UNIVERSIDAD DE MANILA

(City College of Manila)

NR 22 Batch 2012

Nursing Management for Mother during

Labor until Postpartum in a Normal Delivery

In Partial Fulfillment of the Requirements for the

Maternal and Child Health Nursing Care

Submitted by:

Group 3

January, 2010
Background of the Study

Pregnancy is a wonderful thing and a sign of blessing for every womans life.
Being a mother is a challenge for every woman to become more independent and to know
more deeper of life. Pregnancy is such a huge change in a womans life that it brings
about more changes than any other life event besides puberty. A woman experiences
much variation in her attitude towards the process and body alteration is a major reason
for this. Because of this , the major responsibility of a nurse caring for a pregnant woman
is to help the mother maintain a state of wellness throughout the pregnancy and into early
parenthood.
Parenthood is a ladderized process that a mother should take in order to be a better
parent to her child and may leads to a strong relationship and fruitful living for the family.
This is a process of permanent autonomy and life maturity.
This study focuses on a normal process of pregnancy. It utilizes a comprehensive
nursing process that can be an effective tool in assisting the patient in attaining and
maintaining an optimum level of functioning.
Roles of the Nurse

Nurses assume a number of roles when they provide care to clients. Nurses often
carry out these roles concurrently, not exclusively of one another. For example, the nurse
may act as a counselor while providing physical care and teaching aspects of that care.
The roles required at a specific time depend on the needs of the client and aspects of the
particular environment.

1. Caregiver/ Care provider

functions as nurturer, comforter, provider

mothering actions of the nurse
provides direct care and promotes comfort of client
activities involves knowledge and sensitivity to what matters and what is
important to clients
shows concern for client welfare and acceptance of the client as a person

2. Teacher

Encourages compliance with prescribed therapy.

promotes healthy lifestyle
interprets information to the client

3. Counselor

provides emotional, intellectual to and psychologic support

Focuses on helping a client to develop new attitudes, feelings and behaviors rather
than promoting intellectual growth.
Encourages the client to look at alternative behaviors recognize the choices and
develop a sense of control.
4. Client advocate

Promotes what is best for the client, ensuring that the clients needs are met and
protecting the clients right.
Provides explanation in clients language and support clients decisions.

5. Manager

Plans, give direction, develop staff, monitors operations, give the rewards fairly
and represents both staff and administrations as needed.

6. Researcher

participates in scientific investigation and must be a consumer of research findings

Must be aware of the research process, language of research, a sensitive to issues
related to protecting the rights of human subjects.
ACKNOWLEDGEMENTS
This case study would not have been possible without the help of the following:
First, to our Almighty God, without His spiritual guidance we will not be able to
do and finish this study.
We wish to express our warm and sincere appreciation to Mr. and Mrs. CP, for
their trust and cooperation, without them, we wouldnt able to conduct the study.
We would like to express our deep and sincere gratitude to our Clinical Instructor,
Ms. Evangeline V. Fermin. Her wide knowledge and her logical way of thinking have
been of great value for us. Her understanding, encouragement and personal guidance
have provided a good basis for the present case study.
To the midwives and staffs of Esperanza Lying-in Clinic, their assistance,
guidance and accommodation have given us opportunity to do and conduct the study.
To our friends and classmates, for their enthusiasm and upholdment for us to
accomplish the study.
Lastly, we owe our loving gratitude to our family without their encouragement,
understanding and financial support, it would have been impossible for us to finish the
study.

GROUP 3
Terminologies
Bloody show - is the passage of a small amount of blood or blood-tinged mucus through
the vagina near the end of pregnancy
Brant-Andrews maneuver - slowly pulling the cord and wind at the clamp
Childbirth - is the culmination of a human pregnancy or gestation period with birth of
one or more newborn infants from a woman's uterus.
Dilatation an induced, temporary enlargement of an opening or passageway, as to aid
examination.
Effacement - is the shortening, or thinning, of the cervical canal, stretched and dilated by
the fetus during labor.
Gestation pregnancy or maternal condition of having a developing fetus in the body.
Internal Examination - A physical examination in which the health care professional
will feel for lumps or changes in the shape of the vagina, cervix, uterus, fallopian tubes,
ovaries, and rectum.
Involution a process whereby the reproductive organs return to their non-pregnant
state.
Labor is the process by which the fetus & placents are expelled from the uterus and the
vagina into the external environment.
Leopold's Maneuvers - are a common and systematic way to determine the position of a
fetus inside the woman's uterus.
Multiparous - refers to a woman who has given birth two or more times
Newborn Screening -is the process of testing and screening newborn babies for certain
potentially dangerous conditions.
Obstetrics - is the surgical specialty dealing with the care of women and their children
during pregnancy, childbirth and postnatal
Parity - is a technical term that refers to the number of times a woman or female animal
has given birth.
Postnatal - is the period beginning immediately after the birth of a child and extending
for about six weeks
Pregnancy - is the carrying of one or more offspring, known as a fetus or embryo, inside
the uterus of a female.
Prenatal care -refers to the medical and nursing care recommended for women before
and during pregnancy.
Primipara - a woman in her first pregnancy
Puerperium the state of a woman at and immediately following childbirth.
Vaginoplasty surgery on the vagina.
Viability capability of living, usually accepted as 24 weeks, although survival is rare.
 Introduction
The care of the childbearing and childrearing families are the major focus of the
practice because to have a heathy adults, you must have a healthy children at first. To
have a healthy children, it is important to promote the childbearing woman and her
family from the time before the children are born until adulthood. Both preconceptual and
prenatal care are essential contribution to the health of the woman and the fetus to a
familys emotional preparation for the and childrearing family.

Maternal health refers to the health of women during pregnancy, childbirth and the
postpartum period. While motherhood is often a positive and fulfilling experience, for too
many women it is associated with suffering, ill-health and even death.

The major direct causes of maternal morbidity and mortality include haemorrhage,
infection, high blood pressure, unsafe abortion, and obstructed labour.

For the past so many years in the past, there has been a huge percentage of
maternal death that dappen during the entire course of pregnancy. This also leads to the
increase of the infant mortality rate. Primary reason of this is the improper management
of the mother and infant during the course of delivery.
Because of this, a very important of role of nurse is needed to be implied, the
study holds a very essential vsion of studying and establishing what are the roles of the
nurse in assessing, caring and evaluating a mother before, during, and after a childbearing
process.

The first step for avoiding maternal deaths is to ensure that women have access to
family planning and proper nursing management during the entire period of pregnancy.

The women who continue pregnancies need care during this critical period for
their health and for the health of the babies they are bearing. Most maternal deaths are
avoidable, as the health care solutions to prevent or manage the complications are well
known. Since complications are not predictable, all women need care from skilled health
professionals, especially at birth, when rapid treatment can make the difference between
life and death.

Given all of these situations and conditions, it is very important that there should
be an established practice about maternal management during the course of prenancy. It is
very important for nurses that they can efficiently assess, mange, and evaluate a normal
maternal pregnancy.
 Objectives
General Objective:
To make an established concept on the proper assessment, management, and
evaluation of a normal pregnancy and the period after it.

Specific Objectives:
1. To determine the conditions and measures that the mother has undergone during
pregnancy for the promotion of maternal and infant health.

2. To determine what are the emotional responses by the mother and her family
during the course of acceptance of pregnancy.

3. To determine what are the management done by the mother after delivery of infant
for the promotion of maternal health.

4. To gain knowledge regarding different drugs. Citing its side/adverse effects and
nursing management with patient.

5. To educate appropriate health teaching that will promote wellness of the mother
and the baby. At the same time, equip the patient knowledge that will eliminate
their doubts about health.
 Biographical Data

Mothers name: Mrs. C.P.

Age: 27 y/o
Birthday: October 8, 1982
Place of birth: Sta. Mesa, Manila (ELIC)
Address: 4730 Old Sta. Mesa St. Manila
Height: 5 2
Weight: 48 kg
Religion: Roman Catholic
Language: Tagalog, English
Marital status: Single
Occupation: Saleslady
Name of husband : Mr. C.P.
Age: 25 y/o
Occupation: Employee
Religion: Roman Catholic
Usual Source of medical care: Health Center/ Family care/Clinic
No. of children: 1 child
Obstetrics: G1P1
 Physical Assessment
(Cephalocaudal)
Mrs. C.P., a twenty-seven years old, was a newly postpartum mother who
delivered her first baby. She was a well-groomed and active mother. She stands 5 ft and
weighs 48 kgs. Her BP-110/70 mmHg, PR-90 bpm, Respiration-25 breaths/min and
temperature-36.8C.

Body Part Tool-Technique Findings Interpretation

Head Inspection Skull is well-formed Normal bcause its
Palpation Rigid w/ no damage
hard and no wounds
found.
Hair Inspection Black and evenly distributed Normal because of
Palpation Shiny and smooth
good hair growth.
Eyes Inspection Properly aligned, transparent Normal because no
cornea, round & equal pupil, visible irregularities
clear conjuctiva seen and no visual
Palpation Eyelids show no evidence of
blurring.
swelling or tenderness
Nose/Sinuses Inspection Symmetrical, lesion free, no Normal because no
deviation of the septum or evidence of foreign
discharge bodies or dried blood
Palpation External nose is free from
in the nose and the
structural deviation, no
patient can identify
tenderness and sweelling
familiar odors.
Ears Inspection Same color as the skin, no Normal because
inflammation, no discharge, external and internal
no swelling meatus are patent.
Mouth/Throat Inspection Pink lips, no dryness and Normal because there
cracking, no lesions is no unusual odor to
Palpation Free from tenderness,
the breath and no
 nodules and swelling, no inflammation.
pain
Skin/Nails Inspection Pink color nails, no areas of Normal because there
pallor, jaundice and is adequate circulating
cyanosis, slightly curved blood and nails tissues
nailbed, nail base angle of are intact.
160 or less.
Palpation Relatively dry skin, smooth
and warm, quickly returns to
its original shape when
gently squeezed.
Breast Inspection Slightly asymmetrical, no Normal because left
edema, same color as the breast is usually larger
rest of the skin than the right as its
Palpation No nodules or unusual
normal size and no
tenderness is apparent
presence of discharge
or masses formation.
Cardiovascular Inspection No pulsations are visible Normal because there
Palpation No lifts or heaves are
System is a good
detectable
cardiovascular sounds
Auscultation No murmurs
heared.
Abdomen Inspection Symmetrical, free from Normal because no
lesions, stretch marks seen masses were detected.
Palpation No tenderness or masses are
detectable, free from rigidity
Percussion Tympany over the stomach,
dullness over the liver,
kidneys, pacreas and spleen
Auscultation No bruits and murmurs
Musculo- Inspection Body parts are symmetrical, Normal because there
skeletal no gross deformities are is no presence of
 System apparent, gait is smooth, no
swelling and tenderness
Palpation No involuntary contractions
or twitching is detectable
Neurologic Inspection Memory and attention span
System are intact, reflexes are intact
contractions and any
inflammations.
Normal because the
cranial nerves fuctions
properly.

Past Medical History

The client has complete immunization. She experienced having chickenpox during
her elementary days. She also experienced Urinary Tract Infection during her high school
days. She has no allergy to any foods, detergents, medications and etc. And during the
period of gestation on her first baby, on the first and second month of pregnancy the level
of infection of UTI increased, then after the third month of pregnancy the level of
infection decreased. Because it is her first time to get pregnant she often have prenatal
check-up.

Present Medical History

Last December 09, 2009 Mrs. C.P. was admitted to Esperanza Lying-in Clinic due
to labor pains she experienced. She did not experience any complications during and after
her delivery. She normally delivered her first baby. She never had a postnatal check-up
after she has been discharged.
She is currently taking her medication as prescribed by the physician. Mrs. C.P.
had injected Tetanus Toxoid 1 and 2 for her immunization as administered by the
physician.

Family Medical History

Mrs. C.P. mother is the only person who had an illness of hypertension. Her father
died because of an accident at the age of 33. Among the five children of her parents, she
and her sister had their own family.
 On Mr. C.P. side, his father had an illness of arthritis, while his mother died
because of cancer in the pancreas. They are both complete in immunization like BCG,
DPT, OPV, Hepa B and measles.

Stages of Labor
(First stage Puerperium)
FIRST STAGE
First Stage: onset of contractions to full dilatation & effacement of the cervix stage of
effacement & dilatation
Latent Phase:
Assessment:
Dilatations: 0-3 cm
Frequency: 5-10 mins
Duration: 20-40 mins
Intensity: mild
Mother is excited, apprehensive but can communicate

Nursing Care:
Encourage walking (shortens the 1st stage of labor)
Encourage to void q2-3 hrs. (full bladder inhibits uterine contraction)
Breathing (chest breathing technique)

Active Phase:
Assessment:
Dilatations: 4-8 cm
Frequency: q 3-5 mins lasting for 30-60 secs
Duration: 30-60 secs
Intensity: moderate

Nursing Care:
M edications (have medication ready)
A ssessment (include: v/s, cervical dilatation & effacement, fetal monitor, etc)
D ry lips (oral care -ointment, dry linens)
Breathing (abdominal breathing)

Transitional Phase:
Assessment:
Dilatations: 8-10cm
Frequency: q 2-3 mins contractions
Duration: 45-90 sec
Intensity: strong
Mood of mother suddenly change accompanied by hyperesthesia (hypersensitivity
of mother to touch) of the skin. Management:sacral pressure, cold compress

Nursing care:
T tires
I inform of progress (to relieve emotional support)
R restless support her breathing technique
E encourage & praise
D discomfort
Duration of Labor:
Primipara 14 hrs but not more than 120 hrs
Multipara 8 hrs but not more than 14 hrs

Pelvic Exams: Effacement & Dilatation

Station relationship of the presenting part to the ischial spine

5 -1 = the presenting part is above the ischial spine
Engagement 1-0 = the presenting part is in line with the ischial spine
(-) fetus is floating
(+) below the ischial spine

Presentation the relationship of the long axis of the fetus to the long axis of themother.
spine relationship of the spine of the mother & the spine of the fetus
Two Types:
Longitudinal Lie (Parallel)/ Vertical
Cephalic when the fetus is completely flexed
o Vertex
o Face
o Brow
o Chin
Breech
o Complete breech thigh rest on abdomen while legs rest on thigh
o Incomplete breech
Frank thigh resting on abdomen while legs extend to the head
Footling
Kneeling

Transverse Lie (Perpendicular)/Horizontal lie

Position relationship of the fetal presenting part to specific quadrant of the mothers
pelvis.
o ROA/LOA
left occipito anterior
most common & favorable position
o ROT/LOT left occipito transverse
o ROP/LOP left occipito posterior
o L/R- side of maternal pelvis
o Middle presenting part
o ROP/ROT most common malposition
 o ROP/LOP most painful mgt: pelvis squatting
o Breech sacro
place the stethoscope above the umbilicus
o Chin mentum
o Shoulder acromnio dorso

Monitoring the contractions & fetal heart tone

spread the finger lightly over the fundus to monitor the contraction
Increment/Cresendro - beginning of contraction until it increases
Apex/Acne height of contraction
Decrement/Decresendro from height of contraction until it decreases
Duration beginning of contraction to the end of the same contraction
Interval from end of contraction to the beginning of the next contraction
Frequency from the beginning of 1 contraction to the beginning of next contraction
Intensity strength of contraction
if contract blood vessel constricts; the fetus will get the oxygen on the placenta
reserve which is capable of giving oxygen to the fetus up to 1min.
Duration of placenta to the fetus should not exceed 1min.
Significance During active phase, if to 1min should notify the AMD
BP; FHT : best time to get BO & FHT just after a contraction

NURSING CONSIDERATION:
Bath is necessary
Monitor VS especially BP
o Same BP = rest
o Elevated = notify the physician
NPO
o Prevent aspiration chemical pneuminitis
Enema (per hospital policy)
o Purpose
Cleanse the bowel
Prevent infection
o 12 18 inches normal length of tube
o 18 inches optimal length
o Lateral sims position
o If there is contraction clump the tube
o If there is resistance slowly remove
o Before and after administration: check FHT (120 160) and contractions
Encourage mother to void
Perineal preparation (rule of 7)
 Rest on left side lying position
o Prevent supine vena cava syndrome or supine hypotension
If membrane doesnt rupture amniotomy
Fetal trashing - hyperactivity of fetus due to lack of Oxygen
For Pain
o Systemic analgesic
DEMEROL (Meperidine HCl)
Narcotic and antispasmonic
Dont give during latent phase
Given at 6-8 cm dilated
WOF : Respiratory depression
Narcan (Naloxone, nalorfan, nalline)
Antidote for toxicity
Injected on the baby
Epidural Anesthesia
WOF : Hypotension
Prehydrate the client to prevent hypotension
In case of Hypotension
Elevate leg
Fast Drip IV

SECOND STAGE (FETAL STAGE)

Second Stage: Complete dilatation and effacement to birth

Crowning occurs
PRIMI transfer to DR at 10 cm dilatation
MULTI transfer to DR at 7 8 cm dilatation
Position in lithotomy both legs at the same time
Bulging of perineum surest sign of delivery initiation
Pant & Blow Breathing, fetal pushing should be done on an open glottis
Respiratory alkalosis
o Due to incorrect breathing
o Hyperventilation
o S/sx:
RR
Lightheadedness
Tingling sensation
Carpopedal spasm
 Circumoral numbness
Episiotomy
o Prevent laceration
o Widen the vaginal canal
o Shortens the 2nd stage of labor
o 2 types:
MEDIAN
Less bleeding
Less pain
Easy repair
Possible urethroanal fistula major disadvantage
MEDIOLATERAL
More bleeding
More pain
Hard to repair and slow healing
o Ironing the Perenium prevent laceration

Mechanism of Labor:
Engagement
Descent
Flexion
Internal Rotation
Extension
External Rotation
Expulsion
PELVIS
3 Parts
o Inlet AP diameter narrow, transverse wider
o Cavity between inner and outer
o Outlet AP diameter wider, transverse narrow
Nursing Care:
Modified Rigens maneuver
o Done by supporting the perenium with a towel during delivery
o Facilitates complete flexion
o Avoids laceration
First intervention: Support the head and suction secretion
Do not milk the cord, wait for pulsation to stop before cutting
o Milking may cause too much blood going to the baby that may cause
cardiac overload
When there is still birth, let the mother see the baby to accept the finality of death
THIRD STAGE (PLACENTAL STAGE)

3 10 minutes after child birth

1st sign Fundus rises Calkins sign
Signs of Placental Separation:
o Fundus becomes globular and rises calkins sign
o Lengthening of the cord
o Sudden gush of blood
Brant-Andrews maneuver
o slowly pulling the cord and wind at the clamp
o rapidly may cause uterine inversion
Types Placental Delivery:
o SHULTZ (Shiny)
From center to the edges
Presenting fetal side
o DUNCAN (Dirty)
Form edges to center
Presenting the maternal side

NURSING CONSIDERATIONS:
Check placental completeness
o Should be 500 g
Check Fundus Massage if Boggy
BP Check
Methergine, methylergonovine mallate (IM)
Oxytocin (IV) if methergine is not present
Check perenium for lacerations
Assist in episiorapy
Vaginoplasty/ Vaginal Landscape Virgin again

FOURTH STAGE (Recovery Stage)

Fourth Stage: First 1 2 hours after delivery of placenta

Maternal observation body system stabilize

o 1st hour q15 min
o 2nd hour - q 30 min
 Placement of fundus
o In between umbilicus and pubis symphysis
o Check bladder, assist in voiding, May lead to uterine atony hemorrhage

Lochia
Perineum
o Check REEDA
R edness
E dema
E cchymosis
D ischarge
A pproximation
o Fully saturated 30 40 cc

NURSING CONSIDERATIONS:
Flat on bed to prevent dizziness
If with Chills give blanket due to dehydration
Give nourishment (progression of meal)
o Clear liquids gatorade, ginger juice, gelatins
o Full liquid milk, ice cream
o Soft diet
o Regular diet
Check VS/ Pain
Pychic State
Bonding interaction between mother and newborn
o Strict 24 hours with mother
o Partial morning with mother, night nursery

FIFTH STAGE (Puerperium)

The postpartum period, or puerperium, refers to the 1 to 6 or 8-weeks period after

delivery during which the mothers body returns to its prepregnant state. Some people
refer to this period as the fourth trimester of pregnancy. Many physiologic and
psychological changes occur in the mother during this time. Nursing care should focus on
helping the mother and her family adjust to these changes and on easing the transition to
the parenting role.

Psychological Responses:
Taking in phase dependent phase (1st three days) mom passive, cant make decisions,
activity is to tell child birth experiences. During this time, the womans attention is
focused on her own needs for sleep, rest and she is dependent on others.
Nursing Care: - proper hygiene

Taking hold phase dependent to independent phase (4 to 7 days). Mother is active, can
make decisions. The concern of the mother at this time is focused on her ability to control
body function and her ability to assume the mothering role. She prefers to do things by
herself. As she is not yet completely recovered, she feels impatient that shes not strong
enough to do everything she wishes to accomplish. Because of the tendency of the
woman to overwork herself, fatigue and exhaustion is common at this stage.
- Begins to take a strong interest for her child
- Give the woman brief demonstration of baby care
- Allow her to care for the child herself with watchful guidance

Letting go interdependent phase 7 days & above. Mother redefines new roles, may
extend until child grows. Letting-Go the act of ending old ways of thinking or
believing.
- The woman finally redefines her new role
- Gives up fantasized image of her child and accepts the real one
- Gives up her old role of being childless or the mother of only one or two
- Extended and continues during the childs growing years

Maternal Concerns & Feelings during Postpartum:

ABANDONMENT Only hours before, they were the center of attention, with
everyone asking about their health and well-being. Now suddenly, the baby is the
chief interest. The woman may feel confused by a sensation very close to jealousy.
Father may have much same feelings. Shared responsibility for infant care can
help to make both partners feel equally involved in the babys care and can help
alleviate these feelings.
DISAPPOINTMENT It can be difficult for parents to feel positive immediately
about a child who does not meet their expectations. Handle the child warmly.
Comment on the child good points.
POSTPARTUM BLUES (Baby blues) 50% of women experience some feelings
of overwhelming sadness. The mother burst into tears easily or may feel let down
or be irritable. Maybe due to hormonal changes (decrease estrogen &
progesterone). It maybe a response to dependence and low self-esteem caused by
exhaustion, being away from home, physical discomfort, and the tension
endangered by assuming a new role. A woman needs aasurance that sudden crying
episodes are normal. Allow to Verbalize feelings.

Physiologic Changes:
Blood Components
Hct rises in the first 3 to 7 days due to hemoconcentration caused by excretion of
large amounts of fluids in the urine (diuresis during the first few days after
delivery). Hct level returns to normal on the fourth to fifth postpartum week.
Leukocytosis of 20,000 to 30,000 (normal is 5000 to 10000) during the first 12
days characterized by increased neutrophils and easinophils and decreased
lymphocytes.
Fibrinogen and thromboplastin remains elevated until the 3rd postpartum week.
Increased leukocyte sedimentation rate.

INTEGUMENTARY SYSTEM
Chloasma, palmar erythema, linea nigra and other skin changes during pregnancy
gradually disappear during the postpartum period.
Striae gravidarum do not disappear and assumes a silvery white appearance.
Hyperpigmentation of the areola may not disappear completely. Some women are
left with a wider and darker areola after pregnancy.
Linea nigra will be barely detectable in 6 weeks time

GASTROINTESTINAL SYSTEM
Many women are hungry after delivery because of foods and fluids restriction
during labor, diaphoresis and the strenuous labor they just went through.
Bowel movement maybe delayed for days after delivery resulting in constipation.
This is caused by:
o Decreased muscle tone during labor and puerperium
o Lack of food during labor
o Dehydration
o Perineal pain caused by episiotomy, hemorrhage,laceration
o Bowel sounds are active, but passage of stool through the bowel may be
slow

URINARY SYSTEM
Voiding is difficult because of the pressure on the bladder and urethra
making it edematous.
To prevent permanent damage to the bladder from over distention, assess the
womans abdomen frequently in the immediate postpartum period
Increase daily output from 1500ml/day to 3000ml/day during the second to fifth
day after birth
Diuresis begins 12 hour after delivery and extends up to the 5 th day as the body
gets rid of extracellular fluid accumulated during pregnancy. The woman loses up
to 9 lbs. weight from the excretion of these fluids and electrolytes.
 Acetone in the urine right after labor and lactosuria during the first week is
normal.
The bladder and urethra are traumatized by the pressure exerted by the fetal head
as it passes through the birth canal. Trauma to bladder results in loss of bladder
tone, edema and hyperemia. As a result, the woman experiences bladder tone
that results in bladder capacity. Decreased bladder tone causes decreased
sensation to the filling and distention of the bladder, the woman may not
experience the urge to void even if her bladder is already distended with urine w/c
predisposes to infection.
When catheterization of postpartum patient with urinary retention:
o Use straight catheter if one hour catheterization is ordered; use foley for 24
hours catheterization
o Maitain aseptic technique.
o Provide gentle touch as the area is sore.
o When amount of urine reaches 900-1000 cc, clamp catheter to prevent rapid
decompression in the abdomen w/c can cause hypotension
o Check vital signs after catheterization.
o Unclamp after 1 hour to drain urine.

HORMONAL SYSTEM
HCG & HPL almost negligible by 24 hours
Progestin, Estrone & Estradiol are at pre-pregnant level by 7th day
FSH remains low for about 12 days, then begins to rise to initiate a new menstrual
cycle
Pregnancy hormones begin to decrease as soon as the placenta is no longer
present.

REPRODUCTIVE SYSTEM
UTERUS
INVOLUTION a process whereby the reproductive organs return to their non-pregnant
state.
Promotion of Uterine Involution : (well-nourished, ambulates early after
birth,breastfeeding)
24 hours after birth the uterus is at the level of umbilicus.
1 cm or 1 fingerbreadths every postpartum day.
After 9-10 days the fundus is no longer palpable.
a well-contracted fundus should feel firm
Uterine Atony relaxed uterus, woman may loss blood rapidly
After pains intermittent cramping of the uterus
Common in multiparas, and those who have given birth to large babies
Uterus contracts more forcefully
 Intense with breastfeeding (because of oxytocin)
Weight of the uterus:
o Right after delivery : 1000 grams
o One week after delivery: 500 grams
o 2 weeks after delivery: 300 grams
o 6 weeks after delivery: 50-60 grams

FUNDUS
Height:
Measure the position or height of fundus by using umbilicus as a landmark. Place
fingers on the abdomen of the woman just below the umbilicus and count the
number of fingerbreadths that fit btwn the top of the fundus and umbilicus.
Immediately after delivery, the fundus is located midway btwn the umbilicus and
symphysis pubis or slightly higher. After several hours, it rises to the level of the
umbilicus. It then, descends into the pelvic cavity by one cm or one fingerbreadth
a day.
Palpation:
Place woman supine with small pillow under her head and knees flexed to relaxed
abdominal muscles. Make sure the bed is flat. Palpate the fundus by placing a
hand at the umbilicus and pressing it downward while the other hand is placed just
above the symphysis to support the lower segment of the uterus. Never palpate the
uterus without supporting the lower segment as this can result to uterine inversion.
If on palpation, the uterus feels boggy:
Massage it gently in circular motion, this is the first action to take
Place infant on mothers breast to stimulate uterine contractions by the release of
oxytocin
Administer oxytocin (as ordered) or increase infusion, do not administer ergot
products if BP is above 140/90mmHg.

LOCHIA
The seperation of the placenta and membranes occurs in the spongy layer or outer
portion of the decidua basalis
2nd day after birth, the layer of the deciduas remaining under the placental site and
throughout the uterus differentiates into two distinct layers.
o Inner layer
o Adjacent layer
-Uterine flow, consisting of blood, fragments of deciduas, white blood cells,
mucus and some bacteria
 Type of Lochia Color Duration Composition
Rubra red 1-3 days Blood,fragments of deciduas, mucus
Serosa pink 3-10 days Blood,mucus,invading leukocytes
Alba white 10-14 days Largely mucus,leukocyte count high

CERVIX
Immediately after birth, the cervix is soft and malleable
Both the internal and external os are open
By the end of 7 days the external os is narrowed to the size of a pencil opening and
the cervix feels firm and nongravid again
Does not return exactly to its prepregnant state
External will usually remain slightly open
Cervical os appears slitlike or stellate (star shaped)

VAGINA
After a vaginal birth, the vagina is soft with few rugae
Hymen is permanently torn and heals with small separate tags of tissue
Gradually turns to its approximate prepregnant state
Outlet will remain slightly more distended than before.

AMBULATION
Advantages of early ambulation:
o Prevent constipation
o Prevent thrombophlebitis
o Prevent urinary problems
o Promote rapid recovery and return of womans strength
o Hastens drainage of lochia
o Improves GIT & GUT function
o Provides a sense of well-being

REST & SLEEP

The woman should rest & sleep as much as needed during the early postpartum
period to overcome fatigue, excitement, anxiety & discomfort associated with long
& exhausting labor & delivery. Sleep and rest promote healing by reducing BMR
and allowing O2 & nutrients to be utilized for tissue growth, healing &
regeneration.
Instruct the mother to avoid heavy lifting and strenous activity after discharge
The woman may resume light housekeeping on the second week and can go back
to normal activities by 4 to 6 weeks.
Resumption of Sex:
 o Sexual intercourse can be resumed 3 to 4 weeks after vaginal delivery if
bleeding has stopped, perineum is healed and if does not cause pain to the
woman.

DISCHARGE
The newly delivered mother is ready to go out of the health care facility 24-48
hours after NSD
Primiparas may leave after 2-3 days and multiparas after 1-2 days if they are
recovering normally.
After a CS, a woman maybe discharged on the 3rd or 4th day.

Before leaving, she should be insructed re: schedule of follow-up clinic visit and
to report immediately to the doctor if the ff. signs & symptoms appear:
o Heavy vaginal bleeding or bright red vaginal discharge
o Fever
o Foul smelling lochia
o Swollen, tender, hot area on her leg
o Burning sensation on urination
o Persistent pelvic or perineal pain
 Health Teachings

BREASTFEEDING TECHNIQUE
It is a preferred feeding method that provides optimal infant nutrition, easily
digested; it contains antibodies to bolster the immune system as well as nutrients
needed by the infant.
Purposes:
To help mothers body return to prepregnant state faster.
To provide some child spacing.
Through breastfeeding, the infants sucking stimulates production of
prolactin which eventually stimulates milk production.
Physiology:
estrogen, progesterone releases prolactin acts on acinar/alveoli cells
produces foremilk store in lactiferous tubules
Sucking stimulates posterior pituitary gland releases oxytocin causes
contraction of smooth muscles of lactiferous tubules milk ejection reflex let-
down reflex
Advantages:
Economical
Promotes bonding
Contains Lactobacillus bifidus interfere the attack of pathogenic bacteria
in the GIT.
Helps in early involution of uterus oxytocin causes contraction
Always available
incidence of breast cancer
Breastfed babies have higher IQ than bottles fed ones
Antibody IgA
Macrophages
Disadvantages:
No iron
Possibility of transfer of Hepa B, HIV, CMV (13-39% possibility)
Father cant bond with the mother and baby instead, father can sing, kiss,
put baby to sleep.
Milk:
o Freezer good for 6 mos. / dont reheat
o Should be stored in a sterile plastic container
Colostrum:
o Present 2 4 days
o Contents: fats, CHO, immunoglobulin, protein, fat soluble vitamin,
minerals
Problems and Interventions:
Engorgement
o More frequent breastfeeding
o Apply warm packs before feeding and ice packs between feeding
 Retracted Nipples
o Nipple-rolling before feeding
o Wear breast shield before feeding, which would act as a vacuum
when baby suck and consequently pull nipple out.
Cracked Nipples
o Lubricate nipple with A & D ointment after feeding
o Rotate feeding position
o Expose nipples to air for 10-20 mins every after feeding
o Manually express milk at affected side
o Breastfed using the unaffected side
No milk or inadequate supply
o Increase frequency of feeding and make the interval longer
Contraindications:
Maternal Conditions
o HIV
o Hepa B
o CMV
o Coumadin/Warfarin taking moms give heparin instead
Newborn Conditions
o Erythroblastocis Fetalis
o Inborn errors of metabolism (hydrofetalis, phenylketonuria, galactosemia,
tay-sachs disease)

NEWBORN SCREENING
It is the process of testing newborn babies for treatable genetic, endocrinologic,
metabolic and hematologic diseases.
History:
 Robert Guthrie is given much of the credit for pioneering the earliest screening for
phenylketonuria in the late 1960s using blood samples on filter paper obtained by
pricking a newborn baby's heel on the second day of life to get a few drops of blood.
Congenital hypothyroidism was the second disease widely added in the 1970s. The
development of tandem mass spectrometry screening by Edwin Naylor and others in
the early 1990s led to a large expansion of potentially detectable congenital metabolic
diseases that affect blood levels of organic acids. Additional tests have been added to
many screening programs over the last two decades.

Common considerations in determining whether to screen for disorders:

1. A disease that can be missed clinically at birth
2. A high enough frequency in the population
3. A delay in diagnosis will induce irreversible damages to the baby
4. A simple and reasonably reliable test exists
5. A treatment or intervention that makes a difference if the disease is detected early
Mandated in the R.A. 9288 or Newborn Screening program of 2004.
A negative screen mean that the result of the test is normal and the baby is not
suffering from any of the disorders being screened. In case of a positive screen, the
NBS nurse coordinator will immediately inform the coordinator of the institution
where the sample was collected for recall of patients for confirmatory testing.
Babies with positive results should be referred at once to the nearest hospital or
specialist for confirmatory test and further management.
Newborn screening results are available within three weeks after the NBS Lab
receives and tests the samples sent by the institutions. Results are released by NBS
Lab to the institutions and are released to your attending birth attendants or
physicians. Parents may seek the results from the institutions where samples are
collected.

Disorders Screened:
 CH (Congenital hypothyroidism) - is a condition of thyroid hormone deficiency
present at birth. Approximately 1 in 4000 newborn infants has a severe deficiency
of thyroid function, while even more have mild or partial degrees. If untreated for
several months after birth, severe congenital hypothyroidism can lead to growth
failure and permanent mental retardation. Treatment consists of a daily dose of
thyroid hormone (thyroxine) by mouth. Because the treatment is simple, effective,
and inexpensive, nearly all of the developed world practices newborn screening to
detect and treat congenital hypothyroidism in the first weeks of life.
CAH (Congenital adrenal hyperplasia) - refers to any of several autosomal
recessive diseases resulting from mutations of genes for enzymes mediating the
biochemical steps of production of cortisol from cholesterol by the adrenal glands
(steroidogenesis). Most of these conditions involve excessive or deficient
production of sex steroids and can alter development of primary or secondary sex
characteristics in some affected infants, children, or adults. Approximately 95% of
cases of CAH are due to 21-hydroxylase deficiency.
GAL (Galactosemia) - is a rare genetic metabolic disorder which affects an
individual's ability to properly metabolize the sugar galactose. Lactose in food
(such as dairy products) is broken down by the body into glucose and galactose. In
individuals with galactosemia, the enzymes needed for further metabolism of
galactose are severely diminished or missing entirely, leading to toxic levels of
galactose to build up in the blood, resulting in hepatomegaly (an enlarged liver),
cirrhosis, renal failure, cataracts, and brain damage. Without treatment, mortality
in infants with galactosemia is about 75%.
PKU (Phenylketonuria) - is an autosomal recessive genetic disorder
characterized by a deficiency in the enzyme phenylalanine hydroxylase (PAH).
This enzyme is necessary to metabolize the amino acid phenylalanine to the amino
acid tyrosine. When PAH is deficient, phenylalanine accumulates and is converted
into phenylpyruvate (also known as phenylketone), which is detected in the urine.
PAH is found on chromosome number 12.Left untreated, this condition can cause
 problems with brain development, leading to progressive mental retardation and
seizures. However, PKU is one of the few genetic diseases that can be controlled
by diet. A diet low in phenylalanine and high in tyrosine can be a very effective
treatment. There is no cure. Damage done is irreversible so early detection is
crucial.
G6PD Deficiency - is an X-linked recessive hereditary disease characterized by
abnormally low levels of the glucose-6-phosphate dehydrogenase enzyme
(abbreviated G6PD or G6PDH). It is a metabolic enzyme involved in the pentose
phosphate pathway, especially important in red blood cell metabolism.

EXPANDED PROGRAM ON IMMUNIZATION

Began in July 1979.

In 1986, made a response to the Universal Child Immunization

goal. The four major strategies include:

Sustaining high routine Full Immunized Child (FIC) coverage of at least

90% in all provinces and cities,
Sustaining the polio-free country for global certification
Eliminating measles by 2020,
Eliminating neonatal tetanus by 2020.

Routine Immunization Schedule for Infants:

Vaccine Minimum Age # Dose Dose Minimum Site Reason

at 1st Dose Interval
Between
 Doses

Bacillus Birth or 1 0.05 Right deltoid BCG given at earliest

Calmette anytime after mL region of the possible age protects
Gurin birth arm the possibility of TB
meningitis and other
TB infections in
which infants are
prone.

Diphtheria 6 weeks 3 0.5 mL 4 weeks Upper outer An early start with

Pertussis portion of the DPT reduces the
Tetanus thigh chance of severe
Vaccine pertussis.

Oral Polio 6 weeks 3 2-3 4 weeks Mouth The extent of

Vaccine drops protection against
polio is increased the
earlier the OPV is
given. Keeps the
Philippines polio-
free.

HepatitisB At birth 3 0.5 mL 6 weeks Upper outer An early start of

Vaccine interval from portion of the Hepatitis B vaccine
1st dose to thigh reduces the chance of
2nd dose,8 being infected and
weeks becoming a carrier.
 interval from Prevents liver
2nd dose to cirrhosis and liver
third dose. cancer which are
more likely to
develop if infected
with Hepatitis B
early in life.About
9,000 die of
complications of
Hepatits B. 10% of
Filipinos have
Hepatitis B infection.

9 months 1 0.5 mL Upper outer At least 85% of

Measles
portion of the measles can be
Vaccine
arms prevented by
immunization at this
age.
Freezes (-15 -25C): OPV, Measles
Sensitive to heat & freezing (+2 +8C): BCG, DPT, Hepa B, TT
Half-life packs: 4 hrs.(BCG, DPT, Polio); 8 hrs.(Measles, TT, Hepa B)

Tetanus Toxoid Immunization Schedule for Women:

Vaccine Minimum Percent Duration of Protection

Age/Interval Protected

TT1 As early as possible

during pregnancy
 infants born to the mother will be protected
TT2 At least 4 weeks 80%
from neonatal tetanus
later
gives 3 years protection for the mother
TT3 At least 6 months 95% infants born to the mother will be protected
later from neonatal tetanus

gives 5 years protection for the mother

TT4 At least 1 year later 99% infants born to the mother will be protected
from neonatal tetanus

gives 10 years protection for the mother

TT5 At least 1 year later 99% gives lifetime protection for the mother

all infants born to that mother will be

protected

Allowable time frames for the storage of vaccines at different levels are:

6 months Regional level

3 months Provincial level/district level
1 month main Health Centers with refrigerator
Not more than 5 days Health Centers using transport boxes