
 Sudden gush of vaginal blood
 Change in the shape of the uterus

Nursing Care

 Assess maternal status – palpate the uterus if its contracted, may develop uterine atony
 Assess blood loss, note time of delivery of placenta
 Administer medications if ordered
 Oxytocin (Methergin) – once placenta is delivered, oxytocin is ordered by IM/IV, to increase uterine
contraction and minimize uterine bleeding. BP should be monitor because oxytocin causes HPN by
vasoconstriction

Inspect the Placenta

 Make sure it is complete

 Look for missing pieces
 Look for malformations
 Look for areas of adherent blood clot

Recovery and Bonding

• Begins after delivery of the placenta and continues for 1 – 4 hours after delivery

Nursing Care

 Assess VS, fundus and flow every 15 minutes

 Encourage hydration and elimination
 Promote comfort
 Promote bonding
 POSTPARTAL CARE

Postpartal Care

Refers to the medical and nursing care given to a patient from the time of delivery until her body returns to near its non-
pregnant state

Puerperium

• The 6-week period after the delivery, beginning with termination of labor and ending with the return of the
reproductive organs to the non-pregnant state
• Often times referred as the fourth trimester

Involution

• Progressive changes in the uterus after the delivery

• The descent of the uterus into the pelvic cavity
• Fundic height descends 1cm per day
• After birth, at umbilicus
• Day 10, behind symphysis pubis, non-palpable.

To promote uterine involutions

1. Early ambulation
2. Emptying of the bladder
3. Foods high in protein, vitamins and minerals
4. Knee chest or prone position

Goal of Postpartal Care

• Promote normal involution and return to the non-pregnant state

• Prevent or minimize postpartum complications
• Facilitate newborn care and self-care by the new mother

Factors Affecting Postpartal Experience

• Nature of labor and delivery and the birth outcome

• Preparation for labor and delivery and for parenting
• Postpartal complications
a. Pre-eclampsia/eclampsia
b. Bleeding – S/S: bright red blood with chills
 Bleeding can be prevented by:
 Performing nipple stimulation
 Initiating breastfeeding (cramping is normal and is caused by baby’s sucking, which
stimulates release of oxytocin)
 Administering oxytocin IM/IV
c. Precipitous/prolonged labor

Postpartal Biophysical Changes

System Changes
Reproductive Uterus o Firm in the midline below the umbilicus
o Must avoid if deviated at the right midline

Lochia o Rubra (1 – 3)
o Serosa (3 – 10)
 o Alba (10 – 14)
o If with very foul odor, sign of infection
Cervix o Gradually closes at week 6
Perineum o Edematous 1 – 2 days
o Healing of episiotomy takes 4 – 6 months
Breast o Rapid drop in estrogen and progesterone levels with an increase in
secretion of prolactin after delivery
o Immunoglobulin A – transferred from mother to newborn through
breastfeeding
o Apply a firm bra and ice packs to breasts (if in pain)
o Colostrum (first milk produced by body during pregnancy)
o Average amount of milk produced
 First week: 6 to 10oz
 1 to 4 weeks: 20oz
 After 4 weeks: 30iz
 Breastfeed per demand
Endocrine o Estrogen and progesterone drop rapidly after delivery
o Ovulation and return of menstruation
o Requirements for rest and sleep increase significantly
Cardiovascular o BV decrease to non-pregnant level by 2 weeks after delivery
o HCT rises by day 3 to 7
o BP remains stable; PR returns to non-pregnant state by 3 months postpartum
Respiratory o Pulmonary functions return to non-pregnant status by 6 months after delivery
Renal and Urinary o Over-distention of the bladder is common
o A full bladder will displace the uterus (in the right) and can cause postpartum
hemorrhage
o Adequate urinary emptying generally resumes in 5 -7 days
Gastrointestinal o Hunger and thirst are common
o GI motility and tone return to the non-pregnant state within 2 weeks after
delivery
o Hemorrhoids
Musculoskeletal o Ambulates 4 to 8 hours after delivery for NSD
Integumentary o Melanin, striae gravidarum gradually fades

Physical Assessment for Postpartum

B-U-B-B-L-E-H-E

• B – Breasts
• U – Uterine fundus (going down 1cm per day)
• B – Bladder function
• B – Bowel function
• L – Lochia (wearing pad, not normal 6 inches)
Rubra: dark red – small clots, mild, period-like cramping
Serosa: pinkish brown – less bloody and more watery, flow is moderate
Alba: whitish yellow – little to no blood, light flow or spotting
• E – Episiotomy (Perineum)
• H – Homan’s Sign (checking for deep vein thrombosis, supine, extended legs, flex ankles) AB: pain in muscle
• E – Emotions
Postpartal Adaptation Stages

Taking-in Period

• 1 to 2 days after delivery

• New mother is typically passive and dependent with energies focused on bodily concerns
• She may review her labor and delivery experience frequently
• Uninterrupted sleep is important

Taking-hold Period

• 2 to 4 days after delivery

• The mother becomes concerned with her ability to parent successfully
• Accepts increasing responsibility for her infant
• The mother strives to master infant-care skills
• The mother focuses on regaining control over her body functions

Letting-go Period

• Occurs when the new mother returns home

• Mother assumes responsibility for newborn care
• Postpartum depression most commonly occurs

Maternal Concerns and Feelings in the Postpartal Period

1. Abandonment
2. Disappointment
3. Post-partal blues

Portpartal Discharge Instructions

1. Work
2. Rest
3. Exercise
4. Hygiene
5. Coitus
6. Follow-up
7. Contraception

FOR LAM

1. No menstruation
2. Less than 6 months of age
3. Completely and exclusively breastfeeding
 NEWBORN CARE

Newborn

• Neonate – term for the first 28 days of life

Vital Signs

Respiratory Rate 30 – 60 cpm

Body temperature 36.5 – 37.5 C
Heart rate 120 – 160 bpm

ADDITIONAL INFO

Temperature for baby best in: Apical pulse, 3 rd – 4th intercostal spaces on left, under the nipple

Anthropometric Measurements

Weight 5.5 – 7.5 lbs

Length 46 – 54 cm
Head circumference 34 – 35 cm
Chest circumference 32 – 33 cm
Abdominal circumference 32 – 33 cm

Immediate Care of the Newborn

1. Maintenance of patent airway – slight Trendelenburg position

2. Provision of warmth – kangaroo hold
3. Identification
4. Nutrition – breastfeed per demand
5. Protection from infection and injury

Physiologic Weight Loss

>5 – 10% weight loss during the first few days of life

• NB is no longer under the influence of maternal hormone

• NB voids and passes tools
• NB experiences diuresis on the 2nd and 3rd day of life
• NB receives low calorie content milk (colostrum) on the first 3 days of life
• NB has ineffective sucking on the first few days of life

>Recaptures BW within 10 days

• 2lbs/months (6 – 8oz/week) for the first 6 months of life

Physiologic Functions

Cardiovascular System  Placenta used to supply the baby with oxygenated blood
 Lungs supply oxygenated blood to the baby
 Structures open intrauterinely:
Ductus arteriosus
Foramen ovale
Ductus venosus
 Peripheral circulation is sluggish during the first 24 hours
  Acrocyanosis is common (bluish discoloration of extremities)
 False high HCT and HGB at birth
 Leukocytosis is common due to trauma at birth
 Vitamin K injection
 BP is not routinely measured (legs are used for BP)
Respiratory System  RN should watch the rise and fall of abdominal or diaphragm muscle
 NB clears the airway by coughing and sneezing
 NB is an obligate nose breather
 Short periods of crying is beneficial
Gastrointestinal System  Sterile at birth
 After 5 hours, bacteria may be found
 Bacteria in the stomach is important for the synthesis of vitamin K
 Vitamin K is deficient in NB
 NB has immature cardiac sphincter
 Meconium:
Sticky, blacking green, odorless material from mucus, vernix, lanugo,
hormones that accumulate during intrauterine life, evident within the
first 24 hours
 NB has immature liver
Urinary System  Urine should be present within 24 hours of birth (pink and dusky due to uric acid
in utero)
 Male: small projected arc
 Female: steady continuous stream
 Urine: light colored and odorless
 At 6th week, urine concentration and reabsorption are evident (15 ml/void)
Immune System  Until 2 months, has difficulty forming antibodies against invading antigen
 Has previous antibodies at birth
 Has little natural immunity against herpes simplex
 Hepatitis B vaccine is given on the first 12 hours of life
Neuromuscular System  NB has immature NS, assess by the presence of absence of movement of
extremities, attempt to control head movement, and a strong cry
 Neuromuscular system is assessed by testing the reflex:
Blink reflex
Rooting reflex
Sucking reflex
Swallowing reflex
Extrusion reflex
Palmar grasp reflex
Step in place reflex
Placing reflex
Plantar grasp reflex
Tonic neck reflex
Moro reflex
Babinski reflex
Magnet reflex
Crossed extension reflex
Trunk incurvation reflex
Landau reflex
Deep tendon reflex
 Senses Hearing
• Appears to have difficulty locating the sound, but is able to hear
Vision
• Can see as soon as they are born and possibly have been seeing in the utero
for the last month of pregnancy
• Blinking and pupillary reflex is present at birth, can focus on object not
exceeding the midline at 9 – 12 inches
Touch
• Well developed at birth, as evidenced by reaction to painful stimuli
Taste
• Taste buds are developed and functioning before birth, as evidenced by
swallowing sweet tasting milk more readily than the bitter taste of salt
Smell
• Present as soon as nose is clear of mucus and amniotic fluid

Appearance of the Newborn

Skin – initially, hands and feet have a bluish color

Red complexion  Due to increased concentration of RBC and decreased amount of subcutaneous fat
Cyanosis  Due to peripheral circulation
Acrocyanosis  First 24 – 48 hours after birth (upper and lower extremities)
Mottling  Common
 Central cyanosis (cyanosis of the trunk), cause of concern due to decreased
oxygenation
 Result from temporary respiratory obstruction or an underlying disease state
 Intervention: swaddle NB and make sure that environment is not cold
Jaundice  Yellowish discoloration of the skin due to serum bilirubin of more than 7mg/100ml
 Intervention: paarawan si baby and drink fluids
Cephalhematoma  Collection of blood under periosteum of the skull bone
Vernix caseosa  A white cream cheese-like substance that serves as a skin lubricant
Lanugo  Fine, downy hair that covers a newborn’s shoulder, back, upper arm, forehead and
ears
Desquamation  Skin peeling due to change of squamous cells
Milia  White papule due to a plugged or unopened sebaceous gland found on the cheek,
across the bridge of the nose, and chin
Erythema toxicum  “Newborn rash”
 Lack of pattern, also known as “flea bite” rash
 Needs no treatment
Pallor  Result of anemia
Excessive blood loss when cord was cut
Short lived RBC
Poor maternal nutrition: low iron store
Harlequin sign  Redness on dependent side
 Due to immature circulation
Birthmarks

Hemangiomas  Vascular tumors of the skin

Strawberry hemangiomas  Elevated and immature capillaries
 Can occur anywhere but common in scalp, face, and neck
 Can be removed or lessened by surgical removal and steroids
Cavernous hemangiomas  Dilated vascular spaces
 Irregular in shape
 Does not disappear in time
 Appears in face, ear, neck
 Treatment: surgical removal and steroids
Mongolian spot  Collection of pigment cells that appear as slate gray patches across the sacrum or
buttocks and possibly the arms and legs
 Disappears by school age without treatment
 Common in Asian Southern European
Forceps mark  Circular or linear contusion matching the shape of the blade of forceps
 Disappears in 1 – 2 days

Head

• Appears disproportionately large, about ¼ of total NB length

• Forehead is large and prominent
• Full bodied hair-well-nourished NB

Fontanelles  Spaces or opening where the skull bones join

 Anterior fontanelles
located at the junction of the 2 parietal lobes and frontal lobe
diamond in shape
closes at 12 to 18 months
 Posterior fontanelles
located at the junction of parietal bones and the occiput bone
triangular in shape
closes by the end of second month
Sutures  Separating lines of the skull, may override at birth because of the extreme pressure
exerted by passage through the birth canal
Molding  Presenting head part that engages in the cervix, molds to fit the cervix contour
 Normal shape is restored after a few days to one week
Caput Succedaneum  Edema of the scalp at the presenting part
 Disappear at the third day of life without treatment
Cephalhematoma  Collection of blood between the periosteum of the skull bone and the bone itself
caused by rupture of a periosteum capillary due to pressure at birth
 Occurs 24 hours after birth, will subside by itself after a few weeks

Eyes

• NB cry tearlessly until 3 months

• NB iris may be gray or blue
• Permanent color may be assessed at 3 months
• Eyes of the NB should be clear, without redness and purulent discharge
• AB: Crede’s Prophylaxis – occasional crossing of eyes

Ears
 • Pinna of NB tends to bend easily
• Outer canthus of the eye should be in line with the upper pinna
• Absence of skin tags in front of the ear

Nose

• May appear large for the face

Mouth – should open evenly

• Suction mouth first before the nose to prevent air from forcing mucus back into the bronchi and alveoli
• Newborns are obligatory nose breathers until they are about 3 weeks
• Intact palate, no harelip
• Has mucus, but not blowing bubbles
• Check for natal teeth
• AB: Epstein pearl – small round glistening, well circumscribed cyst

Neck

• Short and should not be rigid

Chest

• May have breast engorgement that will subside in a week time, do not manipulate
• May secrete thin, watery fluid “witch’s milk”

Abdomen

• Slightly protuberant
• Bowel sounds can be heard after 1 hour

Anogenital Area

• Patent anus
• Time of meconium
 Males
Check for testes (undescended)
Retracted to test for phimosis (tight foreskin)
Small penis with 2cm length
Location of urethra
 Females: swollen vulva

Back

• Straight and flat

• Lumbar and sacral curves start to develop when child has learned how to sit up or stand up

Extremities

• Proportional in length
• Legs are normally bowed

Infant’s Reflexes
 • A reflex is a response to a stimulus and that occurs without conscious thought
• Babies are born with a unique set of reflexes that can tell a physician about their health and development
• Within the first minute after birth, nurses and doctors assess these reflexes

Reflexes

Reflex Description When does it disappear

Blink May be elicited by shining a strong light such as flashlight or otoscope
light on an eye.

A sudden movement toward the eye sometimes can elicit the blink
reflex.

To protect the eye from any object coming near it by rapid eyelid
closure
Rooting If the check is brushed or stroked near the corner of the mouth, a At about 6th week of life
newborn infant will turn in that direction
Newborn eyes focus steadily,
Severs to help a newborn find food; when a mother holds the child so a food source can be seen,
and allows her breast to brush the newborn’s cheek, the reflexes and the reflex is no longer
make the baby turn toward the breast needed
Sucking When baby’s lips are touched, the baby makes a sucking motion Begins to diminish at about 6
months of age. It disappears
Helps the newborn find food: when the newborn’s lips touch the immediately if it is never
mother’s breast or a bottle, the baby sucks and so takes in food stimulated.

It can be maintained in such

an infant by offering the child
a non-nutritive sucking object
such as pacifier
Swallowing Swallowing reflex in a newborn is the same as in the adult. Food t hat
reaches the posterior portion of the tongue is automatically
swallowed.

Gag, cough and sneeze reflexes are also present to maintain a clear
airway in the event that normal swallowing does not keep the
pharynx free of obstructing mucus
Extrusion A newborn extrudes any substance that is placed on the anterior About 4 months of age. Until
portion of the tongue then, the infant may seem to
be spitting out or refusing
Protective reflex prevents the swallowing of inedible substances solid food placed in the mouth
Step (Walk)- Newborns who are held in a vertical position with their feet touching 3 months of age
in-Place a hard surface will take a few quick, alternating steps
By 4 months, babies can bear
a good portion of their weight
unhindered by this reflex
 Reflex What it is When does it disappear
Placing Similar to step-in-place reflex, except that elicited by touching the
anterior surface of the newborn’s leg against a hard surface such
as the edge of the bassinette or table

The newborn makes a few quick lifting motions, as if to step onto

the table, because of the reflex
Palmar Newborn grasp an object placed in their palm by closing their 6 weeks to 3 months of age
fingers on it

A baby begins to grasp meaningfully at about 3 months

Plantar When an object touches the sole of a newborn’s foot at the base of 8 to 9 months of age in
the toes, the toes grasp in the same manner as the fingers do preparation for walking.
However, it may be present in
during sleep for a longer
period
Tonic Neck If you turn a newborn’s head to the opposite side, he or she will Second and third months of
often change the extension or contraction of legs and arms life
accordingly

Also called the “boxer or fencing reflex”

Moro A moro “startle” reflex can be initiated by startling a newborn with Strong for the first 8 weeks
a loud noise or by jarring the bassinet and fades by the end of the 5th
and 9th month
The most accurate method of eliciting is to hold the newborns in a
supine position and allow their heads to drop backwards about 1 At the same time the infant
inch can roll away from danger
Babinski When the side of the foot is stroked in an inverted “J” curve from Occurs because nervous
the heel upward, a newborn fans the toes (positive Babinski sign) system development is
immature. It remains positive
In contrast to the adult, who flexes the toes (toes fan) until at least 3
months of age, when it is
supplanted by the down-
turning or adult flexion
response
Magnet If pressure is applied to the soles of the newborn lying in a supine
position, he or she pushes back against the pressure

This and two following reflexes are tests of spinal cord integrity
 Reflex What it is
Crossed If one leg of a newborn lying supine is extended and the sole of that foot is irritated by being rubbed
Extension with a sharp object, such as a thumbnail, the infant raises the other leg and extends it, as if trying to
push away the hand irritating the first leg
Trunk When newborns lie in a prone position and are touched along the paravertebral line area by a probing
Incurvation finger, they flex their trunk and swing their pelvis toward the touch
Landau A newborn who is held in a prone position with a hand underneath, supporting the trunk, should
demonstrate some muscle tone

Babies may not be able to lift their head or arch their back in the position (as they will at 3 months of
age), but neither should they sag into an inverted “U” position. The latter response indicates
extremely poor muscle tone
Deep Tendon A patellar reflex can be elicited in a newborn by tapping the patellar tendon with the tip of the finger
Biceps A test for spinal nerves C5 and C6
Patellar Test for spinal nerves L2 through L4

Newborn Screening

(Newborn Act of 2004 – RA 9288)

• A procedure done to find out if a baby has a congenital metabolic disorder that may lead to mental retardation
and even death if left untreated
• Ideally done 24 hours after CHON intake
• Using the heel prick method, a few drops of blood are taken and blotted on a special absorbent filter card
• If with positive results, confirmatory testing should be done. If still with positive results, refer to specialist

The Philippine Newborn Screening Program is currently screening for five disorders and the following are:

Congenital Hypothyroidism (CH) • Most common, absence or lack of thyroid hormone which is essential to
growth of the brain and the body
Congenital Adrenal Hyperplasia • Most rare but dangerous because it can cause death within 9 – 13 days
(CAH) • Causes severe salt loss, dehydration and abnormally high levels of male sex
hormones
Galactosemia (GAL) • Unable to process galactose
• Excessive galactose in the blood can cause liver damage, brain damage and
cataracts
Phenylketonuria (PKU) • Unable to process phenylalanine (building blocks of CHON)
• Causes brain damage
Glucose 6 Phosphate • Lacks the enzyme G6PD
Dehydrogenase Deficiency • Prone to hemolytic anemia once exposed to oxidative substances found in
(G6PD Def) drugs, food, and chemicals
APGAR Scoring

Done at first minute of life then after 5 minutes of life

Criteria Indicator 0 1 2
Appearance Color Pale or Blue Acrocyanosis (body is pink Totally pink
but extremities are blue)
Pulse Heart Rate Absent Less than 100 More than 100
<60 60 - 100
Grimace Reflex No response Grimace, aggressive Cough/Sneeze, cry on
Irritability stimulation for cry stimulation
Activity Muscle Tone Absent/Floppy/Limp/Flaccid Some flexion Active movement
Flexes + resist extension
Respiration Respiratory Absent Slow and irregular/Weak Good cry
effort and Gasping

Score Interpretations

0–3 4–6 7 – 10
• Severely depressed • Moderately depressed • Good condition
• CPR is needed • Infant needs specialized, • Infant will do well in normal
• Prognosis of newborn is grave intensive care newborn nursery

Expanded Program for Immunization (EPI)

 IMMEDIATE NEWBORN CARE

Introduction

 Newborn undergo profound physiological changes at the moment of birth

 Within minutes after being plunged into the environment, a newborn’s body must initiate respirations and
accommodate a circulatory system to extrauterine oxygenation
 How well a newborn makes these major adjustments depends on things (genetic composition, competency of
recent intrauterine environment, care the newborn receives during labor and birth period, and newborn or
neonatal period) – where the NURSES PLAY A MAJOR ROLE IN ACHIEVING THIS GOAL

Goals of the Immediate Newborn Care

1. Establish, maintain and support respiration

 Newborn’s position should be the one
 It should be Trendelenburg position or head should be lower than the rest of the body
 Full term: fr. 8 suction catheter; preterm: fr. 5 suction catheter
 Do suction gently and quickly
 Mouth first before the nose to prevent air from forcing mucus back into the bronchi and alveoli
 A crying infant is a breathing infant

ADDITIONAL INFOAbnormal Cry

High pitch – indicates hypoglycemia, increased intracranial pressure

Weak cry – preterm or premature
Hoarse cry – might have laryngeal stridor  results from weakness of larynx or voice box present during birth

 NB: obligatory nose breather until 3 weeks

2. Provide warmth and prevent hypothermia
 Newborn suffers large losses of heat because he/she is wet at birth (newborn has amniotic fluid)
 Perform responsibilities like drying the baby from head to foot using soft cloth, delay initial breathing
until temperature has stabilize (after 6 hours), maintain ambient temperature of nursery
3. Ensure safety and prevent injury and infection
4. Identify actual or potential problems that may require immediate attention

Prepare the Things Needed

 2 sterile gloves (when receiving newborn baby,  Sterile cord clamp

and cord care)  Erythromycin/Terramycin ophthalmic ointment
 Droplight  Vitamin K
 2 clean cloths  Tuberculin syringe
 Tape measure  Diaper
 Weighing scale  Isolette (incubator)/bassinette (NSD: crib)
 70% isopropyl alcohol  Sterile cotton balls

Procedure

1. Anthropometric Measurements (normal measurements for normal NB)

 Weight: 5.5 – 7.5lbs
 Height/length: 46 – 54cm (start at foot to head part  follow curve)
 Head circumference: 34 – 35cm (landmark: eyebrows)
 Chest circumference: 32 – 33 cm (landmark: nipples)
 Abdominal circumference: 32 – 33cm (landmark: above cord)
 2. Change sterile Gloves
 For nurses alone, they do double gloving (wearing 2 sets of gloves for immediate nursing care to prevent
hyperthermia)
3. Cord Care
 Use 70% isopropyl alcohol and sterile cotton balls
 Apply in a circular manner form the sterile part to the clean part
Clamp the cord ½ - 1 inch above the abdomen and cut it  Cord changed 24 hours with sterile suture, if
not, cord usually falls after 7 – 10 days
 Use a sterile blade in cutting the cord
 Inspect for the presence of 2 arteries and 1 vein (AVA)  absence of one of these meaning NB is not
normal
4. Eye care
 Crede’s prophylaxis: tetracycline or erythromycin ophthalmic ointment or 1% silver nitrate, OU (both
eyes)  to avoid gonorrhea or chlamydia infection
 Apply over the lower eyelids of both eyes from inner to outer canthus
5. Vitamin K injection
 Because NB do not have vitamin K necessary for clogging factors
 Aquamephyton/phytomenadione
 DOSE: .05ml (preterm)/0.10ml (full term)  check first whether infant is full term or pre term
 MANNER: inject-aspirate-push
 ROUTE: intramuscular (vastus lateralis)

For babies delivered via NSD

 Diaper the baby

 Dress the baby
 Wrap the baby with a thick cloth in a ‘swaddle” manner
 Place the baby in bassinette
 Render droplight

For babies delivered via C.S.

 Diaper the baby

 Place in an isolette for 6 hours (SOP) after delivery  after isolation will be transferred in bassinette

Don’t Forget

 Clean your area (CLAYGO)

 Baseline vital signs after 30 minutes
Temperature anus initially (for temperature and to
 Temp: 36.5C – 37C
check for patent anus); check underarm or axilla
 PR: 120 – 160 bpm
 PR when crying: up to 180 bpm Check PR by auscultation in apical pulse below nipples
 PR when asleep: as low as 100 bpm
 RR: 30 – 60 cpm
 Watch out for any signs of distress
 Document necessary data (anthropometric data, medications given, necessary data such as abnormal findings)
 Newborn’s ID tag (usually in lower extremities)