Mindanao Autonomous College, Foundation, Incorporated

Maternal
and
Child Health
Nursing

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Lesson 1- INTRODUCTION TO MCH
Definition of MCH
Goal of MCH
Philosophy MCH
BeMONC- Basic Emergency Obstetrics and Newborn Care
CeMONC- Comprehensive Emergency Obstetrics and
Newborn Care Facility
Tetanus Toxoid Immunization
Micronutrient Supplementation
Clean and Safe delivery
Home delivery
Delivery in the Hospital
Newborn Screening
Family planning
Breastfeeding

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 Introduction to MCH

Definition of MCH
o Maternal and Child Health refer to the philosophy of mother and child relationship to one another and
consideration of the entire family as well as the culture and socio-economic environment as framework
of the patient.
o It involves the care of the woman and family throughout pregnancy and childbirth and the health
promotion and illness care of the children and families.

Goal of MCH
o To ensure that every expectant and nursing mother maintains good health learns the art of child care,
has normal delivery and bears healthy child.
o That every child, whenever possible lives and grows up in a family unit with love and security, in healthy
surroundings, receives adequate nourishment, health supervision and efficient medical attention, and is
taught the elements of healthy living (Reyala, 2000)
o Promotion and maintenance of optimum health of the women and new born.

Philosophy of MCH
o Is community-centered
o Is research-centered
o Is based on nursing theory
o Protects the rights of all family members
o Uses a high degree of independent functioning
o Places importance on promotion of health
o Is based on the belief that pregnancies or childhood illness are stressful because they are crises.
o Is a challenging role for the nurse and is a major factor in promoting high level wellness in families.
o Pregnancy, labor and delivery and puerperium are part of the continuum of the total life cycle.
o Personal, cultural and religious attitudes and beliefs influence the meaning of pregnancy for individuals
and make each experience unique.
o Maternal and child nursing is family centered. The father of the child is as important as the mother.

BeMONC- Basic Emergency Obstetrics and Newborn Care

o It refers to lifesaving services for emergency maternal and newborn conditions/complications being
provided by a health facility or professional to include the following services.
 Administration of Parenteral oxytocic drugs.
 Administration of dose of Parenteral anticonvulsants.
 Administration of Parenteral antibiotics
 Administration of maternal steroids for preterm labor
 Performance of assisted vaginal deliveries.
 Removal of retained placental products
 Manual removal of retained placenta

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 o It also includes neonatal interventions which include at the minimum:
 Newborn resuscitation
 Provision of warmth
 Referral
 Blood transfusion

o BeMONC facility consists of the core district hospital.

o For geographically isolated/disadvantaged areas/densely populated areas, the designated BeMONC

facilities are the following:
 Rural Health Unit (RHU)
 Barangay Health Station (BHS)
 Lying-in-Clinics and Birthing Homes

o Accessibility within 1 hour from residence or referring facility within the ILHZ (Inter-Local Health Zones)

o Shall operate within 24 hours within 6 signal obstetric function.

o Shall have access to communication and transportation facilities to mobilize referrals.

o Staff composition:
 1 medical doctor
 1 registered nurse
 1 registered midwife

CeMONC- Comprehensive Emergency Obstetrics and Newborn Care Facility

o Refers to lifesaving services for emergency maternal and newborn condition/complications as in Basic
Emergency Obstetric and Newborn Care plus the provision of surgical delivery and blood bank services
and other specialized obstetric interventions.

o Essential Health Services available in the Health Care Facilities

o Antenatal Registration/Prenatal Care

o OBJECTIVE: To reach all pregnant women, to give sufficient care to ensure a healthy pregnancy and the
birth of a full term healthy baby.

o Normal Patients- following the initial evaluation they will be given healthy instructions and counseling.
This will include advice for prompt prenatal care examination.

o Patients with mild complications-a thorough evaluation of the needs of patients with mild
complications will determine the frequency of follow-up of these cases by the rural health unit, city
health clinic or puericulture center.
o Patients with potentially serious complications-these patients shall be referred to the most skilled
source of medical and hospital care. As a first choice they will be referred if at all possible for continuing
care or consultation. Second choice will be followed carefully by the rural health unit, city health clinic or
puericulture center.
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 o All RHUs and BHS should have a master list of pregnant women in their respective catchment center.

o The Home Based Mother’s Record (HBMR) shall be used when rendering prenatal care as a guide in the
identification of risk factors, danger signs and to be able to do appropriate measure.
o There should be at least 3 prenatal visits following the prescribed timing:
 First prenatal visit- as early in pregnancy as possible, during the first trimester.
 Second prenatal visit- during the second trimester
 Third and subsequent visits- during the third trimester
 More frequent visits should be done for those at risk or with complications.

TETANUS TOXOID IMMUNIZATION

o Neonatal Tetanus is one of the public health concerns, that is why it is important for pregnant women
and child bearing age women to get a tetanus toxoid immunization in order to protect them from this
deadly disease.

o A series of 2 doses of TT vaccination must be received by woman one month before delivery to protect
baby from neonatal tetanus.

o And the three booster dose shots to complete the five doses following the recommended schedule
provide full protection. The mother is then called as a “Fully Immunized Mother” (FIM)

MICRONUTRIENT SUPPLEMENTATION
o It is necessary to prevent anemia, vitamin A deficiency and other nutritional disorders.
o Vitamin A
 Dose: 10,000 IU
 Given a week starting on the 4th month of pregnancy
 Do not give it before the 4th month of pregnancy because it might cause congenital problems in
the baby.
o Iron
 Dose: 60mg/400ug tablet
 Schedule: daily

CLEAN AND SAFE DELIVERY

A- Check for Emergency signs
o Unconsciousness
o Vaginal bleeding
o Severe abdominal bleeding
o Looks very ill
o Severe headache with visual disturbance
o Severe breathing difficulty
o Fever
o Severe vomiting
B- Made woman comfortable
C- Assess the woman in labor

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 o LMP
o Number of Pregnancy
o Start of Labor Pains
o Age/Height
o Danger signs of Pregnancy
D- Determine the stage of Labor
E- Decide of the woman can safely deliver
F- Give supportive care throughout labor
G- ,monitor and manage labor
H- Monitor closely after delivery
I- Continue care for at least two hours postpartum
J- Inform, counsel and teach woman
o Birth registration
o Importance of Breastfeeding
o Newborn Screening
o Schedule of Postpartum visits
 1st visit- 1st week postpartum preferably 3-5 days
 2nd visit- 6 weeks postpartum

HOME DELIVERY
o It is for normal pregnancies attended by licensed health personnel
o Trained hilots may be allowed to attend home deliveries only in the following circumstances:
 Areas where there are no health personnel on maternal care
 When, at the time of delivery, such personnel is not available
o Actively practicing but untrained birth attendants (hilots) should be identified, trained and supervised by
a personnel of the nearest BHS/RHU trained on maternal care
o The following are qualified for home delivery:
 Full term
 Less than 5 pregnancies
 Cephalic position
 Without existing diseases such as diabetes, bronchial asthma, heart disease, hypertension,
goiter, tuberculosis, severe anemia
 No history of complication like hemorrhage during previous deliveries
 No history of difficult delivery and prolonged labor (more than 24 hours for primi gravida and
more than 12 hours for multiu gravid)
 No previous cesarean section
 Imminent deliveries (those are about to deliver and can no longer reach the nearest facility in
time for delivery)
 No premature rupture of membranes
 Adequate pelvis
 Abdominal enlargement is appropriate for age of gestation

o Home delivery kit must contain the following:

 Two pairs of clamps
 A pair of scissors
 Antiseptic (may use 70% Povidone-iodine)
 Soap and hand brush
 Clean towel/piece of cloth
 Flashlight
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  Sphygmomanometer
 Stethoscope
 Clean hands, clean surface and clean cord must strictly followed to prevent infection
o Guide for home delivery:
For registered patient:
 Time when regular pain started
 Whether bag of water ruptured or not
 Presence or absence of vaginal discharges, bleeding, etc;;
 Whether mother moved her bowels and has urinated
 Fetal movement felt by the mother or not
 Unusual symptoms such as bleeding, headache, spots before eyes
For unregistered:
 Get same information as for those registered patient and get medical and obstetric
history.
o Delivery in Healthy Facility
 At lying-in clinics
 Birthing homes within the BHS’s/RHU’s
Normal pregnancies and with labor progressing normally must be encourage to deliver in
this facility.

DELIVERY IN THE HOSPITAL

o Delivery in Hospital Risk pregnancies should be advised to deliver in the hospital are the following:
 Pregnancy more than 4
 Previous CS
 History of postpartum hemorrhage
 History of medical illness such as heart disease, goiter, tuberculosis, diabetes, severe anemia,
hypertension, bronchial asthma
 Antepartum hemorrhage
 Hypertensive disorders of pregnancy and ecclampsia
 Cephalo-pelvic disproportion
 Placenta previa and abruption placenta
 Multi-fetal pregnancy
 Post term and pre-term pregnancies
 Previous uterine surgery such as myomectomy

APGAR SCORING
o It provides a valuable index for evaluation of the infant’s at birth. It is based on the five signs ranked in
order of importance as follows:
1. Heart rate
2. Respiratory effort
3. Muscle tone
4. Reflex irritability
5. Color
o In general, they made after 1 minute of life and after 5 minutes
o Each signs is evaluated according to the degree to which it is presented and given a score 0, 1 and 2. The
scores of each sign is added together to give a total scores (10 is the maximum)

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NEWBORN SCREENING

o It is a public health program aimed at the early identification of infants who are affected by certain
genetic/metabolic/infectious conditions. Early identification and intervention can lead to significant
reduction of morbidity, mortality and associated disabilities in affected infant
o Significance:
 Most babies with metabolic disorders look “normal” at birth. By doing NBS, metabolic disorders
may be detected even before clinical signs and symptoms are present. And as a result of this,
treatment can be given early to prevent consequences of untreated conditions. Timing:
 It is ideally done on the 48th-72nd hours of life. However, it may also be done after 24 hours
from birth.
o Procedure:
 A few drops are taken from the baby’s heel, blotted on a special absorbent filter card and then
sent to the Newborn Screening Center (NSC).
 The blood samples for Newborn Screening (NBS) may be collected by any of the following:
physician, nurse, medical technologies or trained midwife.
 The procedure costs P550. The DOH advisory Committee on Newborn Screening has approved a
maximum allowable fee of P50 for the collection of the sample. Newborn Screening is now
included in the Phil health Newborn Care Package. It is widely available in hospitals, Lying- ins,
Rural Health Unit, Health Centers, and some private clinics. If babies are delivered at home,
babies may be brought to the nearest institution offering newborn screening.
o Results can be claimed from the health facility where NBS was availed. Normal NBS results are available
by 7-14 working days from the time samples are received at the NSC.
 Positive NBS results are relayed to the parents immediately by the health facility. A NEGATIVE
SCREEN MEANS THAT THE NBS IS NORMAL.
 A positive screen means that the newborn must be brought back to his/her health practitioner
for further testing. Babies with positive results may be referred at once to a specialist for
confirmatory testing and further management.
o Disorders detected in Newborn Screening
1. Phenylketonuria
 it is the inability to metabolize the amino acid phenylaline, which is a common component
such a milk. Excessive accumulation of phenylalanine in the blood causes brain damage.
 The babies may look like “albino” with musty odor of the skin, hair, sweat and urine. PKU is
treated with a special low-phenylalanine diet which the amount of amino acid is carefully
regulated.

2. Congenital Hypothyroidism 
 Most common causes of mental retardation. Most affected infants may look normal at
birth; however, they may have large fontanels and tongues, big tummies and prolonged
yellowish discoloration of the skin and eyes.

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  Infants are treated with thyroid hormones and it continues throughout life. If the disorder is
not detected and hormone replacement is not initiated within two weeks, the baby with CH
may suffer from mental and growth retardation
3. Galactosemia
 It is the absence of enzymes necessary for conversion of the milk sugar galactose to glucose.
Affected infants present with difficulty in feeding, vomiting and diarrhea, yellowish skin and
eyes, weakness, white eyes (cat’s eyes) and bleeding after blood extraction.
 Accumulation of excessive galactose in the body may cause liver damage, brain damage and
cataracts. Treatment may include elimination of milk from the diet and use of milk
substitute.

4. Glucose 6 phosphate dehydrogenase deficiency (G6PD deficiency) 

 The body lacks the enzyme called G6PD that may cause hemolytic anemia, when the body
exposed to oxidative substances found in certain drugs, foods and chemicals. Children
become pale, with yellow skin and eye, tea colored urine and fast breathing. It may lead to
heart failure.

5. Congenital Adrenal Hyperplasia 

 refers to a group of disorders with an enzyme defect that prevents adequate adrenal
corticosteroid and aldosterone production an increases production of androgens.
 It manifested by poor feeding, vomiting and diarrhea and weak cry. It also causes short
stature, early puberty excessive hair growth and infertility. Treatment of corticosteroids for
the rest of child’s life.

BREASTFEEDING
o Support to Breastfeeding Motivate, mothers to practice breastfeeding
A. The Rooming-in and Breastfeeding Act of 1992 
 To encourage, protect and support the practice of breastfeeding. It shall create an
environment where the basic physical, emotional and psychological needs of mothers and
infants are fulfilled.
B. Milk Code of 1986 
 The aim of this code is to contribute to the provision of safe and adequate nutrition for
infants by the protection and promotion of breastfeeding and by ensuring the proper use of
breast milk substitutes and breast milk supplements when these are necessary, on the basis
of adequate information and through appropriate marketing and distribution.

FAMILY PLANNING COUNSELING

o Family Planning Counseling 
 Proper counseling of couples on the importance of family planning will help them inform on
the right choices of family planning methods, proper spacing of birth and addressing the
right number of children. Birth spacing of three to five years interval will help completely
develop the health of a mother from

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Lesson 2- Reproductive Health
Family Planning

1. Natural Family Planning Method

a. Abstinence
b. Calendar (Rhythm Method)
c. Basal Body temperature
d. Cervical Mucus Method/Spinnbarkeit Test
e. Symptothermal Method
f. Ovulation Detection
g. Lactation Amenorrhea Method (LAM)
h. Coitus Interruptus
i. Post-coital Douching
2. Artificial Family Planning Method
A- Chemical Barrier
a. Gels or cream
b. Films
c. Vaginal suppositories
d. Sponges or foams
B- Mechanical Barrier
a. Diaphragm
b. Cervical Cap
c. Male Condoms
d. Female Condoms
C- Hormonal Method
a. Oral Contraceptives/Pills
b. Transdermal Route
c. Vaginal Insertion
d. Contraceptive Implant
e. Injection (DMPA)
f. Intrauterine Insertion (IUD)
D- Surgical Method
a. Vasectomy
b. Tubal Ligation

Reproductive Health Law/Responsible Parenthood (RA 10354)

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 FAMILY PLANNING
o Family planning is the planning of when to have children, and the use of birth control and other
techniques to implement such plans
o Purposes:
 Raising a child requires significant amounts of resources: time, social, financial, and
environmental. Planning can help assure that resources are available
 To improve the health of the mother and child.
 Helping to prevent HIV/AIDS
o Criteria for ideal contraceptive method:
 It should be safe for use means free from any kind of side effects.
 It should be reliable.
 It should be easy to administer and convenient.
 It should be cost effective.
 It should be culturally feasible and acceptable.

Methods of Contraception
1.) Spacing methods:
 Help in prevention of pregnancy as long as they are used.- These methods can help in
timing and spacing of pregnancies, preventing unwanted children. These methods are
temporary methods
a. Natural methods

 Natural methods do not involve the use of any of the man made devices. These methods
are useful for timing and spacing of pregnancies.

b. Barrier :-
 Physical/mechanical barrier methods –
 chemical barrier methods –
 hormonal methods –
2.) Terminal methods
 Vasectomy
 Tubal ligation

o The failure of contraceptive is determined by the experience of 100 women for 1 year. It’s expressed as
pregnancies per 1000 woman.

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Natural Family Planning
 Involves no introduction of chemical or foreign material into the body. The effectiveness of
these methods depending mainly on the couples’ ability to refrain from sexual relations on
fertile days.

1. ABSTINENCE
o Refraining from sexual relations
o Advantage: most effective way to prevent STI’s, no cost
o Disadvantage: it has a failure rate of 85%, high motivation needed, highly unreliable

2. CALENDAR (RHYTHM) METHOD

o Requires a couple to abstain from coitus on the days of menstrual cycle when the woman is likely
conceive (3 or 4 days before ovulation and 3 or 4 days after ovulation)
o To plan for this, the woman keeps a diary of 6 menstrual cycles.
o To calculate safe days, subtracts 18 from the shortest cycle documented. This number represents her
first fertile day. Then subtracts 11 from the longest cycle. This represents her last fertile days. If she had
6 menstrual cycles ranging from 25 to 29 days, her fertile period would be from 7th day to the 18th day.
To avoid pregnancy she would avoid coitus during those days.
o Advantage: no cost
o Disadvantage: failure rate of 9-25%, requires motivation and cooperation

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3. BASAL BODY TEMPERATURE METHOD
o Just before the day of ovulation, a woman’s BBT or temperature of her body at rest falls about 0.5oF. at
the time of ovulation, her BBT rise a full degree because of the influence of progesterone.
o The woman takes her temperature each morning immediately after waking either orally or with an ear
thermometer before she undertakes any activity, this is her BBT. As soon as she notices a slight dip in
temperature followed by an increase she knows that she was ovulated
o The woman should refrains from having coitus for the next 3 days after ovulation ( the life of discharged
ovum). Because sperm can survive for at least 4 days in the female reproductive tract, it is usually
recommended that the couple combine this method with a calendar method, so that they abstain for a
few days before ovulation as well.
o Advantage: no cost
o Disadvantage: requires motivation and cooperation, failure rate of 9-25%

4. CERVICAL MUCUS METHOD/SPINNBARKEIT TEST

o Before ovulation each month, the cervical mucus is thick and does not stretch when pulled between the
thumb and finger. Just before ovulation mucus secretion increases. With ovulation, cervical mucus
becomes copious, thin, watery and transparent. It feels slippery and stretches at least 1 inch before
the strand break, a property known as spinnbarkeit. In addition, breast tenderness and anterior tilt to
the cervix occur.
o All the days on which cervical mucus is copious and for at least 1 day afterward, are considered to be
fertile days or days on which the woman should abstain from coitus to avoid conception.
o Advantage: no cost
o Disadvantage; requires motivation and cooperation

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 5. SYMPTOTHERMAL METHOD
o Combines the cervical mucus and BBT method
o The woman takes her temperature daily, watching for the rise in temperature that marks ovulation. She
also analyzes her cervical mucus everyday and observes for other signs of ovulation such as
mittelschmertz (mid-cycle abdominal pain).
o The couple must abstain from intercourse until 3 days after the rise in temperature or the fourth day
after the peak of mucus change, because these are woman’s fertile days.
o The symptothermal method is more effective than either the BBT or the cervical mucus method alone.
o Advantage; no cost
o Disadvantage: requires motivation and cooperation

6. OVULATION DETECTION
o Still another method to predict ovulation is by the use of an over-the-counter ovulation detection kit.
These kits detects the mid-cycle surge of luteinizing hormone (LH) that can be detected in urine 12 to 24
hours before ovulation
o Such kits are 98% to 100% accurate in predicting ovulation.
o Advantage: easy to use
o Disadvantage: needs funds for monthly kit.

7. LACTATION AMENORHEA METHOD (LAM)

o As long as woman is breastfeeding an infant, there is some natural suppression of ovulation.
o Disadvantage: Because women may ovulate, however, but not menstruate, a woman may still be fertile
even if she had a period since childbirth.
o If the infant is receiving a supplemental feeding or not sucking well, the use of lactation as an effective
birth control method is questionable.
o As a rule after 3 months of breastfeeding, the woman should be advised to choose another method of
contraception.

8. COITUS INTERRUPTUS/WITHDRAWAL
o Is one of the oldest known methods of contraception. The couple proceeds with coitus until the moment
of ejaculation. Then the man withdraws and spermatozoa are emitted outside the vagina.
o Disadvantage: Unfortunately, ejaculation may occur before withdrawal is complete and despite the care
used, some spermatozoa may be deposited in the vagina. Furthermore, because there may be a few
spermatozoa present In pre-ejaculation fluid, fertilization may occur even if withdrawal seems
controlled. For these reasons, coitus interruptus is only about 75% effective.

9. POST-COITAL DOUCHING
o Douching following intercourse, no matter what solution is used, is ineffective as a contraceptive
measure, as sperm may be present in cervical mucus as quickly as 90 seconds after ejaculation

Artificial Family Planning

Barrier methods
 Are forms of birth control that work by placement of a chemical or other barrier between
the cervix and advancing sperm so that sperm cannot enter the uterus or fallopian tubes
and fertilize the ovum.
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  Advantage: they lack of hormonal side effects associated with Combined Oral
Contraceptives (COC)
 Disadvantage: failure rate are higher and sexual enjoyment may be lessened.
 Types of Barriers: Chemical Barrier and Mechanical Barrier

A- Chemical Barrier Method

o A spermicidal is an agent that causes death of spermatozoa before they can enter the cervix. Such
agents are not only actively spermicidal but also change the vaginal pH to a strong acid level, a condition
not conducive to sperm survival.
o Advantages:
 They may be purchased without a prescription
 When used in conjunction with another contraceptive, they increase the other method’s
effectiveness.
 Various preparations are available including gels, creams, sponges, films, foams and
suppositories.
o Side effects and contraindication of Chemical Barrier:
 Vaginally inserted, spermicidal products are contraindicated in women with acute cervicitis,
because they might further irritate the cervix.
 May cause leakage (disadvantage)

1. GELS OR CREAMS
o Are inserted to the vagina before coitus with an applicator.
o The woman should do this no more than 1 hour before coitus for the most effective results.’
o The woman should not douche to remove the spermicidal for 6 hours after coitus, to ensure that the
agent has completed its spermicidal action.

2. FILMS
o Another form of spermicidal protection is a film of glycerin impregnated with a spermicidal agent that is
folded and is inserted vaginally.
o On contact with vaginal secretions or pre-coital penile emissions, the film dissolves and a carbon dioxide
foams forms to protect the cervix against invading spermatozoa.

3. VAGINAL SUPPOSITORIES
o Still other vaginal products are cocoa butter and glycerin-based vaginal suppositories filled with
spermicide. Inserted vaginally these dissolve and release the spermicidal ingredients. Because it takes
about 15 minutes for a suppository to dissolve, it must be inserted 15 minutes before coitus.

4. SPONGES/FOAM
o Are foam impregnated synthetic sponges that are moistened to activate the impregnated spermicide
and then inserted vaginally to block sperm access to the cervix.
o They should remain in place for 6 hours after intercourse to ensure sperm destruction. PROV

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B- Mechanical Barrier (Physical)

1. DIAPHRAGM
o Is a circular rubber disk that is placed over the cervix before intercourse.
o A diaphragm is prescribed and fitted initially by a physician, nurse practitioner or nurse-midwife to
ensure a correct fit. Because the shape of a woman’s cervix changes with pregnancy, miscarriage,
cervical surgery (D & C) or elective termination of pregnancy.

o Health teachings:
 Teach woman to return for a second fitting if any of these circumstances occur.
 A woman should also have the fit of the diaphragm checked if she gains or losses more than 15
lbs because this could also change her pelvic and vaginal contours.
o How to use it?
 It is inserted into the vagina after first coating the rim and center portion with a spermicidal gel,
by sliding it along the posterior wall and pressing it up against the cervix so that it is held in
place by the vaginal fornices.
 A woman should check her diaphragm with a finger after insertion to be certain that it is fitted
well up over the cervix, she can palpate the cervical os through the diaphragm.
 A diaphragm should remain in place for at least 6 hours after coitus because spermatozoa
remain viable in the vagina for the length of time. It may be left in place for as long as 24 hours.
If it is left in the vagina longer than 24 hours, the stasis of fluid may cause cervical inflammation
or urethral irritation.
 A diaphragm is removed by inserting a finger into the vagina and loosening the diaphragm by
pressing against the anterior rim and then withdrawing it vaginally.
 After use, a diaphragm should be washed in mild soap and water, dried gently and stored in its
protective case. With this case, a diaphragm will last for 2-3 years.
o Advantage: easy to insert
o Disadvantage: prescription needed

o Side effects and Contraindications:

 If there is an abnormality in the position of the uterus
 If there is an intrusion on the vagina (cystocele, rectocele)
 History of toxic shock syndrome/TSS-staphylococcal infection introduced through the vagina.
 Allergy to rubber or spermicide
 History of recurrent UTI’s
o To prevent TSS while using a diaphragm, advice women to:
 Wash their hands thoroughly with soap and water before insertion or removal.
 Do not use a diaphragm during a menstrual period
 Do not leave a diaphragm in place longer than 24 hours.
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  Be aware of the symptoms of TSS, such as elevated temperature, diarrhea, vomiting, muscle
aches, & sun-burn like rash.
 If symptoms of TSS should occur, immediately remove the diaphragm and call a health care
provider.

2. CERVICAL CAP
o Are made of soft rubber, is shape like a thimble with a thin rim and fit snugly over the uterine cervix.
o The precautions for use are the same as for diaphragm use except it can be kept in place longer.
o Advantage:
 Can be use for several days if desired.
 Cervical caps can remain in place longer than diaphragm because they do not put pressure on
the vaginal walls or urethra, however this time period should not exceed 48 hours, to prevent
cervical irritation.
o Disadvantages:
 May be difficult to insert, can irritate cervix.
 Caps tend to dislodge more readily than diaphragm during coitus.
 Cervical caps, like diaphragm must be fitted individually by a health care provider.
o Contraindications:
 An abnormally short or long cervix.
 A previous abnormal Pap smear
 A history of TSS
 An allergy to latex or spermicide
 A history of pelvic inflammatory disease, cervicitis or papillomavirus infection.
 A history of cervical cancer.
 An undiagnosed vaginal bleeding

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3. MALE CONDOMS
o Is a latex rubber or synthetic sheath that is placed over the erect penis before coitus to trap sperm.
o Advantage:
 Protection against STI
 No healthcare prescription
o Disadvantage:
 Insertion may be difficult
 May inhibit sexual pleasure because it may require interruption of sexual activity.
o Contraindications:
 Allergy to latex.
The husband can use a polyurethane or natural membrane condom type. Caution him that these
types do not give the same level of protection against STI’s as does latex.
o How to use it?
 To be effective, condom must be applied before any penile-vulvar contact, because even pre-
ejaculation fluid may contain sperm. A condom should be positioned so that it is loose enough
at the penis tip to collect the ejaculate without placing undue pressure on the condom.
 The penis with the condom held carefully in place must be withdrawn before it begins to
become flaccid after ejaculation. If it is not withdrawn at this time sperm may leak from the
loosely fitting sheath into the vagina.

4. FEMALE CONDOMS
o Are latex sheaths made of polyurethane and pre-lubricated with a spermicide. The inner ring (closed
end) covers the cervix and the outer ring (closed end) covers the cervix and the outer ring (open end)
rests against the vaginal opening.
o The sheath may be inserted any time before sexual activity begins and then removed after ejaculation
occurs.
o Like male condoms they are intended for one time use and offer protection against both conception and
STI’s

C- Hormonal Contraception
o As the name implies, hormones that cause such fluctuations in a normal menstrual cycle that
ovulation does not occur.
o It may be administered orally, transdermally, vaginally, by implantation or through injection.

1. ORAL ROUTE/ORAL CONTRACEPTIVES (aka pill)

o Are composed of varying amounts of synthetic estrogen combined with a small amount of
synthetic progesterone (progestin)
o Actions: the estrogen acts to suppress FSH and LH, thereby suppressing ovulation. The
progesterone action complements that of estrogen by causing a decrease in the permeability of
cervical mucus, thereby, limiting sperm motility and access to ova. Progesterone also interferes
with tubal transport and endometrial proliferation to such degrees that the possibility of
implantation is significantly decreased.
o Benefits: decreased incidence of:
 Dysmenorrheal (because of lack of ovulation)
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  Premenstrual dysphoric syndrome and acne (because of the increased progesterone
level)
 Iron deficiency anemia (because of the reduced amount of menstrual flow)
 Acute pelvic inflammatory disease/PID and tubal scarring
 Endometrial and ovarian cancer, ovarian cysts and ectopic pregnancies
 Fibrocystic breast disease
 Possibly osteoporosis, endometriosis, uterine myoma (fibroid uterine tumors) and of
progression of rheumatoid arthritis
 Colon cancer
o Side effects:
 Nausea
 Weight gain
 Headache
 Breast tenderness
 Breakthrough bleeding (bleeding outside the menstrual period)
 Monilial vaginal infections
 Mild hypertension
 Depression

o Types of Pills
a. Combined oral contraceptives (COC’s)
 Not advisable for breastfeeding mothers
b. Progestin only Pills (POP’s)
 Can be taken by breastfeeding mothers because ity will not reduced the flow of
milk
o Consideration:
 IT SHOULD BE TAKEN REGULARLY TO MAINTAIN ITS EFFECTIVENESS
 EFFECTIVE AND CAN BE STOP ANYTIME
 IT CAN BE USED AT ANY AGE
 YOU MAY EXPERIENCE SPOOTING BUT IT IS NOT HARMFUL

o What to do if woman forgets to take the pill?

 If a patient misses a menstrual period while taking an oral contraceptive exactly as
prescribed, she should continue taking the contraceptive.
 If a patient misses two consecutive menstrual periods while taking an oral
contraceptive, she should discontinue the contraceptive and take a pregnancy test.
 If a patient who is taking an oral contraceptive misses a dose, she should take the pill as
soon as she remember or take two at the next scheduled interval and continue with the
normal schedule.
 If a patient who is taking an oral contraceptive misses two consecutive doses, she
should double the dose for 2 days and then resume her normal schedule. She should
also use an additional birth control method for 1 week.
 If the pill omitted was one of the placebo ones, ignore it and just take the next pill on
time the next day.

19
  If you miss three or more pills in a row, throw out the rest of the pack and start a new
pack of pills. You should use extra protection until 7 days after starting a new pack of
pills.
 If you think that you might be pregnant, stop taking pills and notify your health care
provider.

2. TRANSDERMAL ROUTE
o Refers to patches that slowly but continuously release a combination of estrogen and
progesterone.
o How to use it?
 Patches are applied each week for 3 weeks. No patch is applied the fourth week. During
the week on which the woman is patch free, a menstrual flow will occur. After the patch
free week, a new cycle of 3 weeks on / 1 week off begins again.
 The efficiency of transdermal patches is equal to that of COC’c although they may be
less effective in women weighs more than 90 kg (198 lbs). Because they contain
estrogen, they have the same risk for thromboembolic symptoms as COC’s.
o May be applied one of the following areas:
 Upper outer arm
 Upper torso (front or back excluding the breast)
 Abdomen
 Buttocks

o Side effects:
 Mild breast discomfort
 Irritation at the application site
o Considerations:
 They should not be placed on any area where make-up, lotions or creams will be
applied, at the waist where bending might loosen the patch or any where the skin is red
or irritated or has an open lesion.
 If a patch comes loose, the woman should remove it and immediately replace it with a
new patch. No additional contraception is needed if the woman is sure the patch has
been loose for less than 24 hours.
 If the woman is not sure how long the patch has been loose, she should remove it and
apply a new patch, but this will start a new 4 week cycle, with a new day one and a new
day to change the patch. She should also use a back-up contraception method such as a
condom or spermicide for the first week of a new cycle.

20
3. VAGINAL INSERTION
o Vaginal ring is a silicone ring that surrounds the cervix and continually releases a combination of
estrogen and progesterone.
o It is inserted vaginally by the woman and left in place for 3 weeks, then remove for 1 week.
Menstrual bleeding occurs during the ring-free week.
o The hormones released are absorbed directly by the mucus membrane of the vagina, thereby
avoiding a “first pass” through the liver as happens with COC’s, this is an advantage for woman
with liver disease.

21
4. IMPLANTATION/CONTRACEPTIVE IMPLANT
o The rods contain estonogestrial, the metabolite of desogestrel, the same progestin that is used
in Nuva ring. Once embedded, the implants appear as irregular lines on the skin, simulating the
small veins.
o Over the next 3-5 years, the implants slowly release the hormone, suppressing ovulation,
stimulating thick cervical mucus and changing the endometrium so that implantation is difficult.
o Advantages:
 Can be used while breastfeeding
 Women have fewer, lighter periods
 30% women have no more bleeding periods
 May lessen typical PMS symptoms
o Side effects:
 Weight gain
 Irregular menstruation
 Scarring at the insertion site
 Need for removal
 Depression
o The implants are inserted with the use of local anesthetic, during the menses or no later than
day 7 of the menstrual cycle, to be certain that the woman is not pregnant at the time of
insertion. At the end of 3-5 years, the implants are removed under local anesthesia.

22
What is it?
 Contraceptive implants are small rods about
the size of match stick which are put under the
skin in the inside of your arm. You can feel
them under the skin. They slowly release a
hormone called progesterone. Implants last
either 3 or 5 years depending on which one
you have.
 These implants are effective as contraception
but are not useful for women who are trying
to control painful periods or bleeding
problems
How do they work?
 Implants can stop the body from releasing an
egg each month. They also thicken the mucus
in the cervix so that sperm cannot travel up to
meet an egg.
How well does it work?
 Implants are more than 99% effective in
preventing pregnancy (this means that only a
few women out of a thousand will get
pregnant each year)
23
What are the advantages?
 Long-acting-once inserted it will be effective
for several years.
 Easy to use-there is nothing to do or
remember once it has been inserted.
 Effective- it is extremely effective as a
contraceptive
 Return to fertility- rapid return once it is
removed
What are the disadvantages?
 Irregular bleeding, or periods that last longer.
This is quite common especially in the first 6
months and may last for whole 5 years. While
it can be annoying, it is not harmful and does
not mean the implant is less effective. There
are treatments to control irregular bleeding so
ask Family Planning or your health professional
about it if this is a problem for you.
 No bleeding- periods stops for some women.
This is safe for your body.
 Wound problem- you may have bruising.
Occasionally there can be soreness or
infection.
 Insertion and removal-needs to be done by
the trained health practitioner
 Difficulty in removing implant-occasionally
the implant cannot be easily felt under the
skin and you may need to be referred to
someone else to remove it.
 The research does not show the implants
cause any change in weight, mood, headaches
or libido.
Becoming pregnant after removal?
 Your natural fertility will return as soon as you
have the implant removed.
 If you get pregnant with the implant in place
and decide to continue with your pregnancy
and the change of having an abnormal baby is
not increased. You will need to have the
implant removed.
What will I notice?
 Your periods are likely to change. A few
women have no periods, a few women have
their normal periods, but most women have a
change in bleeding pattern. This may be
infrequent bleeding, frequent bleeding, light
bleeding or heavy bleeding. This is safe for
your body, and there are pills to treat this if it
happens. Research has shown that about one
woman in every seven has the implant
removed because of bleeding problems.
Does it Protect you from sexually transmissible
infections (STI’s)
 No, you need to use condom (and lubricant) as
well to protect against STIs.
Who can use it?
 Almost every woman can use it whatever her
age. It is suitable for women who may forget
pills, injection appointments or who may have
a medical reason that stops them using the
combined pill.
Who should not use it?
 Women who had breast cancer
 Women who are taking some medications-
check with your doctor if you are taking
regular medication.

How is it put in and taken out?

 You need to see someone who is trained to
insert and remove implants. A local injection is
used to numb the area. The rods are placed
under the skin and steristrips are used to hold
the skin together until the skin heals. It is
removed in the same way. You will have a
small scar from each procedure.

5. INJECTION (DMPA-DEPO MEDROXY PROGESTERONE ACETATE)

o Progesterone given every 12 weeks/3 months inhibits ovulation, alters the endometrium and
changes the cervical mucus.
o Do not massage the injection site after administration as you want the drug to absorb slowly
from the muscle.
o Advantages:
 It can be used during breastfeeding
 Reduction in ectopic pregnancy, endometrial cancer, endometriosis and reduction in the
frequency of sickle cell crises.
o Side effects:
 Irregular menstrual cycle
 Headache
 Weight gain
 Depression

24
INTRAUTERINE DEVICE (IUD)
o It is a small plastic object that is inserted into the uterus through the vagina.
o Today, the IUD is thought to prevent fertilization as well as creating a local sterile inflammatory
condition that prevents implantation. When copper is added to the device, sperm mobility
appears to be affected as well. This decreases the possibility that sperm will successfully cross
the uterine space and reaches the ovum.
o An IUD must be fitted by a physician, nurse practitioner or nurse midwife. The device is inserted
before a woman has had coitus menstrual flow to ascertain that the woman is not pregnant.
o A T-shape plastic device wound with copper and LNG-IUS (Mirena), which holds a drug reservoir
of reservoir of progesterone in the stem. The progesterone in the drug reservoir gradually
diffuses into the uterus through plastic. It both prevents endometrium proliferation and
thickens cervical mucus.
o It should be avoided by woman who are prone or at risk for STI.
o Effective until 12 years (Mirena Type-5 to 7 years) (Copper T380-10 years)
o The client may experience heavy bleeding

Who can use it? What is an IUD?

 Most women are able to use an IUD-including
young women and women who have not had
children.
Mirena is particularly suitable for women with heavy
periods.
 A small device that fits inside your womb. You
can’t feel it or tell it is there except by
checking for the threads. Your partner should
not be able to feel it and you can use tampons.
The removal threads come out your cervix and
curl up inside the top of your vagina-they don’t
hang outside

 There are two types of IUD. One type contains

copper (Copper IUD). The other type has a
progesterone hormone which is slowly
released into your womb (Mirena)

25
Who should not use it?
 Women who have symptoms of infection should
have treatment before an IUD is inserted.
 The Copper IUD is not suitable for women with
heavy or painful periods as it may make them more
heavy or painful.
Getting an IUD
 Talk to Family Planning about all the possible
benefits, risks and side effects of an IUD for you.
 You may be offered tests for STI’s (sexually
transmitted infections)
 An IUD can be inserted any time it is clear you are
not already pregnant
 Ideally:
 During or just after menstrual period
 6 weeks after your baby is born
 At the time of a surgical abortion
 Copper IUD as emergency contraception
after unprotected intercourse.
 Eat something before your appointment as you are
less likely to feel faint.
 You may want to take pain relief tablets before the
appointment-ask the doctor or nurse which tablets
and when to take them.
 Most people go straight back to their routine after
an IUD is put in. in case you feel faint or have cramps
after the procedure, you may want to have someone
available to drive you home, and have the option of
resting for a few hours.
 Allow an hour to be in clinic
What are the advantages?
 Long acting reversible contraception
 Very effective contraception
 Can stay in place for many years
 Multiload and Mirena licensed for 5 years,
Copper T licensed for 10 years.
 However IUDs may be effective longer for
some women-you can discuss this with your
doctor or nurse.
 Can be easily removed (by any doctor or Family
Planning Nurse) if you don’t like it or want to get
pregnant.
26
How does it work?
The main an IUD works is by preventing
fertilization of the egg. The copper or the
hormone from the IUD stops the sperm moving
through the womb towards the egg.
Occasionally an egg is fertilized. The IUD then
stops the egg setting (implanting) into the
womb.
What will I notice?
 Copper IUD: spotting, light bleeding,
heavier or prolonged bleeding is
common in the first 3-6 months of use.
This is usually improves with time
 Mirena: for the first 3-6 months your
periods may be lighter but longer and
you may have some bleeding or
spotting in between your periods. After
this, most women have lighter periods
and some have no bleeding at all. This
is safe for your body.
Caring for your IUD
 You will be given more details when
your IUD is put in.
 You should return to the clinic for a
check up about 6 weeks after your IUD
is put in, to make sure it is still in the
correct place.
Self care:
 Check your IUD threads after each
period or at the beginning of each
calendar month.
 See a doctor if:
 You have unusual pain,
bleeding or discharge
 You think your IUD is coming
out or has come out (you may
need emergency
contraception)
 You think you may be pregnant
 If you are pregnant with an UD in place
you need to have a check that the
pregnancy is not ectopic (in the tubes).
If you decide to continue with the
pregnancy the IUD needs to be
removed to decrease the risk of
  It is possible to get pregnant as soon as the IUD is
removed.
 It does not affect breastfeeding
 It does not interfere with sexual intercourse.
 No one else need know you are using it.
 There is no evidence of an increased risk of cancer
 Copper IUDs do not contain any hormones.
 Copper IUDs can also be used to prevent pregnancy
after unprotected sexual intercourse (emergency
contraception)
 Mirena IUDs have a very small dose of hormone and
most women have no side effects from this:
 Mirena reduces period bleeding and pain so most
women will have light bleeding or no periods at all.
What are the disadvantages?
 You have to have the IUD inserted. This is usually a
simple, safe procedure carried out by a doctor or
nurse who is experienced at fitting IUD’s. it takes
about 5-1o minutes. Most women have some
period-like cramping. Some women feel pain and
occasionally feel faint when the IUD is put in or taken
out.
 There are some risks from having an IUD put in:
 There may be small chance of infection
(about 1%) when an IUD is put in.
 There is a very small risk of damage or
perforation of the womb (about 1 in 1,000)
 You may (rarely) get pregnant with an IUD in place.
 Any pregnancy can be ectopic (in the tubes) this risks
is less than in women not in using any contraception.
 Copper IUDs may cause more bleeding and cramping
during periods.
 Copper can very rarely cause an allergic reaction.
 Mirena may initially cause irregular, light bleeding
for more days than normal.
 There is no evidence that Mirena causes acne,
headaches, breast tenderness, nausea, mood
changes, and loss of libido or weight gain.
 An IUD can occasionally come out by itself (about
5%)-you can check the strings are still in place after
each period or at the beginning of each month.
 Sometimes the thread cannot be seen so that it may
be more difficult t remove the IUD.
27
infection and miscarriage.
Safer Sex:
 An IUD does not stop you from getting
sexually transmissible infections (STIs).
If you or your partner has sexual
intercourse with someone else, always
use a condom (and lubricant). If there
is a chance you may have an STI, have a
checkup.
IUD removal
 Your doctor or nurse can remove an
IUD by inserting a speculum and pulling
the threads. This may be
uncomfortable for a few seconds. If
you want to become pregnant the IUD
can be removed at any time of your
cycle. If you don’t want to become
pregnant we need to be sure there is
no chance of an unplanned pregnancy
from sexual intercourse during the last
week. It is better to start alternative
contraception before removing the IUD
or do not have any sexual intercourse
for at least 7 days before the removal.
Becoming pregnant after removal
 Your natural fertility will return as soon
as you have the IUD removed.
 If you get pregnant with an IUD in place
and decide to continue with your
pregnancy, the chance of having an
abnormal baby is not increased. You
will need to have the IUD removed
TERMINAL METHODS/SURGICAL METHODS

1. VASECTOMY
o A small incision or puncture wound is made on each side of the scrotum. The vas deferens at
that point is then located, cut and tied, cauterized or plugged, blocking the passage of
spermatozoa.
o Spermatozoa that were present in the vas deferens at the time of surgery can remain viable for
as long as 6 months. Therefore, although the man can resume sexual intercourse within 1 week,
an additional birth control method should be used for 3 months.

28
What is vasectomy?

 Vasectomy is a small operation to cut the vas deferens. This is the tube that takes sperm from the testicles
(testes) to the penis. Sperm are made in the testes. Once the vas deferens is cut, sperm can no longer get
into the semen that comes out (is ejaculated) during sex.
 Vasectomy is an effective and permanent form of contraception. The operation is quicker, easier and
more effective than female sterilisation. There is a very small failure rate. Sterilisation is only for people
who have decided they do not want children, or further children in the future. It is considered a permanent
method of contraception, as reversal is a complicated operation which is not always successful. In
addition, reversal is not usually available on the NHS.

How is a vasectomy done?

 Vasectomy is usually done under a local anaesthetic. This means you are awake but have an injection into
the skin so that you do not feel pain. Local anaesthetic is injected into a small area of skin on either side
of the scrotum above the testicles (testes). A small cut is then made to these numbed areas of skin.
Occasionally vasectomy is done under a general anaesthetic.
 A tiny cut or puncture hole is made in the skin on each side of the scrotum. The vas deferens can be seen
quite easily under the cut skin. It can be cut with a surgical knife (scalpel) or using diathermy. Diathermy
is electrical current that cuts and seals the ends of the tubes. It stops bleeding at the same time. Sometimes
a small piece of the vas deferens is removed.
 The hole is so small you may not need any stitches. If you do, dissolvable stitches are used, or a special
surgical tape. The operation takes about 15 minutes.
 There is usually some discomfort and bruising for a few days afterwards. This normally goes away
quickly. The discomfort can be helped by wearing tight-fitting underpants day and night for a week or so
after the operation. It is also best not to do heavy lifting or strenuous exercise for four weeks or so after
the operation.

Are there any risks to the operation?

Most men have no problems after a vasectomy. Problems are uncommon but include the following:

 As with any operation or cut to the skin, there is a small risk of a wound infection.
 The bruising around the operation site is sometimes quite marked. However, it will go in a week or so.
 Rarely, sperm may leak into the scrotum and form a swelling which may need treatment.
 A small number of men have a dull ache in the scrotum for a few weeks or months after the operation.
This usually settles within three months.
 A small number of men develop a pain which does not settle over time. This can be mild or severe. It
may be in the scrotum, the penis, the testicles (testes) or the lower tummy.

29
  If you have a general anaesthetic, as with any operation, there is a small risk associated with the
anaesthetic.

How do I know it has been successful?

Some sperm survive in the upstream part of the vas deferens for several weeks after vasectomy. These can get into
the semen for a while after the operation. About twelve weeks after the operation you will need to produce a
semen test. This is looked at under the microscope to check for sperm. If there are no sperm in this sample, you
will be given the all clear. If not, you will need another test a month later. You will be told when the test shows
the operation has been successful. Until this time you should continue using another method of contraception.

What are the advantages of vasectomy?

It is permanent and you don't have to think of contraception again. It is easier to do and more effective than
female sterilisation.

What are the disadvantages of vasectomy?

It may take a few months before the semen is free from sperm. As it is permanent, some people regret having a
vasectomy, especially if their circumstances change. Vasectomy does not protect you from sexually transmitted
infections.

Will it affect my sex drive?

No. The sex hormones made by the testicles (testes) - for example, testosterone - continue to be passed into the
bloodstream as before. Also, vasectomy does not reduce the amount of semen when you come (ejaculate) during
sex. Sperm only contributes a tiny amount to semen. Semen is made in the seminal vesicles and prostate higher
upstream.

Sex may even be more enjoyable, as the worry or inconvenience of other forms of contraception is removed.

What happens to the sperm?

Sperm are still made as before in the testicles (testes). The sperm cannot get past the blocked vas deferens and are
absorbed by the body.

Some other points about vasectomy

Do not consider having the operation unless you and your partner are sure you do not want children, or further
children. Consider all sorts of situations including a tragedy in the family or a break-up of your relationship. Only
have a vasectomy if you are sure you would not want more children even in those situations. It is wise not to
make the decision at times of crisis or change, such as after a new baby or termination of pregnancy. It is best not
to make the decision if there are any major problems in your relationship with your partner.

Remember there are reversible forms of long-term contraception which are very effective. Consider these as a
couple before making your decision. Long-acting contraception choices include coils, implants and injections.
These are all for women.

Doctors normally like to be sure that both partners are happy with the decision before doing a vasectomy.
However, it is not a legal requirement to get your partner's permission.

30
 2. TUBAL LIGATION
o The fallopian tubes are occluded by cautery, crushing, clamping or blocking thereby

What is a Tubal Ligation?

 Tubal ligation, commonly known as “getting your tubes tied,” is a surgical sterilization technique for
women. This procedure closes the fallopian tubes, and stops the egg from traveling to the uterus from
the ovary. It also prevents sperm from reaching the fallopian tube to fertilize an egg. In a tubal ligation,
fallopian tubes are cut, burned, or blocked with rings, bands or clips. The surgery is effective
immediately. Tubal ligations are 99.5% effective as birth control. They do not protect against sexually
transmitted infections, including HIV/AIDS.

Procedure?

 A tubal ligation is a relatively simple out-patient surgery done in a clinic, doctor’s office, or hospital. It
can be performed under local or general anesthesia. Mini-laparotomies and laparoscopies are the two
most common techniques for female sterilization. Other procedures include laparotomy, culpotomy,
culdoscopy, hysteroscopy, and hysterectomy. Each procedure carries different risks and benefits. Be sure
the clinic discusses surgical options with you, describes the risks, and answers all of your questions
before the surgery.
 In the laparoscopy procedure, the abdomen is filled with carbon dioxide gas so that the abdominal wall
balloons away from the uterus and tubes. The surgeon makes a small cut just below the navel and inserts a
laparoscope, a small telescope-like instrument. A second incision is made just above the pubic hairline to
allow the entrance of the instrument that will cut, sew or burn the tubes. The surgery takes about half an
hour.
 There may be up to several months delay between your request for surgery and the day it is performed.
You may want to consider other birth control methods in the meantime. Young women with no children
may have difficulty finding a surgeon to perform the procedure.

31
  After surgery, it is recommended that women take 2 to 3 days off and only perform light activities for a
week. Sexual activity can start again when a woman feels comfortable, usually after a week. Women
who have surgery performed through their vagina are advised not to put anything into their vagina for 2
weeks to avoid infection.
Your Health

 Although pregnancy is unlikely, there is a slightly higher risk of ectopic pregnancy after a tubal ligation.
An ectopic pregnancy occurs when a fertilized egg attaches and grows outside the uterus. This can be
very dangerous and requires immediate medical attention.

 Abnormal bleeding and bladder infections are risks after tubal ligations. Each type of surgery also
involves different risks.Some women report having post-tubal sterilization syndrome. The symptoms
include irregular and painful periods, mid-cycle bleeding, or no periods. While some physicians believe
there is no evidence that this syndrome exists, others believe more research should be done.
 Women who have reversal surgery and become pregnant have a higher chance of ectopic pregnancy.

Future Fertility

 Tubal ligation is considered a permanent method of birth control. Surgery to reverse a tubal ligation is not
always effective. In addition, reversals are both difficult and expensive.
Sexuality
Women are fully able to enjoy sex after a tubal ligation. Usually, hormone levels and a woman’s
menstrual cycle are not noticeably changed by sterilization. Ovaries continue to release eggs, but they
stop in the tubes and are reabsorbed by the body. Some women experience improved sexual pleasure
because they are less worried about becoming pregnant.

Advantages

 Permanent birth control.

 Immediately effective.
 Allows sexual spontaneity.
 Requires no daily attention.
 Not messy.
 Cost-effective in the long run.

Disadvantages

 Does not protect against sexually transmitted infections, including HIV/AIDS.

 Requires surgery.
 Has risks associated with surgery.
 More complicated than male sterilization.
 May not be reversible.
 Possible regret.

32
S. No. 2865
H. No. 4244

Republic of the Philippines

Congress of the Philippines
Metro Manila
Fifteenth Congress
Third Regular Session

Begun and held in Metro Manila, on Monday, the twenty-third day of July, two thousand twelve.

[ REPUBLIC ACT NO. 10354 ]

AN ACT PROVIDING FOR A NATIONAL POLICY ON RESPONSIBLE PARENTHOOD AND

REPRODUCTIVE HEALTH

Be it enacted by the Senate and House of Representatives of the Philippines in Congress assembled:

SECTION 1. Title. – This Act shall be known as “The Responsible Parenthood and Reproductive Health Act of
2012″.

SEC. 2. Declaration of Policy. – The State recognizes and guarantees the human rights of all persons including
their right to equality and nondiscrimination of these rights, the right to sustainable human development, the right
to health which includes reproductive health, the right to education and information, and the right to choose and
make decisions for themselves in accordance with their religious convictions, ethics, cultural beliefs, and the
demands of responsible parenthood.

Pursuant to the declaration of State policies under Section 12, Article II of the 1987 Philippine Constitution, it is
the duty of the State to protect and strengthen the family as a basic autonomous social institution and equally
protect the life of the mother and the life of the unborn from conception. The State shall protect and promote the
right to health of women especially mothers in particular and of the people in general and instill health
consciousness among them. The family is the natural and fundamental unit of society. The State shall likewise
protect and advance the right of families in particular and the people in general to a balanced and healthful
environment in accord with the rhythm and harmony of nature. The State also recognizes and guarantees the
promotion and equal protection of the welfare and rights of children, the youth, and the unborn.

Moreover, the State recognizes and guarantees the promotion of gender equality, gender equity, women
empowerment and dignity as a health and human rights concern and as a social responsibility. The advancement
and protection of women’s human rights shall be central to the efforts of the State to address reproductive health
care.

The State recognizes marriage as an inviolable social institution and the foundation of the family which in turn is
the foundation of the nation. Pursuant thereto, the State shall defend:

(a) The right of spouses to found a family in accordance with their religious convictions and the demands of
responsible parenthood;

(b) The right of children to assistance, including proper care and nutrition, and special protection from all
forms of neglect, abuse, cruelty, exploitation, and other conditions prejudicial to their development;

(c) The right of the family to a family living wage and income; and

33
(d) The right of families or family associations to participate in the planning and implementation of policies
and programs

The State likewise guarantees universal access to medically-safe, non-abortifacient, effective, legal, affordable,
and quality reproductive health care services, methods, devices, supplies which do not prevent the implantation of
a fertilized ovum as determined by the Food and Drug Administration (FDA) and relevant information and
education thereon according to the priority needs of women, children and other underprivileged sectors, giving
preferential access to those identified through the National Household Targeting System for Poverty Reduction
(NHTS-PR) and other government measures of identifying marginalization, who shall be voluntary beneficiaries
of reproductive health care, services and supplies for free. ■ •

The State shall eradicate discriminatory practices, laws and policies that infringe on a person’s exercise of
reproductive health rights.

The State shall also promote openness to life; Provided, That parents bring forth to the world only those children
whom they can raise in a truly humane way.

SEC. 3. Guiding Principles for Implementation. – This Act declares the following as guiding principles:

(a) The right to make free and informed decisions, which is central to the exercise of any right, shall not be
subjected to any form of coercion and must be fully guaranteed by the State, like the right itself;

(b) Respect for protection and fulfillment of reproductive health and rights which seek to promote the rights and
welfare of every person particularly couples, adult individuals, women and adolescents;

(c) Since human resource is among the principal assets of the country, effective and quality reproductive health
care services must be given primacy to ensure maternal and child health, the health of the unborn, safe delivery
and birth of healthy children, and sound replacement rate, in line with the State’s duty to promote the right to
health, responsible parenthood, social justice and full human development;

(d) The provision of ethical and medically safe, legal, accessible, affordable, non-abortifacient, effective and
quality reproductive health care services and supplies is essential in the promotion of people’s right to health,
especially those of women, the poor, and the marginalized, and shall be incorporated as a component of basic
health care;

(e) The State shall promote and provide information and access, without bias, to all methods of family planning,
including effective natural and modern methods which have been proven medically safe, legal, non-abortifacient,
and effective in accordance with scientific and evidence-based medical research standards such as those registered
and approved by the FDA for the poor and marginalized as identified through the NHTS-PR and other
government measures of identifying marginalization: Provided, That the State shall also provide funding support
to promote modern natural methods of family planning, especially the Billings Ovulation Method, consistent with
the needs of acceptors and their religious convictions;

(f) The State shall promote programs that: (1) enable individuals and couples to have the number of children they
desire with due consideration to the health, particularly of women, and the resources available and affordable to
them and in accordance with existing laws, public morals and their religious convictions: Provided, That no one
shall be deprived, for economic reasons, of the rights to have children; (2) achieve equitable allocation and
utilization of resources; (3) ensure effective partnership among national government, local government units
(LGUs) and the private sector in the design, implementation, coordination, integration, monitoring and evaluation
of people-centered programs to enhance the quality of life and environmental protection; (4) conduct studies to
analyze demographic trends including demographic dividends from sound population policies towards sustainable
human development in keeping with the principles of gender equality, protection of mothers and children, born
34
and unborn and the promotion and protection of women’s reproductive rights and health; and (5) conduct
scientific studies to determine the safety and efficacy of alternative medicines and methods for reproductive
health care development;

(g) The provision of reproductive health care, information and supplies giving priority to poor beneficiaries as
identified through the NHTS-PR and other government measures of identifying marginalization must be the
primary responsibility of the national government consistent with its obligation to respect, protect and promote
the right to health and the right to life;

(h) The State shall respect individuals’ preferences and choice of family planning methods that are in accordance
with their religious convictions and cultural beliefs, taking into consideration the State’s obligations under various
human rights instruments;

(i) Active participation by nongovernment organizations (NGOs), women’s and people’s organizations, civil
society, faith-based organizations, the religious sector and communities is crucial to ensure that reproductive
health and population and development policies, plans, and programs will address the priority needs of women,
the poor, and the marginalized;

(j) While this Act recognizes that abortion is illegal and punishable by law, the government shall ensure that all
women needing care for post-abortive complications and all other complications arising from pregnancy, labor
and delivery and related issues shall be treated and counseled in a humane, nonjudgmental and compassionate
manner in accordance with law and medical ethics;

(k) Each family shall have the right to determine its ideal family size: Provided, however, That the State shall
equip each parent with the necessary information on all aspects of family life, including reproductive health and
responsible parenthood, in order to make that determination;

(l) There shall be no demographic or population targets and the mitigation, promotion and/or stabilization of the
population growth rate is incidental to the advancement of reproductive health;

(m) Gender equality and women empowerment are central elements of reproductive health and population and
development;

(n) The resources of the country must be made to serve the entire population, especially the poor, and allocations
thereof must be adequate and effective: Provided, That the life of the unborn is protected;

(o) Development is a multi-faceted process that calls for the harmonization and integration of policies, plans,
programs and projects that seek to uplift the quality of life of the people, more particularly the poor, the needy and
the marginalized; and

(p) That a comprehensive reproductive health program addresses the needs of people throughout their life cycle.

SEC. 4. Definition of Terms. – For the purpose of this Act, the following terms shall be defined as follows:

(a) Abortifacient refers to any drug or device that induces abortion or the destruction of a fetus inside the
mother’s womb or the prevention of the fertilized ovum to reach and be implanted in the mother’s womb upon
determination of the FDA.

(b) Adolescent refers to young people between the ages of ten (10) to nineteen (19) years who are in transition
from childhood to adulthood.

35
(c) Basic Emergency Obstetric and Newborn Care (BEMONC) refers to lifesaving services for emergency
maternal and newborn conditions/complications being provided by a health facility or professional to include the
following services: administration of parenteral oxytocic drugs, administration of dose of parenteral
anticonvulsants, administration of parenteral antibiotics, administration of maternal steroids for preterm labor,
performance of assisted vaginal deliveries, removal of retained placental products, and manual removal of
retained placenta. It also includes neonatal interventions which include at the minimum: newborn resuscitation,
provision of warmth, and referral, blood transfusion where possible.

(d) Comprehensive Emergency Obstetric and Newborn Care (CEMONC) refers to lifesaving services for
emergency maternal and newborn conditions/complications as in Basic Emergency Obstetric and Newborn Care
plus the provision of surgical delivery (caesarian section) and blood bank services, and other highly specialized
obstetric interventions. It also includes emergency neonatal care which includes at the minimum: newborn
resuscitation, treatment of neonatal sepsis infection, oxygen support, and antenatal administration of (maternal)
steroids for threatened premature delivery.

(e) Family planning refers to a program which enables couples and individuals to decide freely and responsibly
the number and spacing of their children and to have the information and means to do so, and to have access to a
full range of safe, affordable, effective, non-abortifacient modem natural and artificial methods of planning
pregnancy.

(f) Fetal and infant death review refers to a qualitative and in-depth study of the causes of fetal and infant death
with the primary purpose of preventing future deaths through changes or additions to programs, plans and
policies.

(g) Gender equality refers to the principle of equality between women and men and equal rights to enjoy
conditions in realizing their full human potentials to contribute to, and benefit from, the results of development,
with the State recognizing that all human beings are free and equal in dignity and rights. It entails equality in
opportunities, in the allocation of resources or benefits, or in access to services in furtherance of the rights to
health and sustainable human development among others, without discrimination.

(h) Gender equity refers to the policies, instruments, programs and actions that address the disadvantaged position
of women in society by providing preferential treatment and affirmative action. It entails fairness and justice in
the distribution of benefits and responsibilities between women and men, and often requires women-specific
projects and programs to end existing inequalities. This concept recognizes that while reproductive health
involves women and men, it is more critical for women’s health.

(i) Male responsibility refers to the involvement, commitment, accountability and responsibility of males in all
areas of sexual health and reproductive health, as well as the care of reproductive health concerns specific to men.

(j) Maternal death review refers to a qualitative and in-depth study of the causes of maternal death with the
primary purpose of preventing future deaths through changes or additions to programs, plans and policies.

(k) Maternal health refers to the health of a woman of reproductive age including, but not limited to, during
pregnancy, childbirth and the postpartum period.

(l) Modern methods of family planning refers to safe, effective, non-abortifacient and legal methods, whether
natural or artificial, that are registered with the FDA, to plan pregnancy.

(m) Natural family planning refers to a variety of methods used to plan or prevent pregnancy based on
identifying the woman’s fertile days.

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(n) Public health care service provider refers to: (1) public health care institution, which is duly licensed and
accredited and devoted primarily to the maintenance and operation of facilities for health promotion, disease
prevention, diagnosis, treatment and care of individuals suffering from illness, disease, injury, disability or
deformity, or in need of obstetrical or other medical and nursing care; (2) public health care professional, who is
a doctor of medicine, a nurse or a midwife; (3) public health worker engaged in the delivery of health care
services; or (4) barangay health worker who has undergone training programs under any accredited government
and NGO and who voluntarily renders primarily health care services in the community after having been
accredited to function as such by the local health board in accordance with the guideline’s promulgated by the
Department of Health (DOH).

(o) Poor refers to members of households identified as poor through the NHTS-PR by the Department of Social
Welfare and Development (DSWD) or any subsequent system used by the national government in identifying the
poor.

(p) Reproductive Health (RH) refers to the state of complete physical, mental and social well-being and not
merely the absence of disease or infirmity, in all matters relating to the reproductive system and to its functions
and processes. This implies that people are able to have a responsible, safe, consensual and satisfying sex life, that
they have the capability to reproduce and the freedom to decide if, when, and how often to do so. This further
implies that women and men attain equal relationships in matters related to sexual relations and reproduction.

(q) Reproductive health care refers to the access to a full range of methods, facilities, services and supplies that
contribute to reproductive health and well-being by addressing reproductive health-related problems. It also
includes sexual health, the purpose of which is the enhancement of life and personal relations. The elements of
reproductive health care include the following:

(1) Family planning information and services which shall include as a first priority making women of
reproductive age fully aware of their respective cycles to make them aware of when fertilization is highly
probable, as well as highly improbable;

(2) Maternal, infant and child health and nutrition, including breastfeeding;

(3) Proscription of abortion and management of abortion complications;

(4) Adolescent and youth reproductive health guidance and counseling;

(5) Prevention, treatment and management of reproductive tract infections (RTIs), HIV and AIDS and other
sexually transmittable infections (STIs);

(6) Elimination of violence against women and children and other forms of sexual and gender-based violence;

(7) Education and counseling on sexuality and reproductive health;

(8) Treatment of breast and reproductive tract cancers and other gynecological conditions and disorders;

(9) Male responsibility and involvement and men’s reproductive health;

(10) Prevention, treatment and management of infertility and sexual dysfunction;

(11) Reproductive health education for the adolescents; and

(12) Mental health aspect of reproductive health care.

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(r) Reproductive health care program refers to the systematic and integrated provision of reproductive health
care to all citizens prioritizing women, the poor, marginalized and those invulnerable or crisis situations.

(s) Reproductive health rights refers to the rights of individuals and couples, to decide freely and responsibly
whether or not to have children; the number, spacing and timing of their children; to make other decisions
concerning reproduction, free of discrimination, coercion and violence; to have the information and means to do
so; and to attain the highest standard of sexual health and reproductive health: Provided, however, That
reproductive health rights do not include abortion, and access to abortifacients.

(t) Reproductive health and sexuality education refers to a lifelong learning process of providing and acquiring
complete, accurate and relevant age- and development-appropriate information and education on reproductive
health and sexuality through life skills education and other approaches.

(u) Reproductive Tract Infection (RTI) refers to sexually transmitted infections (STIs), and other types of
infections affecting the reproductive system.

(v) Responsible parenthood refers to the will and ability of a parent to respond to the needs and aspirations of the
family and children. It is likewise a shared responsibility between parents to determine and achieve the desired
number of children, spacing and timing of their children according to their own family life aspirations, taking into
account psychological preparedness, health status, sociocultural and economic concerns consistent with their
religious convictions.

(w) Sexual health refers to a state of physical, mental and social well-being in relation to sexuality. It requires a
positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having
pleasurable and safe sexual experiences, free from coercion, discrimination and violence.

(x) Sexually Transmitted Infection (STI) refers to any infection that may be acquired or passed on through sexual
contact, use of IV, intravenous drug needles, childbirth and breastfeeding.

(y) Skilled birth attendance refers to childbirth managed by a skilled health professional including the enabling
conditions of necessary equipment and support of a functioning health system, including transport and referral
faculties for emergency obstetric care.

(z) Skilled health professional refers to a midwife, doctor or nurse, who has been educated and trained in the
skills needed to manage normal and complicated pregnancies, childbirth and the immediate postnatal period, and
in the identification, management and referral of complications in women and newborns.

(aa) Sustainable human development refers to bringing people, particularly the poor and vulnerable, to the center
of development process, the central purpose of which is the creation of an enabling environment in which all can
enjoy long, healthy and productive lives, done in the manner that promotes their rights and protects the life
opportunities of future generations and the natural ecosystem on which all life depends.

SEC. 5. Hiring of Skilled Health Professionals for Maternal Health Care and Skilled Birth Attendance. – The
LGUs shall endeavor to hire an adequate number of nurses, midwives and other skilled health professionals for
maternal health care and skilled birth attendance to achieve an ideal skilled health professional-to-patient ratio
taking into consideration DOH targets: Provided, That people in geographically isolated or highly populated and
depressed areas shall be provided the same level of access to health care: Provided, further, That the national
government shall provide additional and necessary funding and other necessary assistance for the effective
implementation of this provision.

For the purposes of this Act, midwives and nurses shall be allowed to administer lifesaving drugs such as, but not
limited to, oxytocin and magnesium sulfate, in accordance with the guidelines set by the DOH, under emergency
38
conditions and when there are no physicians available: Provided, That they are properly trained and certified to
administer these lifesaving drugs.

SEC. 6. Health Care Facilities. – Each LGU, upon its determination of the necessity based on well-supported
data provided by its local health office shall endeavor to establish or upgrade hospitals and facilities with adequate
and qualified personnel, equipment and supplies to be able to provide emergency obstetric and newborn care:
Provided, That people in geographically isolated or highly populated and depressed areas shall have the same
level of access and shall not be neglected by providing other means such as home visits or mobile health care
clinics as needed: Provided, further, That the national government shall provide additional and necessary funding
and other necessary assistance for the effective implementation of this provision.

SEC. 7. Access to Family Planning. – All accredited public health facilities shall provide a full range of modern
family planning methods, which shall also include medical consultations, supplies and necessary and reasonable
procedures for poor and marginalized couples having infertility issues who desire to have children: Provided,
That family planning services shall likewise be extended by private health facilities to paying patients with the
option to grant free care and services to indigents, except in the case of non-maternity specialty hospitals and
hospitals owned and operated by a religious group, but they have the option to provide such full range of modern
family planning methods: Provided, further, That these hospitals shall immediately refer the person seeking such
care and services to another health facility which is conveniently accessible: Provided, finally, That the person is
not in an emergency condition or serious case as defined in Republic Act No. 8344.

No person shall be denied information and access to family planning services, whether natural or artificial:
Provided, That minors will not be allowed access to modern methods of family planning without written consent
from their parents or guardian/s except when the minor is already a parent or has had a miscarriage.

SEC. 8. Maternal Death Review and Fetal and Infant Death Review. – All LGUs, national and local
government hospitals, and other public health units shall conduct an annual Maternal Death Review and Fetal and
Infant Death Review in accordance with the guidelines set by the DOH. Such review should result in an evidence-
based programming and budgeting process that would contribute to the development of more responsive
reproductive health services to promote women’s health and safe motherhood.

SEC. 9. The Philippine National Drug Formulary System and Family Planning Supplies. – The National Drug
Formulary shall include hormonal contraceptives, intrauterine devices, injectables and other safe, legal, non-
abortifacient and effective family planning products and supplies. The Philippine National Drug Formulary
System (PNDFS) shall be observed in selecting drugs including family planning supplies that will be included or
removed from the Essential Drugs List (EDL) in accordance with existing practice and in consultation with
reputable medical associations in the Philippines. For the purpose of this Act, any product or supply included or to
be included in the EDL must have a certification from the FDA that said product and supply is made available on
the condition that it is not to be used as an abortifacient.

These products and supplies shall also be included in the regular purchase of essential medicines and supplies of
all national hospitals: Provided, further, That the foregoing offices shall not purchase or acquire by any means
emergency contraceptive pills, postcoital pills, abortifacients that will be used for such purpose and their other
forms or equivalent.

SEC. 10. Procurement and Distribution of Family Planning Supplies. – The DOH shall procure, distribute to
LGUs and monitor the usage of family planning supplies for the whole country. The DOH shall coordinate with
all appropriate local government bodies to plan and implement this procurement and distribution program. The
supply and budget allotments shall be based on, among others, the current levels and projections of the following:

(a) Number of women of reproductive age and couples who want to space or limit their children;

39
(b) Contraceptive prevalence rate, by type of method used; and

(c) Cost of family planning supplies.

Provided, That LGUs may implement its own procurement, distribution and monitoring program consistent with
the overall provisions of this Act and the guidelines of the DOH.

SEC. 11. Integration of Responsible Parenthood and Family Planning Component in Anti-Poverty Programs.
– A multidimensional approach shall be adopted in the implementation of policies and programs to fight poverty.
Towards this end, the DOH shall implement programs prioritizing full access of poor and marginalized women as
identified through the NHTS-PR and other government measures of identifying marginalization to reproductive
health care, services, products and programs. The DOH shall provide such programs, technical support, including
capacity building and monitoring.

SEC. 12. PhilHealth Benefits for Serious .and Life-Threatening Reproductive Health Conditions. – All serious
and life-threatening reproductive health conditions such as HIV and AIDS, breast and reproductive tract cancers,
and obstetric complications, and menopausal and post-menopausal-related conditions shall be given the maximum
benefits, including the provision of Anti-Retroviral Medicines (ARVs), as provided in the guidelines set by the
Philippine Health Insurance Corporation (PHIC).

SEC. 13. Mobile Health Care Service. – The national or the local government may provide each provincial, city,
municipal and district hospital with a Mobile Health Care Service (MHCS) in the form of a van or other means of
transportation appropriate to its terrain, taking into consideration the health care needs of each LGU. The MHCS
shall deliver health care goods and services to its constituents, more particularly to the poor and needy, as well as
disseminate knowledge and information on reproductive health. The MHCS shall be operated by skilled health
providers and adequately equipped with a wide range of health care materials and information dissemination
devices and equipment, the latter including, but not limited to, a television set for audio-visual presentations. All
MHCS shall be operated by LGUs of provinces and highly urbanized cities.

SEC. 14. Age- and Development-Appropriate Reproductive Health Education. – The State shall provide age-
and development-appropriate reproductive health education to adolescents which shall be taught by adequately
trained teachers informal and nonformal educational system and integrated in relevant subjects such as, but not
limited to, values formation; knowledge and skills in self-protection against discrimination; sexual abuse and
violence against women and children and other forms of gender based violence and teen pregnancy; physical,
social and emotional changes in adolescents; women’s rights and children’s rights; responsible teenage behavior;
gender and development; and responsible parenthood: Provided, That flexibility in the formulation and adoption
of appropriate course content, scope and methodology in each educational level or group shall be allowed only
after consultations with parents-teachers-community associations, school officials and other interest groups. The
Department of Education (DepED) shall formulate a curriculum which shall be used by public schools and may
be adopted by private schools.

SEC. 15. Certificate of Compliance. – No marriage license shall be issued by the Local Civil Registrar unless the
applicants present a Certificate of Compliance issued for free by the local Family Planning Office certifying that
they had duly received adequate instructions and information on responsible parenthood, family planning,
breastfeeding and infant nutrition.

SEC. 16. Capacity Building of Barangay Health Workers (BHWs). – The DOH shall be responsible for
disseminating information and providing training programs to the LGUs. The LGUs, with the technical assistance
of the DOH, shall be responsible for the training of BHWs and other barangay volunteers on the promotion of
reproductive health. The DOH shall provide the LGUs with medical supplies and equipment needed by BHWs to
carry out their functions effectively: Provided, further, That the national government shall provide additional and

40
necessary funding and other necessary assistance for the effective implementation of this provision including the
possible provision of additional honoraria for BHWs.

SEC. 17. Pro Bono Services for Indigent Women. – Private and nongovernment reproductive healthcare service
providers including, but not limited to, gynecologists and obstetricians, are encouraged to provide at least forty-
eight (48) hours annually of reproductive health services, ranging from providing information and education to
rendering medical services, free of charge to indigent and low-income patients as identified through the NHTS-
PR and other government measures of identifying marginalization, especially to pregnant adolescents. The forty-
eight (48) hours annual pro bono services shall be included as a prerequisite in the accreditation under the
PhilHealth.

SEC. 18. Sexual and Reproductive Health Programs for Persons with Disabilities (PWDs). – The cities and
municipalities shall endeavor that barriers to reproductive health services for PWDs are obliterated by the
following:

(a) Providing physical access, and resolving transportation and proximity issues to clinics, hospitals and places
where public health education is provided, contraceptives are sold or distributed or other places where
reproductive health services are provided;

(b) Adapting examination tables and other laboratory procedures to the needs and conditions of PWDs;

(c) Increasing access to information and communication materials on sexual and reproductive health in braille,
large print, simple language, sign language and pictures;

(d) Providing continuing education and inclusion of rights of PWDs among health care providers; and

(e) Undertaking activities to raise awareness and address misconceptions among the general public on the stigma
and their lack of knowledge on the sexual and reproductive health needs and rights of PWDs.

SEC. 19. Duties and Responsibilities. – (a) Pursuant to the herein declared policy, the DOH shall serve as the
lead agency for the implementation of this Act and shall integrate in their regular operations the following
functions:

(1) Fully and efficiently implement the reproductive health care program;

(2) Ensure people’s access to medically safe, non-abortifacient, legal, quality and affordable reproductive health
goods and services; and

(3) Perform such other functions necessary to attain the purposes of this Act.

(b) The DOH, in coordination with the PHIC, as may be applicable, shall:

(1) Strengthen the capacities of health regulatory agencies to ensure safe, high quality, accessible and affordable
reproductive health services and commodities with the concurrent strengthening and enforcement of regulatory
mandates and mechanisms;

(2) Facilitate the involvement and participation of NGOs and the private sector in reproductive health care service
delivery and in the production, distribution and delivery of quality reproductive health and family planning
supplies and commodities to make them accessible and affordable to ordinary citizens;

(3) Engage the services, skills and proficiencies of experts in natural family planning who shall provide the
necessary training for all BHWs;
41
(4) Supervise and provide assistance to LGUs in the delivery of reproductive health care services and in the
purchase of family planning goods and supplies; and

(5) Furnish LGUs, through their respective local health offices, appropriate information and resources to keep the
latter updated on current studies and researches relating to family planning, responsible parenthood, breastfeeding
and infant nutrition.

(c) The FDA shall issue strict guidelines with respect to the use of contraceptives, taking into consideration the
side effects or other harmful effects of their use.

(d) Corporate citizens shall exercise prudence in advertising its products or services through all forms of media,
especially on matters relating to sexuality, further taking into consideration its influence on children and the
youth.

SEC. 20. Public Awareness. – The DOH and the LGUs shall initiate and sustain a heightened nationwide
multimedia-campaign to raise the level of public awareness on the protection and promotion of reproductive
health and rights including, but not limited to, maternal health and nutrition, family planning and responsible
parenthood information and services, adolescent and youth reproductive health, guidance and counseling and
other elements of reproductive health care under Section 4(q).

Education and information materials to be developed and disseminated for this purpose shall be reviewed
regularly to ensure their effectiveness and relevance.

SEC. 21. Reporting Requirements. – Before the end of April each year, the DOH shall submit to the President of
the Philippines and Congress an annual consolidated report, which shall provide a definitive and comprehensive
assessment of the implementation of its programs and those of other government agencies and instrumentalities
and recommend priorities for executive and legislative actions. The report shall be printed and distributed to all
national agencies, the LGUs, NGOs and private sector organizations involved in said programs.

The annual report shall evaluate the content, implementation, and impact of all policies related to reproductive
health and family planning to ensure that such policies promote, protect and fulfill women’s reproductive health
and rights.

SEC. 22. Congressional Oversight Committee on Reproductive Health Act. – There is hereby created a
Congressional Oversight Committee (COC) composed of five (5) members each from the Senate and the House
of Representatives. The members from the Senate and the House of Representatives shall be appointed by the
Senate President and the Speaker, respectively, with at least one (1) member representing the Minority.

The COC shall be headed by the respective Chairs of the Committee on Health and Demography of the Senate
and the Committee on Population and Family Relations of the House of Representatives. The Secretariat of the
COC shall come from the existing Secretariat personnel of the Senate and the House of Representatives
committees concerned.

The COC shall monitor and ensure the effective implementation of this Act, recommend the necessary remedial
legislation or administrative measures, and shall conduct a review of this Act every five (5) years from its
effectivity. The COC shall perform such other duties and functions as may be necessary to attain the objectives
of tins Act.

SEC. 23. Prohibited Acts. – The following acts are prohibited:

(a) Any health care service provider, whether public or private, who shall:

42
(1) Knowingly withhold information or restrict the dissemination thereof, and/or intentionally provide incorrect
information regarding programs and services on reproductive health including the right to informed choice and
access to a full range of legal, medically-safe, non-abortifacient and effective family planning methods;

(2) Refuse to perform legal and medically-safe reproductive health procedures on any person of legal age on the
ground of lack of consent or authorization of the following persons in the following instances:

(i) Spousal consent in case of married persons: Provided, That in case of disagreement, the decision of the one
undergoing the procedure shall prevail; and

(ii) Parental consent or that of the person exercising parental authority in the case of abused minors, where the
parent or the person exercising parental authority is the respondent, accused or convicted perpetrator as certified
by the proper prosecutorial office of the court. In the case of minors, the written consent of parents or legal
guardian or, in their absence, persons exercising parental authority or next-of-kin shall be required only in elective
surgical procedures and in no case shall consent be required in emergency or serious cases as defined in Republic
Act No. 8344; and

(3) Refuse to extend quality health care services and information on account of the person’s marital status, gender,
age, religious convictions, personal circumstances, or nature of work: Provided, That the conscientious objection
of a health care service provider based on his/her ethical or religious beliefs shall be respected; however, the
conscientious objector shall immediately refer the person seeking such care and services to another health care
service provider within the same facility or one which is conveniently accessible: Provided, further, That the
person is not in an emergency condition or serious case as defined in Republic Act No. 8344, which penalizes the
refusal of hospitals and medical clinics to administer appropriate initial medical treatment and support in
emergency and serious cases;

(b) Any public officer, elected or appointed, specifically charged with the duty to implement the provisions
hereof, who, personally or through a subordinate, prohibits or restricts the delivery of legal and medically-safe
reproductive health care services, including family planning; or forces, coerces or induces any person to use such
services; or refuses to allocate, approve or release any budget for reproductive health care services, or to support
reproductive health programs; or shall do any act that hinders the full implementation of a reproductive health
program as mandated by this Act;

(c) Any employer who shall suggest, require, unduly influence or cause any applicant for employment or an
employee to submit himself/herself to sterilization, use any modern methods of family planning, or not use such
methods as a condition for employment, continued employment, promotion or the provision of employment
benefits. Further, pregnancy or the number of children shall not be a ground for non-hiring or termination from
employment;

(d) Any person who shall falsify a Certificate of Compliance as required in Section 15 of this Act; and

(e) Any pharmaceutical company, whether domestic or multinational, or its agents or distributors, which directly
or indirectly colludes with government officials, whether appointed or elected, in the distribution, procurement
and/or sale by the national government and LGUs of modern family planning supplies, products and devices.

SEC. 24. Penalties. – Any violation of this Act or commission of the foregoing prohibited acts shall be penalized
by imprisonment ranging from one (1) month to six (6) months or a fine of Ten thousand pesos (P10,000.00) to
One hundred thousand pesos (P100,000.00), or both such fine and imprisonment at the discretion of the
competent court: Provided, That, if the offender is a public officer, elected or appointed, he/she shall also suffer
the penalty of suspension not exceeding one (1) year or removal and forfeiture of retirement benefits depending
on the gravity of the offense after due notice and hearing by the appropriate body or agency.

43
If the offender is a juridical person, the penalty shall be imposed upon the president or any responsible officer. An
offender who is an alien shall, after service of sentence, be deported immediately without further proceedings by
the Bureau of Immigration. If the offender is a pharmaceutical company, its agent and/or distributor, their license
or permit to operate or conduct business in the Philippines shall be perpetually revoked, and a fine triple the
amount involved in the violation shall be imposed.

SEC. 25. Appropriations. – The amounts appropriated in the current annual General Appropriations Act (GAA)
for reproductive health and natural and artificial family planning and responsible parenthood under the DOH and
other concerned agencies shall be allocated and utilized for the implementation of this Act. Such additional sums
necessary to provide for the upgrading of faculties necessary to meet BEMONC and CEMONC standards; the
training and deployment of skilled health providers; natural and artificial family planning commodity
requirements as outlined in Section 10, and for other reproductive health and responsible parenthood services,
shall be included in the subsequent years’ general appropriations. The Gender and Development (GAD) funds of
LGUs and national agencies may be a source of funding for the implementation of this Act.

SEC. 26. Implementing Rules and Regulations (IRR). – Within sixty (60) days from the effectivity of this Act,
the DOH Secretary or his/her designated representative as Chairperson, the authorized representative/s of DepED,
DSWD, Philippine Commission on Women, PHIC, Department of the Interior and Local Government, National
Economic and Development Authority, League of Provinces, League of Cities, and League of Municipalities,
together with NGOs, faith-based organizations, people’s, women’s and young people’s organizations, shall jointly
promulgate the rules and regulations for the effective implementation of this Act. At least four (4) members of the
IRR drafting committee, to be selected by the DOH Secretary, shall come from NGOs.

SEC. 27. Interpretation Clause. – This Act shall be liberally construed to ensure the provision, delivery and
access to reproductive health care services, and to promote, protect and fulfill women’s reproductive health and
rights.

SEC. 28. Separability Clause. – If any part or provision of this Act is held invalid or unconstitutional, the other
provisions not affected thereby shall remain in force and effect.

SEC. 29. Repealing Clause. – Except for prevailing laws against abortion, any law, presidential decree or
issuance, executive order, letter of instruction, administrative order, rule or regulation contrary to or is
inconsistent with the provisions of this Act including Republic Act No. 7392, otherwise known as the Midwifery
Act, is hereby repealed, modified or amended accordingly.

– This Act shall take effect fifteen (15) days after its publication in at least two (2) newspapers of general
circulation.

(Sgd.) FELICIANO BELMONTE JR.

Speaker of the House (Sgd.) JUAN PONCE ENRILE
of Representatives President of the Senate

This Act which is a consolidation of Senate Bill No. 2865 and House Bill No. 4244 was finally passed by the Senate and the
House of Representatives on December 19, 2012.

(Sgd.) MARILYN B. BARUA-YAP

Secretary General (Sgd.) EMMA LIRIO-REYES
House of Representatives Secretary of the Senate

Approved: DEC 21 2012

(Sgd.) BENIGNO S. AQUINO III

President of the Philippines

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Lesson 3- Human Sexuality and Fetal
Development
Human Sexuality
 Definitions
 Concepts
 Elements of sexuality
 Biological
 Psychological
 Sexual orientation
Sexual Response
 By Masters And Johnson
 By Kaplan
 DSM-IV TR
The fertilization
The implantation
Chronological order of growth of the baby
Periods of growth and development
Primary germ layer
Hormones during pregnancy
Special structures of pregnancy
The fetal circulation
Special structures of fetal circulation
Fetal circulation versus adult circulation

45
HUMAN SEXUALITY
 According to WHO, Sexuality is the integration of somatic, emotional, intellectual and social aspect of
sexual beings in ways that are positively enriching and that enhance personality, communication and
love. In other words, sexual health is the physical and emotional state of well being that enables us to
enjoy and act on sexual feelings.
 Other definitions:
 The quality of being human.
 The most intimate feelings of the human heart.
 The totality of the human being
 The ongoing process of recognizing, accepting and expressing oneself as a sexual being.
I- Concepts
1. A person’s sexuality encompasses the complex behaviors, attitudes, emotions and preferences that
are related to sexual self and eroticism.
2. Sex- basic and dynamic aspect of life. Gender male or female. The physiologic act of sexual
intercourse.
3. During reproductive years, the nurse performs as resource person on human sexuality

II- Elements of Sexuality

A. Biologic Elements
 Female fetus has 2x chromosomes
 Male fetus has an X and Y fetus, the X from the mother and the Y from the father.
B. Psychological Elements
1. Gender Identity- sense of feminity and masculinity, 2 to 4 y/o gender identity develops
2. Gender Role- attitudes, behaviors, and attributes that differentiate roles. It is the public
expression of gender identity.
Factors influencing Gender role
 Social influence (peers, parents, media)
 Learned in school
 Learned from the sexual value system of the family and the community
 Sex hormones (estrogen , testosterone)

3. Sexual orientation- is the preference for intimate relationships with a person of the opposite
sex or the same sex.
a. Heterosexual- having a clear sustained and erotic desire for a person of the opposite sex.
b. Homosexual- having similar desires for a person with the same sex-gays lesbians
c. Bisexual- prefers intimate relationships with both sexes.

C. Socio-cultural Elements
 This reflects the belief of a culture or a society. These beliefs shape the development of a
person as a sexual being.
1. Male and female roles
 Culture has clear distinctions of the appropriate roles of males and females.
Male is the breadwinner and support the family
Female is the one rearing the children and does household chores

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 2. Sexual Practices
 Sex must occur only after marriage
 The risk of acquiring STD and becoming pregnant as well as religious belief may also
influence a person’s decision about sexual practice.

SEXUAL RESPONE
A. The physical reactions that develop as responses to effective sexual stimulation were described by
Masters and Johnson (1966) and were grouped in 4 separate phases which they described as the sexual
response sexual cycle:

1. Excitement phase

 The excitement phase (also known as the arousal phase or initial excitement phase) is the first stage of
the human sexual response cycle. It occurs as the result of physical or mental erotic stimuli, such as
kissing, petting, or viewing erotic images, that leads to sexual arousal. During the excitement stage, the
body prepares for sexual intercourse, initially leading to the plateau phase.

 Excitement in both sexes

Among both sexes, the excitement phase results in an increase in heart rate, breathing rate, and a rise in
males arises or is enhanced by direct stimulation of nipples, with only 7–8% reporting that it decreased
their arousal. Vasocongestion of the skin, commonly referred to as the sex flush, will occur in
approximately 50-75% of females and 25% of males. The sex flush tends to occur more often under
warmer conditions and may not appear at all under cooler temperatures.

During the female sex flush, pinkish spots develop under the breasts, then spread to the breasts, torso,
face, hands, soles of the feet, and possibly over the entire body. Vasocongestion is also responsible for the
darkening of the clitoris and the walls of the vagina during sexual arousal. During the male sex flush, the
coloration of the skin develops less consistently than in the female, but typically starts with the
epigastrium (upper abdomen), spreads across the chest, and then continues to the neck, face, forehead,
back, and sometimes, shoulders and forearms. The sex flush typically disappears soon after orgasm
occurs, but this may take up to two hours or so and, sometimes, intense sweating will occur
simultaneously. The flush usually diminishes in reverse of the order in which it appeared.

An increase in muscle tone (myotonia) of certain muscle groups, occurring voluntarily and involuntarily,
begins during this phase among both sexes. Also, the external anal sphincter may contract randomly upon
contact (or later during orgasm without contact).
47
 Excitement in males

In males, the beginning of the excitement phase is observed when the penis becomes partially erect, often
after only a few seconds of erotic stimulation. The erection may be partially lost and regained repeatedly
during an extended excitement phase. Both testicles become drawn upward toward the perineum, notably in
circumcised males where less skin is available to accommodate the erection. Also, the scrotum can tense and
thicken during the erection process.

 Excitement in females

In females, the excitement phase can last from several minutes to several hours. The onset of
vasocongestion results in swelling of the woman's clitoris, labia minora and vagina. The muscle that
surrounds the vaginal opening grows tighter and the uterus elevates and grows in size. The vaginal walls
begin to produce a lubricating organic liquid. Meanwhile, the breasts increase slightly in size and nipples
become hardened and erect.

2. Plateau phase

 The plateau phase is the period of sexual excitement prior to orgasm. The phase is characterized by an
increased circulation and heart rate in both sexes, increased sexual pleasure with increased stimulation,
and further increased muscle tension. Also, respiration continues at an elevated level. Both men and
women may also begin to vocalize involuntarily at this stage. Prolonged time in the plateau phase without
progression to the orgasmic phase may result in frustration if continued for too long (see orgasm control).

 Plateau in males

During this phase, the male urethral sphincter contracts (so as to prevent urine from mixing with semen,
and to guard against retrograde ejaculation) and muscles at the base of the penis begin a steady rhythmic
contraction. Males may start to secrete seminal fluid or pre-ejaculatory fluid and the testicles rise closer to
the body.

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 Plateau in females

The plateau stage in females is basically a continuation of the same changes evident in the excitement
stage. The clitoris becomes extremely sensitive and withdraws slightly and the Bartholin glands produce
further lubrication. The tissues of the outer third of the vagina swell, and the pubococcygeus muscle
tightens, reducing the diameter of the opening of the vagina. Masters and Johnson refer to the changes
that take place during the plateau stage as the orgasmic platform. For those who never achieve orgasm,
this is the peak of sexual excitement.

3. Orgasmic phase

 Orgasm is the conclusion of the plateau phase of the sexual response cycle and is experienced by both
males and females. It is accompanied by quick cycles of muscle contraction in the lower pelvic muscles,
which surround both the anus and the primary sexual organs. Women also experience uterine and vaginal
contractions. Orgasms are often associated with other involuntary actions, including vocalizations and
muscular spasms in other areas of the body, and a generally euphoric sensation. Heart rate is increased
even further.

 Orgasm in males

In men, orgasm is usually associated with ejaculation. Each ejection is associated with a wave of sexual
pleasure, especially in the penis and loins. Other sensations may be felt strongly among the lower spine,
or lower back. The first and second convulsions are usually the most intense in sensation, and produce the
greatest quantity of semen. Thereafter, each contraction is associated with a diminishing volume of semen
and a milder wave of pleasure.

 Orgasm in females

Orgasms in females can vary widely from woman to woman. The overall sensation is similar to that of the
male orgasm. They are commonly associated with an increase in vaginal lubrication, a tightening of the
vaginal walls, and overall pleasure.

4. Resolution phase

 The resolution phase occurs after orgasm and allows the muscles to relax, blood pressure to drop and the
body to slow down from its excited state. The refractory period, which is part of the resolution phase, is
the time frame in which usually a man is unable to orgasm again, though women can also experience a
refractory period.

 Resolution in males

Masters and Johnson described the two-stage detumescence of the penis: In the first stage, the penis
decreases from its erect state to about fifty percent larger than its flaccid state. This occurs during the
refractory period. In the second stage (and after the refractory period is finished), the penis decreases in
size and returns to being flaccid.It is generally impossible for men to achieve orgasm during the refractory
period. Masters and Johnson argue that this period must end before men can become aroused again.

49
 Resolution in females

According to Masters and Johnson, women have the ability to orgasm again very quickly, as long as they
have effective stimulation. They are, as a result, able to have multiple orgasms in a relatively short
period of time. Though generally reported that women do not experience a refractory period and thus
can experience an additional orgasm, or multiple orgasms, soon after the first, some sources state that
men and women experience a refractory period because women may also experience a period after
orgasm in which further sexual stimulation does not produce excitement. For some women, the clitoris
is very sensitive after climax, making additional stimulation initially painful. After the initial orgasm,
subsequent orgasms for women may also be stronger or more pleasurable as the stimulation
accumulates.

B. KAPLAN (1979) defined the three stages of the sexual cycle as:
1. Desire stage
2. Excitement stage
3. Orgasm stage

C. The most recent revision of the stages of sexual response cycle are included in the Diagnostic Manual of
Mental Disorders III-R (1987) and are described as follows:
1. Appetitive
 This stage of the sexual response cycle consists of sexual fantasies and the desire to have
sexual activities.
2. Excitement
 This stage of sexual response cycle includes the subjective sense of sexual pleasure along
the physiologic changes.
 In the male, the major changes include penile tumescence leading to erection and Cowper’s
gland secretions.
 In the female, vasocongestion of the pelvis occurs along with vaginal lubrications, swelling of
the external genitalia and narrowing of the outer third of the vagina, which occurs because
of increases pubococcygeal muscle tension and vasocongestion of the labia minora, breast
tumescence and the lengthening and widening of the inner two-thirds of the vagina.
3. Orgasm
 This stage is the peaking of sexual pleasure along with the release of sexual tension and
rhythmic contractions of the perineal muscles and pelvic reproductive organs.
 More specifically, in the male there is the sensation of ejaculatory inevitability followed by
emission of semen, which is caused by contractions of the prostate, seminal vesicles and
urethra.
 For females, there are contractions of the outer third of the vagina (not always subjectively
experience as such).
 Both male and female often experienced generalized muscular tension and contractions
such as involuntary pelvic thrusting.
4. Resolution
 The final phase of the sexual response cycle consists of a sense of general relaxation, and a
sense of well being. Females may be able to respond to additional stimulation almost
immediately during this phase, however, males are physiologically refractory to further
erection and orgasm for a variable period of time.

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The Fetal Development

THE FERTILIZATION
o Also known as conception and impregnation.
o It is the union of an ovum and a spermatozoon
o It is usually occurs in the outer third of fallopian tube, specifically in the ampullar portion.
o Usually only one ova will reach maturity each month, the ovum life span is 24-48 hours and sperm life
span is 48-72 hours.
o As the ovum is extruded from the graafian follicle of an ovary with ovulation, it is surrounded by a ring
of muco-polysaccharide fluid (zona pellucida) and a circle of cells (corona radiata).

o The ovum and the surrounding cells are propelled into a nearby fallopian tube by currents initiated by
the fimbrae-the fine, hairlike structures that line the openings of the fallopian tubes. A combination of
peristatltic action and the movement of the cilia help propel ovum along the length of the tube.

o Normally an ejaculation of semen averages 2.5ml of fluid containing 50 to 200 million spermatozoa per
milliliter or an average of 400 million sperm per ejaculation.

o At the time of ovulation, there is reduction in the viscosity (thickness) of the cervical mucus, which
makes it easy for spermatozoa to penetrate the ovum.
Sperm transport is so efficient close to ovulation that spermatozoa deposited in the vagina generally
reach the cervix 90 seconds and the ampullar within 5 minutes after deposition. This is one reason why
douching is not an effective contraceptive measure.

51
o Capacitation is a final process that sperm must undergo to be ready for fertilization. This process which
happens as the sperm move toward the ovum, consist of changes in the plasma membrane of the sperm
head, which reveal the sperm-binding receptor sites.

o All of the spermatozoa that achieve capacitation reach the ovum and cluster around the protective layer
of corona cells. Hyaluronidase (proteolytic enzyme) is released by the spermatozoa and dissolves the
layer of cells protecting the ovum. One reason that an ejaculated contains such as large number of
sperm is probably to provide sufficient enzymes to dissolve the corona cells.

o Only one spermatozoa is able to penetrate the cell membrane of the ovum. Once it penetrates the cell,
the cell membrane changes composition to become impervious to other spermatozoa. An exception to
this is the formation of hyatidiform mole in which multiple sperm enter an ovum, this leads to abnormal
zygote formation.

o Immediately, after penetration of the ovum, the chromosomal material of the ovum and spermatozoon
fuse to form a zygote. Because the spermatozoon and ovum each carried 23 chromosomes (22
autosomes and 1 sex chromosomes), the fertilized ovum has 46 chromosomes. If an x-carrying
spermatozoon entered the ovum, the resulting child will have two x-chromosomes and will be female
(XX). If a Y-carrying spermatozoon fertilized the ovum, the resulting child will have X & Y chromosomes
and will be male (XY).

o Fertilization is never a certain occurrence because it depends on at least 3 separate factors::

 Equal maturation of both sperm and ovum
 The ability of the sperm to reach the ovum.
 The ability of the sperm to penetrate the zona pellucida and cell membrane and achieve
fertilization

THE IMPLANTATION
o Once fertilization is complete, a zygote migrates over the next 3 to 4 days toward the body of the
uterus. The first cleavage occurs at about 24 hours, cleavage divisions continue to occur at a rate of
about one every 22 hours.
o By the time the zygote reaches the body of the uterus it consists of 16-50 cells. At this stage, because of
its bumpy outward appearance, it is termed a morula (from the Latin word “morus” meaning
“mulberry”). The morula continues to multiply as it floats free in the uterine cavity for 3 to 4 additional
days. Large cells tend to collect at the periphery of the ball, leaving a fluid space surrounding an inner
cell mass. At this stage, the structure becomes a blastocyst. It is the structure that attaches to uterine
endometrium.

o The cell in the outer ring is trophoblast cells. They are part of the structure that will later form the
placenta and membranes. The inner cell mass called the embryoblast cells is the portion of the structure
that will form the embryo.

o Implantation or contact between the growing structure and the uterine endometrium, occurs
approximately 8-10 days after fertilization. After the third or fourth day of free floating (about 8 days
since ovulation), the blastocyst sheds the last residues of the corona radiata and zona pellucida. It
attaaches to the surface of endometrium and settles down into its soft folds.

o The touching or implantation point is usually high in the uterus, on the posterior surface. If the point of
implantation is low in the uterus, the growing placenta may occlude the cervix and make the birth of

52
 the child difficult (placenta previa). Occasionally, a small amount of vaginal spotting appears on the day
of implantation because capillaries are ruptured by the implanting trophoblast cells.

o Implantation in the uterus occurs 6 to 10 days after ovum fertilization

CHRONOLOGICAL ORDER OF GROWTH OF THE BABY

Zygote
 contains single cell, from fertilization to implantation, the fertilized egg
 a single cell organism that results from the fertilization of an egg cell by sperm
Blastomere
 contains 8-16cells
Morulla
 contains 16-32 cells
Blastocyst-contains 32-50 cells
 The term given to the embryo at about 5 or 6 postfertlization
Embryoblast- the inner cell mass of the blastocyst, which is the developing human organism.
Amniotic sac- a thin membrane arising from a cell mass within the blastocyst that completely
surrounds the embryo/fetus and contatins a protective fluid in which the embryo/fetus is immersed
Trophoblast- a cell mass within the blastocyst that becomes the placenta
Embryo
 from implantation (6-10 days) to 8 weeks
 the term given to a developing human organism between the first cleavage of the single cell
zygote into multiple cells
embryoblast- the inner cell mass of the blastocyst, which is the developing human organism
Fetus- from the 8th week of gestation through delivery
Neonate- newborn, from birth to 28 days

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 Infant-from 28 days to 1 ½ year

PERIODS OF GROWTH AND DEVELOPMENT

1. Pre-embryonic Period/Germinal Period (0-2 weeks)
 The first two weeks of prenatal development from fertilization of the egg to the separation of
the three germ layers of somatic cells, and including implantation of the blastocyst of the
embryo into the uterine wall.
 There is rapid cell division and differentiation
 Development of embryonic membranes and germ layer
 Safe in teratogens
2. Embryonic Period (3-8 weeks)
 Period of organogenesis or organs development
 Organogenesis occurs during the first trimester of pregnancy, specifically, days 14 to 56 of
gestation.
 Most dangerous period in teratogens.
Organogenesis- a period of development of major organ systems during the embryonic period;
by the end of the week 8, 95% of major organs are complete.
3rd week: the neural plate forms and becomes the brain and neural tube (spinal cord). Neurogenesis,
the production of neurons begins. The heart chambers and blood vessels develop.

4th week: the heart begins to beat, arm and leg buds are visible, eyes, ears, nerves, and muscular,
skeletal, and digestive systems begin to form. Vertebrae are present, major veins and arteries are
completed.

5th week: the brain has five components and the nose and the lips begin to form.

6th week: differentiation of external genitalia and internal reproductive organs begins. The head and
brain are prominent; arms and legs are longer; and hands and feet have fingers and toes. The lungs
begin to develop.

7th week: the face, eyelids, and neck begin to form. The stomach and other internal organs are in
position. Muscles are forming, arms and legs are apparent, and the embryo can move.

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 8th week: the embryo appears more human, the inner and middle ear develop, and the embryo is
the size of a grape

3. Fetal Period (9 weeks to birth)

 Every organ system and external structure is present
 Refinement of the fetus and its organs
9-12 weeks: intestines are in position, the spinal cord is visible, the eyes take final form and the
eyelids can close, red blood cells form in the liver. Sex organs are now apparent. Tooth buds
appear. The heartbeat is audible with the right equipment. The fetus is 2.4 to 3 inches long and
weighs 0.7 oz.
13-16 weeks: the skin is almost transparent, the bones and joints are distinct, and the brain’s
hemispheres are visible. Lanugo (fine hair) and vernix caseosa (oil) begin to appear on skin. The
fetus is 4.7 inches long and weighs 3.5 oz. The mother may feel quickening (fetal movement).
17-20 weeks- dental enamel forms, myelination of nerves begins. The intestines and kidneys
work. Ultrasound is typically done at around 20 weeks.
24 weeks: fat begins to accumulate. Bone Marrow begins producing red blood cell. Eyes are fully
formed. The fetus is 9 inches long and weighs 21.6 oz.
Viability- the ability of the fetus to survive outside the womb (24-25 weeks)
28 weeks:

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56
57
 PRIMARY GERM LAYER
1. Ectoderm- outer germ layer of the blastocyst
 Develops into the nervous system (including the brain and spine), skin, nails, and hair, as
well as the salivary, pituitary, and mammary glands
2. Mesoderm- middle germ layer
 Produces connective tissue, muscles, blood, circulatory system (heart), kidneys,
reproductive and musculoskeletal system
3. Endoderm- inner germ layer
 Produces linings of gastrointestinal system, respiratory tracts, endocrine glands and auditory
canals

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 HORMONES DURING PREGNANCY
1. HCG/Human Chorionic Gonadotropin
 The first hormone produce during pregnancy
 Maintain the secretion of progesterone by the corpus luteum. It will deteriorate by 2nd
trimester, as the placenta resumes its function.
 Use to stimulate descend of the testes in case of crytorchidism or undescended testes
 The basis of pregnancy test, it is present in the blood 8-10 days and in the urine 12-18 days.
HCG peaks at 10 weeks then decline for the rest <5mIU/ml in pregnant women.
 Completely negative within 1-2 weeks after birth.

2. Estrogen
 Hormone of women
 It stimulate uterine contraction
 Developed mammary gland for the preparation of lactation.
 Low estrogen concentration after pregnancy stimulates secretion of Prolactin.
 Estriol- pregnant
 Estrone- non-pregnant
 Estradiol- post-menopausal

3. Progesterone
 Hormone of pregnancy (4th week)
 Maintains endometrial lining thickness
 The corpus luteum secretes large quantities of progesterone
 Prevent uterine contractility and prevent premature labor.

4. Human Placental Lactogen (HPL)/Human Chorionic Somatomammotropin

 Stimulate mammary gland growth
 Insulin antagonist/regulates maternal glucose, protein and fat available to fetus
 It is a hormone secreted by the syncytiotrophoblast during pregnancy
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 SPECIAL STRUCTURES OF PREGNANCY

1. DECIDUA- Latin word means “falling off”.

 The thickened endometrium that will be discarded after the birth of the child. It is where the
fertilized embryo implants.

 After fertilization, the corpus luteum in the ovary continues to function rather than atrophying,
because of the influence of HCG, a hormone secreted by the trophoblast cells. This causes the
uterine endometrium to continue to grow in thickness and vascularity, instead sloughing off as
in a usual menstrual cycle.

 The deciduas has three separate areas:

a. Decidua basalis
 The part of endometrium that lies directly under the embryo (or the portion where
the trophoblast cells establish communication with maternal blood vessels)
b. Decidua capsularis
 The portion of the endometrium that stretches
c. Deciduas vera
 The remaining portion of the uterine lining

2. CHORIONIC VILLI
 Once implantation is complete, the trophoblastic layer of cells of the blastocyst begins to
mature rapidly.

 As early as the 11th or 12th day, miniature villi that resembles probing fingers, termed chorionic
villi, reach out from the single layer of cells into the uterine endometrium to begin formation of
the placenta.

 At term 200 villi will have formed. All chorionic villi have a central core of connective tissue and
fetal capillaries. A double layer of trophoblast cells surrounds these:

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 a. Syncitiotrophoblast/syncytial layer
 Produces various placental hormones such as HCG, somatomammotropin (HPL),
estrogen and progesterone.

b. Cytotrophoblast or Langerhan’s layer

 Is present as early as 12 days of gestation. It appears to function early in pregnancy
to protect the growing embryo and fetus from certain infectious organisms such as
the spirochete of syphilis.
 This layer of cells disappears, however, between the 20th and 24th week. This is why
syphilis is not considered to have a high potential for fetal damage early in
pregnancy, only after the point at which cytotrophoblast are no longer present.

3. AMNIOTIC MEMBRANES
 Also known as bag of water.
 There are two parts the amnion and chorion

Amnion - Contains the amniotic fluid and the fetus.

Chorion- Contains the amnion and is the part of the placenta. It is the outermost extra embryonic
membrane that gives rise to the placenta.
4. PLACENTA
 A structure formed when the trophoblast burrows into the lining of the uterus, joining the
uterine mucous membranes of the fetus.
 Substances ingested by the mother cross the placenta via the umbilical cord to the developing
fetus, providing nourishment for its development.

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62
 THE FETAL CIRCULATION

Oxygenated blood from

Maternal circulation

Placenta

Umbilical vein

Ductus venosus

Inferior vena cava (oxygenated blood

mixes with the deoxygenated blood
from lower part of body) and
superior vena cava (deoxygenated blood
from upper part of the body)

Right Atrium

Foramen ovale right ventricle

(most of the blood) via Tricuspid
Valve (some of the blood)
Left Atrium

Left ventricle via pulmonary artery

Mitral valve via pulmonary valve

Ascending aorta
(supply nourishment some blood going some blood
To brain & upper to the lungs to supply going to
Extremities oxygen and nourishment ductus
Arteriosus

Descending aorta
(some blood going to
the lower extremities)

hypogastric
arteries

umbilical arteries

placenta

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Special Structures in Fetal Circulation
1. Placenta
 Where gas exchange takes place during fetal life
2. Umbilical arteries
 Carry unoxygenated blood from the fetus to placenta
3. Umbilical vein
 Brings oxygenated blood coming from the placenta to the fetus.
4. Foramen ovale
 Connects the left and right atrium. It pushes blood from the right
atium to the left atrium so that blood can be supplied to brain,
heart and kidney.
5. Ductus venosus
 Carry oxygenated blood from umbilical vein to inferior vena cava,
bypassing the fetal liver.
6. Ductus Arteriosus
 Carry oxygenated blood from pulmonary artery to aorta,
bypassing fetal lungs.

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 Difference between adult circulation and fetal circulation

Criteria Adult circulation Fetal circulation

Artery Carries oxygenated blood away Carries non-oxygenated
from the heart blood away from the
fetal heart
Veins Carries non-oxygenated blood Carries oxygenated
towards the heart (except blood back to the heart
pulmonary vein)
Exchange Takes place in the lungs Takes place in the
of gases placenta
Pressure Increased pressure on the left Increased pressure on
side of the heart the right side

Fetal Circulation Sequence

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1. Exchange of gases occurs in the placenta. Oxygenated blood is carried
by the umbilical vein towards the fetal heart.

2. The ductus venosus directs part of the blood flow from the umbilical
vein away from the fetal liver (filtration of the blood by the liver is
unnecessary during the fetal life) and directly to the inferior vena cava.

3. Blood from the ductus venosus enters to the inferior vena. Increased
levels of oxygenated blood flows into the right atrium.

4. In adults, the increase pressure of the right atrium causes tricuspid

valve to open thus, draining the blood into the right atrium is directed
by the foramen ovale (opening between the two atria) to the left
atrium.

5. The blood then flows to the left atrium to the left ventricle going to the
aorta. Majority of the blood in the ascending aorta goes to the brain,
heart, head, and upper body.

6. The portion of the blood that drained into the right ventricle passes to
the pulmonary artery.

7. As blood enters the pulmonary artery (carries blood to the lungs), an

opening called ductus arteriosus connects the pulmonary artery and
the descending aorta. Hence, most of the blood will bypass the non-
functioning fetal lungs and will be distributed to the different parts of
the body. A small portion of the oxygenated blood that enters the lungs
remains there for fetal lung maturity.

8. The umbilical arteries then carry the non-oxygenated blood away from
the heart to the placenta for oxygenation.

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Adult Circulation Sequence
1. Non-oxygenated blood enters the right atrium via the inferior and
superior vena cava.
2. Increase level of blood in the right atrium causes the tricuspid valve to
open and drain the blood to the right ventricle.
3. Pressure of blood in the right ventricle causes the pulmonic valve to
open and non-oxygenated blood is directed to the pulmonary artery
then to the lungs
4. Exchange of gases occurs in the lungs. Highly oxygenated blood is
returned to the heart via the pulmonary vein to the left atrium.
5. From the left atrium the pressure of the oxygenated blood that opens
the aortic valve. Blood is then directed to the ascending and descending
aorta to be distributed in the systemic circulation.

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ANTEPARTUM/ANTENATAL
PERIOD
Weight gain during pregnancy
During pregnancy, weight gain average 25 to 30 lb (11 to 13.5 kg)
First trimester- 3 lbs; second trimester-12 lbs; third trimester-12 lbs
Components of Prenatal visit
Health history taking
Gravida- is the number of pregnancies of woman has had, regardless of
outcome
Para- is the number of pregnancies that reached viability, regardless of
whether the fetus was delivered alive or stillborn. A fetus is considered viable
at 20 weeks.
SIGNS OF PREGNANCY
I- Presumptive sign
 Least indicative of pregnancy, taken as single entities and they could
easily indicate other conditions.
 They are experienced by woman but cannot document by an
examiner.
1. Breast Changes
o Feeling of tenderness, fullness or tingling, enlargement and
darkening of areola because of increased stimulation of breast
tissue by high estrogen level.

2. Nausea and vomiting (morning sickness)

o 50% women experienced, appear early in the morning on
arising or if a woman becomes fatigued during the day. This is
due to increased level of HCG and progesterone level.
o It is more frequent in women who smoke cigarette.

3. Amenorrhea
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 o It is the absence or cessation of menstruation, because of the
suppression of follicle stimulating hormone (FSH) by rising of
estrogen levels.
4. Frequent urination
o It is the result of the compression of bladder and ureters by the
growing uterus. It is the effect of high estrogen and
progesterone levels.
5. Fatigue
o It is the general feeling of tiredness
Quickening- occurs between 16 and 19 weeks gestation
Amenorrhea- cessation of menstruation
Ovulation ceases during pregnancy

Probable sign
Goodell’s sign- is softening of the cervix
Chloasma- the mask of pregnancy, is pigmentation of a circumscribed area of
skin (usually over the bridge of the nose and cheeks) that occurs is some
pregnant women.
Linea nigra- a dark line that extends from the umbilicus to the mos pubis,
commonly appears during pregnancy and disappears after pregnancy.
Positive signs of pregnancy
Include ultrasound evidence, fetal heart tones and fetal movement felt by
the examiner (not usually present until 4 months gestation)
Estimation of Age of gestation (AOG)
Nagele’s rule
The nurse counts backward 3 months from the first day of the last menstrual
period and then adds 7 days to this date.
Bartolomew’s Rule
At 12 weeks (3rd lunar month)of gestation, the fundus should be at the top
of the symphysis pubis or slightly above symphysis pubis
At 20 weeks (5th lunar month) of gestation, the fundus is at the level of
umbilicus.
At 36 weeks (9th lunar month) of gestation, the fundus is below the xiphoid
process.
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Teratogens:
Rubella
Rubella has a teratogenic effect on the fetus during the first trimester. It
produces abnormalities in up to 4o% of cases without interrupting the
pregnancy
Immunity to rubella can be measured by hemagglutination inhibition test
(rubella titer). This test identifies exposure to rubella infection and
determines susceptibility in pregnant women. In a woman, a titer greater
than 1:8 indicates immunity.
Alcohol
Pregnant women should be advised that there is no safe level of alcohol
intake.
Fetal alcohol syndrome presents in the first 24 hours after birth and
produces lethargy, seizures, poor sucking reflex, abdominal distention, and
respiratory difficulty
PELVIS
The narrowest diameter of the pelvic inlet is the ateroposterior (diagonal
conjugate)
Types of Pelvis
Gynecoid – most ideal for delivery
Platypelloid- flat
Anthropoid- apelike
Android- malelike

INTRAPARTUM/INTRAPARTAL PERIOD
Mechanism of labor/Cardinal signs of labor
Engagement
Engagement means when the largest diameter of the presenting part has
passed through the pelvic inlet
Descent

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When used to describe the degree of fetal descent during labor, floating
means the presenting part isn’t engaged in the pelvic inlet, but is freely
movable (ballotable) above the pelvic inlet.

Fetal station
Indicates the location of the presenting part in relation to the ischial spine.
Its described as -1,-2, -3,-4 or -5 to indicate the number of centimeters above
the level of the ischial spine; station -5 is at the pelvic inlet.
Fetal station is also described as +1, +2, +3, +4, or +5 to indicate the number
of centimeters it is below the level of the ischila spine; station 0 is at the level
of the ischial spine.
True labor and false labor
Unlike false labor, true labor produces regular rhythmic contractions,
abdominal discomfort, and progressive descent of the fetus, bloody show,
and progressive effacement and dilation of the cervix.
Uterine contractions
The three phases of uterine contractions are increment, acme and
decrement
The intensity of labor contraction can be assessed by the indentability of the
uterine wall at the contraction’s peak,
Intensity is graded as mild (uterine muscle is somewhat tense), moderate
(uterine muscle is moderately tense), or strong (uterine muscle is boardlike)
The frequency of uterine contractions, which is measured in minutes, is the
time from the beginning of one contraction to the beginning of the next.
Stages of labor
First stage or /begins with the onset of labor to full cervical dilatation (10cm)
and effacement
During the first stage of labor, the side-lying position usually provides the
greatest degree of comfort, although the patient may assume any
comfortable position.
3 phases
D
F

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Transition- the cervix is dilated 8-10 cm and contractions usually occur 2-3
minutes apart and last for 60 seconds.
Second stage or/ from the full dilatation cervical dilatation to the delivery of
the neonate
Third stage or/ from the delivery of the neonate to the expulsion of the
placenta
Fourth stage or/ from the expulsion of the placenta lasts up to 4 hours.
It is also known as postpartum stabilization. This time is needed to stabilize
the mother’s physical and emotional state after the stress of childbirth.
Monitoring the fetal well-being
Internal fetal monitoring
Before internal fetal monitoring can be performed, pregnant patient’s cervix
must be dilated at least 2 cm, the amniotic membranes must be ruptured,
and the fetus’s presenting part (scalp or buttocks) must be at station -1 or
lower so that a small electrode can be attached.
Non-stress test
Purpose:
Is usually performed to assess fetal well-being in a pregnant patient with a
prolonged pregnancy (42 weeks or more), diabetes, history of poor
pregnancy outcome or pregnancy induced hypertension.
To assess placental function and oxygenation.
Evaluates fetal heart rate in response to fetal movement
Procedure:
The mother is asks to eat simple CHO and lie in left recumbent position.
This is usually done 10-20 minutes.
Findings:
A non-stress test is considered reactive (negative) if two or more fetal heart
rate accelerations of 15 beats/minute above baseline occurs in 20 minutes.
This is a normal finding.
It is considered nonreactive (positiveI if fewer than two fetal heart rate
accelerations of at least 15 beats/minute above baseline occur in 20 minutes.
This is an abnormal finding.
If no increase in beats per minute and is noticeable on fetal movements,
poor oxygen perfusion of the fetus is suggested.
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Variability of fetal heart Rate (FHR)
Variability is any change in the fetal heart rate from its normal rate of 120 to
160 beats/minute.
Acceleration increased FHR; deceleration decreased FHR
Apgar scoring
An apgar score of 7-10 indicates no immediate distress, 4 to 6 indicates
moderate distress, and 0-3 indicates severe distress
Special Considerations:
During delivery, if the umbilical cord can’t be loosened and slipped from
around the neonate’s neck, it should be clamped with two clamps and cut
between the clamps.

Amniotomy- is artificial rupture of the amniotic membranes

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 INTRAPARTUM PERIOD
STAGES OF LABOR
I- First Stage

 The first stage starts at the onset of regular uterine contractions and ends at full dilatation and
effacement.
 The first stage of labor is divided into three phases: the latent, the active, and the transition
phase.

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Phases of the Stage of Labor
1. Latent “Preparatory Phase”

The latent stage starts at the onset of regularly perceived uterine contractions and ends when rapid
cervical dilation begins. This is also called the “preparatory phase”.

Contractions Duration of Contractions Cervical Dilation Duration

Mild and short 20 to 40 seconds 0-3 cm Nullipara: 6

hoursMultipara: 4.5
hours

Nursing Considerations

 Woman with a “non-ripe” cervix will have a longer than usual latent phase
 Analgesia given too early during this period may prolong this phase
 Woman who is psychologically prepared for labor only have minimal discomfort
 Best time to reinforce health teachings

2. Active Phase

During the active phase, cervical dilatation occurs more rapidly and contractions grow stronger.

Contractions Duration of Contractions Cervical Dilation Duration

Stronger, longer and 40 to 60 seconds every 3 4 to 7 cm Nullipara: 3

causes true discomfort to 5 minutes hoursMultipara: 2 hours

Nursing Considerations:

 It is an exciting time because a woman realizes something dramatic is happening

 Administration of analgesic at this point has little effect on the progress of labor
 Show and spontaneous rupture of membranes occur during this time

3. Transition Phase

During this phase, the contractions reach their peak intensity, cervix to maximum dilatation and to full
effacement.

Contractions Duration of Contractions Cervical Dilation Duration

At peak intensity 60 to 90 seconds every 2-3 minutes 8 to 10 cm Until full cervical dilation

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Nursing Considerations:

 If membranes have not previously ruptured or been ruptured by amniotomy, they will rupture
as a rule at full dilation.
 Both full dilation and cervical effacement have occurred at this stage
 Woman may have intense discomfort and may be accompanied by nausea and vomiting.
 Woman may experience a feeling of loss of control, anxiety, panic or irritability.
 Her focus is on the entirety of delivering her baby.
 This stage ends at 10 cm of dilatation and feels a new sensation (i.e., irresistible urge to push).

Cervical Effacement

II- Second Stage

 The second stage starts from full dilatation and cervical effacement to birth of the infant;
with uncomplicated birth, this stage takes about 1 hour.

 Contractions change to an overwhelming, uncontrollable urge to push or bear down with each
contraction as if to move her bowels. Patient may experience nausea and vomiting at this point.

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 The fetal head touches the internal side of the perineum; the perineum begins to bulge and
appears tense. The anus may become everted and stool may be expelled.
 As the fetal head pushes against the perineum, the vaginal introitus opens and the fetal scalp
appears at the opening to the vagina. At first, it appears slit-like then becomes oval and then
circular. This is called crowning.
 All of her energy and her thoughts are being directed towards giving birth. As she pushes, using
her abdominal muscles to aid the involuntary uterine contractions, the fetus is pushed out of the
birth canal.

III- Third Stage

 The third stage is called the placental stage. It begins with the birth of the infant and ends with
the delivery of the placenta. Two separate phases are involved: placental separation and
placental expulsion.
 After birth, the uterus can be palpated as a firm round mass just inferior to the level of the
umbilicus. After a few minutes, the uterus begins to contract again and assumes a discoid shape.
It retains this shape until placenta is separated, approximately 5 minutes after birth of the infant.

1. Placental Separation

 As the uterus further contracts down on an almost empty interior causing disproportion between
the placenta and the contracting wall of the uterus ultimately causing separation of the placenta.
 The following are the signs indicating that placenta has loosened and is ready to deliver:

 Lengthening of the umbilical cord

 Sudden gush of vaginal blood
 Change in the shape of the uterus
 Firm contraction of the uterus
 Appearance of the placenta at the vaginal opening

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 Bleeding occurs as a normal consequence of placental separation. The normal blood loss is 500
mL.

2. Placental Expulsion

 After separation, the placenta is delivered either by the natural bearing-down effort of the mother
or by gentle pressure on the contracted uterine fundus by the physician or nurse-midwife
(Crede’s maneuver).
 Pressure must never be applied to post-partal uterus in a non-contracted state, because doing so
would cause uterus to evert and maternal blood sinuses are open and gross hemorrhage could
occur.
 If the placenta does not deliver spontaneously, It can be removed manually.

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 POSTPARTUM/POSTPARTAL PERIOD

Nurse’s Assessment
During the first hour after birth
Neonatal reflexes
Moro reflex
To elicit, the nurse holds the neonate both hands and suddenly but gently,
drops the neonate’s head backward.

79
 Difference Between Caput Succedanum and Cephalhematoma

CAPUT SUCCEDANUM
o Is an edema of the scalp of the neonate’s presenting part of the head. It often
appears over the vertex of the newborn’s head as a result of pressure against the
mother’s cervix during labor. The edema in caput succedaneum crosses the
suture lines. It may involve wide areas of the head or it may just be a size of a
large egg.
o Causes:
1. Mechanical trauma of the initial portion of scalp pushing through a narrowed
cervix.
2. Prolonged or difficult delivery
3. Vacuum extraction
o The pressure (at birth) interferes with blood flow from the area causing a
localized edema. The edematous area crosses the sutured line and is soft. It also
occurs when a vacuum extractor is used. In this case, the caput corresponds to
the area when the extractor is used to hasten the second stage of labor.
o Signs and symptoms
1. Scalp swelling that extends across the midline and over suture lines.
2. Soft and puffy swelling of part of a scalp in a newborn’s head
3. May be associated with increased molding of the head.
4. The swelling may or may not have some degrees of discoloration or bruising.
o Management
1. Needs no treatment. The edema is gradually absorbed and disappears about
the third day of life.
o Complication
1. Jaundice- results as the bruises breaks down into bilirubin.

CEPHALHEMATOMA
o Definition:
It is a collection of blood between the periosteum of a skull bone and the bone
itself. It occurs in one or both sides of the head. It occasionally forms over the
occipital bone. The swelling with cephalhematoma is not present at birth rather it
develops within the first 24 to 48 hours after birth.
o Causes:
1. Rupture of a periostal capillary due to pressure of birth.
2. Instrumental delivery
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 o Signs and Symptoms
1. Swelling of the infant’s head 24-48 hours after birth
2. Discoloration of the swollen site due to presence of coagulated blood
3. Has clear edges that end at the suture lines
o Management

1. Observation and support of the affected part.

2. Transfusion and phototherapy may be necessary if blood accumulation is
significant

o Complication

1. Jaundice

Difference between a Caput Succedaneum and

Cephalhematoma
INDICATORS CAPUT CEPHALHEMATOMA
SUCCEDANEUM
Location Presenting part of the Periosteum of skull
head bone and bone
Extent of Both hemispheres; Individual bone; DOES
Involvement CROSSES the suture NOT CROSS the suture
lines lines
Period of 3 to 4 days Few weeks to months
Absorption
Treatment None Support

Normally, the neonate abducts and extends all extremities bilaterally and
symmetrically, forms a C shape with the thumb and forefinger, and first
adducts and then flexes the extremities.
Breastfeeding
To help a mother break the suction of the breast-feeding infant, the nurse
should teach her to insert a finger at the corner of the infant’s mouth.
Cow’s milk shouldn’t be given to infants younger than age 1 because it has a
low linoleic acid content and its protein that difficult for infant to digest.
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Stress, dehydration, and fatigue may reduce a breastfeeding mother’s milk
supply.
When both breasts are used for breastfeeding, the infant usually doesn’t
empty the second breast. Therefore, the second breast should be used first
at the next feeding.
Interventions for normal neonate
After delivery, the first nursing action is to establish neonate’s airway.
Cord clamping
After birth, the neonate’s umbilical cord is tied 1” (2.5 cm) from the
abdominal wall with a cotton cord, plastic clamp.
When teaching parents to provide umbilical cord care, the nurse should
teach them to clean the umbilical area with a cotton ball saturated with
alcohol after every diaper change to prevent infection and to promote
drying.
Vitamin K administration
It is administered to neonates to prevent hemorrhagic disorders because a
neonate’s intestine can’t synthesize Vitamin K (neonate intestine is sterile)

Special considerations:
Administering high levels of oxygen to a premature neonate can cause
blindness as a result of retrolental fibrolasia.
If jaundice is suspected in a neonate, the nurse should examine the infant
under natural window light. If natural light is unavailable, the nurse should
examine the infant under a white light.
To perform Nasotracheal suctioning in an infant, the nurse positions the
infant with his neck slightly hyper extended in a “sniffing position”, with his
chin up and his head tilted back slightly.

Expected assessment/Interventions for neonate with substance abuse

mother:
Heroin, Methadone (narcotics/downers/opioids)
Expected assessment
In a neonate, the symptoms of heroin withdrawal may begin several hours to
4 days after birth
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Methadone is a drug of choice for narcotic withdrawal. The symptoms of
methadone withdrawal may begin 7 days to several weeks after birth.
In a neonate, the cardinal signs of narcotic withdrawal include coarse
flapping tremors, sleepiness, restlessness, prolonged persistent high pitched
cry and irritability.
Chlorpromazine (Thorazine) is used to treat neonates who are addicted to
narcotics.
Interventions:
The nurse should provide a dark, quiet environment for neonates who are
addicted to narcotics.

A NORMAL NEONATE
The percentage of water in a neonate’s body is about 78% to 80%
In a full term neonate, skin creases appear over two-thirds of the neonate’s
feet.
Preterm neonates have heel creases that cover less than two thirds of the
feet.
Vital statistics
The circumference to the neonate’s head is normally 2-3cm greater than the
circumference of the chest.

ABNORMALITIES IN PREGNANCY
Nurse’s considerations:
Any vaginal bleeding during pregnancy should be considered a complication
until proven otherwise.
Pregnancy-induced Hypertension (Pre-eclampsia)
Is an increase in blood pressure of 30/15 mmHg over baseline or blood
pressure of 140/95 mmHg on two occasions at least 6 hours apart
accompanied by edema and albuminuria after 20 weeks gestation.
Classic triad: hypertension, edema and proteinuria

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Additional symptoms of severe preeclampsia include hyperreflexia, cerebral
and vision disturbances and epigastric pain.
Eclampsia- is the occurrence of seizures that aren’t caused by a cerebral
disorder in a patient who has pregnancy-induced hypertension.
After administering magnesium sulfate to a pregnant patient for
hypertension or preterm labor, the nurse should:
Monitor the respiratory rate
Check the deep tendon reflexes
Ectopic Pregnancy
It is one that implants abnormally outside the uterus
Abortion
Habitual abortion- three or more consecutive spontaneous abortions.
Threatened abortion- occurs when bleeding is present without cervical
dilatation
Complete abortion- occurs when all products of conception are expelled.
Incomplete abortion
The fetus is expelled, but parts of the placenta and membrane remain in the
uterus
Hydramnios (Polyhydramnios)
It is excessive amniotic fluid (more than 2000 ml in the third trimester
Placenta Previa
Is abnormally low implantation of the placenta so that it encroaches on or
covers the cervical os.
In placenta previa, bleeding is painless and seldom painless on the first
occasion, but it becomes heavier with each subsequent episode.
Types of placenta previa
Complete (total)- the placenta completely covers the cervical os
Partial (incomplete or marginal)- the placenta covers only a portion of the
cervical os.

Abruptio placenta
Is a premature separation of a normally implanted [lacenta. It may be partial
or complete, and usually causes abdominal pain, vaginal bleeding and
boardlike abdomen.
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Treatment for abruption placentae is usually immediate cesarean delivery.

ABNORMALITIES IN NEONATES
Respiratory Distress Syndrome (hyaline membrane disease)
Develops in premature infants because their pulmonary alveoli lack of
surfactant
Whenever an infant is being put down to sleep, the parent or caregiver
should position the infant on the back.
Premature Neonate
Is one born before the end of 37th week of gestation
Low birth weight neonate
Weighs 2500 g (5 lb 8 oz)
Teenage mothers are more likely to have a low-birth weight neonates
because they seek prenatal care late in pregnancy (as a result of denial) and
are more likely than older mothers to have nutritional deficiencies.
Very low birth weight neonate
Weighs 1500 g (3 lb 5 oz)
Cutis marmorata
Is mottling or purple discoloration of the skin. It is a transient vasomotor
response that occurs primarily in the arms and legs of infants who are
exposed to cold.
Ortolani’s sign
An audible click or palpable jerk that occurs with thigh abduction, confirms
congenital hip dislocation in neonate
Down Syndrome
Infant with Down Syndrome typically have marked hypotonia, floppiness,
slanted eyes, excess skin on the back of the neck, flattened bridge of the
nose, flat facial features, spadelike hands, short and broad feet, small male
genitalia, absence of moro reflex and a simian crease on the hands.

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Gestational diabetes mellitus or what we commonly known as gestational diabetes is a
state where individuals without previously diagnosed diabetes display high blood glucose
levels during pregnancy. This increase in blood glucose levels is exhibited during the
second trimester of pregnancy. During pregnancy, instances happen where women do
not produce adequate insulin required during this stage. Babies born to mothers with
gestational diabetes can have some complications after birth. Usually, babies are large for
gestational age (weigh much more than normal) that can cause delivery difficulties,
problems and complications; have low blood sugar level, exhibits jaundice, or your baby
may. Even if gestational diabetes goes away after the child is born complications during
perinatal stage may and can be very serious. Treatment of gestational diabetes is
essential to not further aggravate the complications.

Types

The two types of gestational diabetes are:

 Type A1
o Reveals altered finding during oral glucose tolerance test (OGTT), but with
normal blood glucose levels with fasting and after two hours with meals.
o With this stage of gestational diabetes, diet modification is enough to
manage the increased glucose levels.
 Type A2
o Reveals altered finding during oral glucose tolerance test (OGTT), it also has
elevated glucose levels even during fasting and/ or during after meals.
o Apart from modification of lifestyle and diet, adjunct therapy with insulin
and other diabetes medications are indicated and necessary.

Risk Factors
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Classical risk factors for developing gestational diabetes are:

 Poor obstetric history

 Genetics
o Family history of diabetes
o First-degree relative with type 2 diabetes
 Maternal age
o Women increase the risk of acquiring gestational diabetes as her age
increases. For gestational diabetes, women at the age of 35 and above are
prone to develop this condition.
 Weight, pregnant women who are overweight, obese and those severely obese
are at high risk for having gestational diabetes. a previous pregnancy which
resulted in a child with a high birth weight.
 Previous diagnosis of gestational diabetes
 Previous episodes of impaired glucose tolerance
 Previous episodes of impaired fasting glycemia
 Ethnic background
o South Asians
o African-Americans
o Hispanics
o Pacific Islanders
o Afro-Caribbeans
o Native Americans

Assessment and Diagnosis

 Regular blood tests to check blood sugar level

 Glucose-screening test between 24 and 28 weeks

Management

1. Exercise regularly as planned and prescribed, exercise can help keep the blood
sugar level normal.
2. Take frequent blood tests to check blood sugar level.
3. Have insulin therapy as indicated and as ordered to control increased blood sugar
level.
4. Eat well-balanced meals, controlled as prescribed by the physician or nutritionist.
5. Gestational diabetes goes away after the baby’s birth, however it increases the
risk for diabetes onto the next pregnancy, it is essential therefore that the
management listed above should be followed.

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