FEMALE REPRODUCTIVE ANATOMY AND PHYSIOLOGY

I. The External Reproductive Organs

A. Mons Pubis or Veneris – pad of fat which lies over the symphysis
pubis covered by skin and at puberty, by short hairs; protects the
surrounding delicate tissues from trauma.
B. Labia Majora – two folds of skin with fat underneath; contain
Bartholin’s glands (believed to secrete a yellowish mucus which acts
as a lubricant during sexual intercourse. The openings of the
Bartholin’s glands are located posteriorly on either side of the vagina
orifice.
C. Labia Minora – two thin folds of delicate tissues; form an upper fold
encircling the clitoris (called the prepuce) and unite posteriorly (called
the fourchetes, which is highly sensitive to manipulation and trauma
that is why it is often torn during a woman’s delivery.)
D. Clitoris – small, erectile structure at the anterior junction of the labia
minora, which is comparable to the penis in its being extremely
sensitive. Landmark for catheterization
E. Vestibule – narrow space seen when the labia minora are separated.
F. Urethral Meatus – external opening of the urethra; slightly behind and
to the side are the openings of the Skene’s glands (which are often
involved in infections of the external genitalia).
G. Vaginal orifice/Introitus – external opening of the vagina, covered by
a thin membrane (called hymen) in virgins. Myrtiform caruncle
H. Perineum – area from the lower border of the vaginal orifice to the
anus; contains the muscles (e.g., pubococcygeal and levator ani)
which support the pelvic organs, the arteries that supply blood and the
pudendal nerves which are important during delivery under anesthesia.

II. The Internal Reproductive Organs

A. Vagina – a 3-4 inch long dilatable canal located between the bladder
and the rectum; contains rugae (which permit considerable stretching
without tearing); passageway for menstrual discharges, copulation and
fetus. CBQ
B. Uterus – hollow pear-shaped fibromuscular organ 3 inches long, 2
inches wide, 1 inch thick, and weighing 50-60 grams in a non-pregnant
woman; hold in place by broad ligaments (from sides of the uterus to
pelvic wall; also hold Fallopian tubes and ovaries in place) and round
ligaments (from sides of uterus to mons pubis); abundant blood supply
from uterine and ovarian arteries; composed of three muscle layers
(perimetrium, myometrium, and endometrium). Consists of three parts:
corpus (body) – upper portion with triangular part called fundus;
isthmus – area between corpus and cervix which forms part of the
lower uterine segment; and, - cylindrical portion. Organ of
 menstruation, site of implantation and retainment and nourishment of
the products of conception. Main support comes from cardinal
ligaments
C. Fallopian Tubes – 4 inches long from each side of the fundus; widest
part (called ampulla) spreads into fingerlike projections (called
fimbriae). Responsible for transport of mature ovum from ovary to
uterus; fertilization takes place in its outer third or outer half.
D. Ovaries – almond-shaped, dull white sex glands near the fimbriae,
kept in place by ligaments. Produce, mature and expel ova and
manufacture estrogen and progesterone.

III. The Pelvis

- although not a part of the Female Reproductive Organs but of the
skeletal system, is a very important body part of pregnant women.

A. Structure
1. 2 Os Coxae/Innominate bones – made up of:
a. Ilium – upper, extended part; curved upper border is
the iliac crest.
b. Ischium – under part; when sitting, the body rests on
the ischial tuberosities; ischial spines are important
landmarks.
c. Pubes – front part; join to form an articulation of the
pelvis called the symphysis pubis.
2. Sacrum – wedge-shaped, form the back part of the pelvis.
Consists of 5 fused vertebrae, the first having a prominent under
margin called the sacral promontory. Articulates with the ilium,
the sacroiliac joint.
3. Coccyx – lowest part of the spine; degree of movement
between sacrum and coccyx, made possible by the third
articulation of the pelvis called sacrococcygeal joint which
allows room for delivery of the fetal head.

B. Divisions – set apart by the linea terminalis, (pelvic brim, ileopectineal

line) and imaginary line from the sacral promontory to the ilia on both
side to the superior portion of the symphysis pubic.
1. False pelvis – superior half formed by the ilia. Offers
landmarks for pelvic measurements; supports the growing
uterus during pregnancy; and directs the fetus into the true
pelvis near the end of gestation.
2. True pelvis – inferior half formed by the pubis in front, the ilia
and the ischia on the sides and the sacrum and coccyx behind.
Made up of three parts:
a. Inlet – entranceway to the true pelvis. Its transverse
diameter is wider than its anteroposterior diameter. Thus:
Transverse diameter = 13.5 cm
 Anteroposterior diameter = 11 cm
Right and left oblique diameters = 12.75 cm
b. Cavity – space between the inlet and outlet
c. Outlet – inferior portion of the pelvis bounded in the back by
the coccyx, on the sides by the ischial tuberosities and in front
by the inferior aspect of the symphysis pubis and the pubic arch.
Its anteroposterior (AP) diameter is wider than its transverse
diameter.

C. Types/Variations
1. Gynecoid – “normal female pelvis. Inlet is well rounded forward
and back. Most ideal for childbirth.
2. Anthropoid – transverse diameter is narrow, AP diameter is
larger than normal.
3. Platypelloid – inlet is oval, AP diameter is shallow
4. Android – “male” pelvis. Inlet has a narrow, shallow posterior
portion and pointed anterior portion.

D. Measurements
1. External – suggestive only of pelvic site.
a. Intercristal – distance between the middle points of the iliac
crests.
Average = 28 cm.
b. Interspinous – distance between the anterosuperior iliac
spines. Average = 25 cm.
c. Intertrochanteric – distance between the trochanters of the
femur. Average = 31 cm.
d. External conjugate/Daudelocque’s – the distance between
the anterior aspect of the symphysis pubis and depression
below L5. Average = 18-20 cm.
2. Internal – give the actual diameters of the inlet and outlet
a. Diagonal conjugate – distance between sacral promontory
and inferior margin of the symphysis pubis. Average = 12.5 cm.
b. True conjugate/conjugata vera – distance between the
anterior surface of the sacral promontory and the superior
margin of the symphysis pubis. Very important measurement
because it is the diameter of the pelvic inlet. Average = 10.5 -
11 cm.
c. Bi-ischial diameter/tuberischial – transverse diameter of
the pelvic outlet. Is measured at the level of the anus. Average
= 11 cm

IV. Feedback Mechanism of Menstruation

A. General Considerations
1. 300,000 – 400,000 immature oocytes per ovary are present at
birth (ware formed during the first 5 months of intrauterine life);
many, however, degenerate and atrophy (process called
atresia). About 300 – 400 mature during the entire reproductive
cycle of women.
2. Ushered in by the menarche, (first menstruation in girls) and
ends with menopause (permanent cessation of menstruation; no
more functioning oocytes in the ovaries). Age of onset and
termination vary widely, depending on heredity, racial
background, nutrition and climate.
3. Normal period (days when there is menstrual flow) lasts for 3-6
days; menstrual cycle (from first day of menstrual period to first
day of next menstrual period) maybe anywhere from 25-35
days, but accepted average length in 28 days.
4. Anovulatory states after menarche not unusual because of
immaturity of feedback mechanism (anovulatory states occur
also in pregnancy, lactation and related disease conditions).
5. Associated terms:
a. Amenorrhea – temporary cessation of menstrual flow
b. Oligomenorrhea – markedly diminished menstrual flow,
nearing amenorrhea
c. Menorrhagia – excessive bleeding during regular
menstruation
d. Metrorrhagia – bleeding at completely irregular intervals
e. Polymenorrhea – frequent menstruation occurring at
intervals of less than three weeks
6. Body structures involved:
a. Hypothalamus
b. Anterior pituitary gland
c. Ovary
d. Uterus
7. Hormones which regulate cyclic activities:
a. Follicle-stimulation hormone (FSH)
b. Luteinizing hormone (LH)
8. Effects of estrogen in the body:
a. Inhibits production of FSH
b. Causes hypertrophy of the endometrium
c. Stimulates growth of the ductile structures of the breasts
d. Increases quantity and pH of cervical mucus, causing it to
become thin and watery and can be stretched to a distance
of 10-13 cm. (Spinnbarkeit test of ovulation)
9. Effects of progesterone in the body:
a. Inhibits production of LH
b. Increases endometrial tortuosity
c. Increases endometrial secretions
d. Inhibits uterine motility
 e. Decreases muscle tone of gastrointestinal and urinary tracts
f. Increases musculoskeletal motility
g. Facilitates transport of the fertilized ovum through the
Fallopian tubes
h. Decreases renal threshold for lactose and dextrose
i. Increases fibrinogen levels; decreases hemoglobin and
hematocrit
j. Increases body temperature after ovulation. Just before
ovulation, basal body temperature decreases slightly
(because of low progesterone level in the blood) and then
increases slightly a day after ovulation (because of the
presence of progesterone).

B. Sequential Steps in the Menstrual Cycle

1. On the third day of the menstrual cycle, serum estrogen level is
at its lowest. This low estrogen level serves as the stimulus for
the hypothalamus to produce the Follicle-Stimulating Hormone
Releasing Factor (FSHRF).
2. FSHRF is responsible for stimulating the Anterior Pituitary Gland
(APG) to produce the first of 2 hormones which regulate cyclic
activities, the Follicle-Stimulating Hormone (FSH).
3. FSH, in turn, will stimulate the growth of an immature oocyte
inside a primordial follicle by stimulating production of estrogen
by the ovary. Once estrogen is produced, the primordial follicle
is not termed Graafian follicle (The Graafian follicle, therefore,
is the structure which contains high amounts of estrogen).
4. Estrogen in the Graafian follicle will cause the cells in the
uterine endothelium to proliferate (grew very rapidly), thereby
increasing its thickness to about eightfold. This particular phase
in the uterine cycle, therefore, is called proliferative phase. In
view of the change from primordial to Graafian follicle, it is also
called the follicular phase. Because of the predominance of
estrogen, it is also called the estrogenic phase. And since it
comes right after the menstrual period, it is also called
postmenstrual phase. And, it is also called the pre-ovulatory
phase.
5. On the 13th day of the menstrual cycle, there is now a very low
level of progesterone in the blood. This low serum
progesterone level is then the stimulus for the Hypothalamus to
produce the Luteinizing Hormone Releasing Factor (LHRF).
6. LHRF is responsible for stimulating the APG to produce the
second hormone which regulates cyclic activity, the Luteinizing
Hormone (LH).
7. LH, in turn, is responsible for stimulating the ovary to produce
the second hormone produced by the ovaries, progesterone.
 8. The increased amounts of both estrogen and progesterone
pushes the now mature ovum to the surface of the ovary until,
on the following day (the 14th day of the menstrual cycle), the
Graafian follicle ruptures and releases the mature ovum, a
process called ovulation.
9. Once ovulation is taken place, the Graafian follicle, because it
now contains increasing amounts of progesterone is the Corpus
Luteum.
10. Progesterone causes the glands of the uterine endothelium to
become corkscrew or twisted in appearance because of the
increasing amount of capillaries. Progesterone, therefore, is
said to be the hormone designed to promote pregnancy
because it makes the uterus nutritionally abundant with blood in
order for the fertilize zygote to survive should conception take
place. That is why this phase in the uterine cycle is what we call
progestational phase. This phase in the uterine cycle is also
called the secretory phase because it secretes the most
important hormone in pregnancy. In view of the change from
Graafian follicle, to Corpus Luteum, it is also called the luteal
phase. Because it occurs just after ovulation, it is also called
the post-ovulatory phase. And, it is also called the pre-
menstrual phase.
11. Up until the 24th day of the menstrual cycle, if the mature ovum
is not fertilized by a sperm, the amounts of hormones in the
Corpus Luteum will start to decrease. The Corpus Luteum,
turning white, is now called the corpus albicans and after 3-4
days, the thickened lining of the uterus produced by estrogen
starts to degenerate and slough off and the capillaries rupture.
And thus begins another menstrual period.

C. Additional Information
1. When the ovary releases the mature ovum on the day of
ovulation, sometimes a certain degree of pain in either the right
or left lower quadrant is felt by the woman. This sensation is
normal and is termed mittelschmerz.
2. The first 14 days of the menstrual cycle is a very variable
period. The last 14 days of the menstrual cycle is a fixed period
exactly 2 weeks after ovulation, menstruation will occur (unless
a pregnancy has taken place) because the corpus luteum has a
life span of only 2 weeks. Implication: when given options
regarding the exact date of ovulation, choose two weeks before
menstruation.
3. In a 28-day cycle, ovulation takes place on the 14th day. In a 32-
day cycle, ovulation takes place on the 18th day. In a 26-day
cycle, ovulation takes place or the 12th day (Subtract 14 days
from the cycle).
 4. Menstruation can occur even without ovulation (as in women
taking oral contraceptives). Ovulation can likewise occur even
without menstruation (as in lactating mothers).
PREGNANCY AND PRENATAL CARE

I. Obstetric Terms in Statistical Data

A. Birth rate – the number of births per 1,000 population

B. Fetal death rate – the number of total deaths per 1,000 births. (both live
births and stillbirths)
C. Perinatal mortality rate – the number of deaths occurring between 28
weeks gestation until 6 days after birth
D. Neonatal mortality rate – the number of neonatal (first 28 days of life)
deaths per 1,000 live births
E. Infant mortality rate – the number of infant (first 12 months of life) deaths
per 1,000 live births
F. Maternal mortality rate – the number of deaths that occur as the direct
result of the reproductive process per 10,000 live births

II. Fertilization
A. Definition: the union of the sperm and the mature ovum in the outer third
or outer half of the Fallopian tube.

B. General considerations:
1. Normal amount of semen per ejaculation = 3 – 5 cc = 1 teaspoon
2. Number of sperms in an ejaculate = 120 – 150 million/cc
3. Mature ovum is capable of being fertilized for 12-24 hours after
ovulation. Sperms are capable of fertilizing even for 3-4 days after ejaculation
4. Normal life span of sperms = 7 days
5. Sperms, once deposited in the vagina, will generally reach the cervix
within 90 seconds after deposition.
6. Reproductive cells, during gametogenosis, divide by meiosis (haploid
number of daughter cells); therefore, they contain only 23 chromosomes (the rest
of the body cells have 46 chromosomes). Sperms have 22 autosomes and 1 X
sex chromosome or 1 Y sex chromosome; ova contain 22 autosomes and 1 X
sex chromosome. The union of an X-carrying sperm and a mature ovum results
in a baby girl (XX); the union of a Y-carrying sperm and a mature ovum results in
a baby boy (XY). Important: Only fathers determine the sex of their children.

III. Implantation

Immediately after fertilization, the fertilized ovum or zygote stays in the

Fallopian tube for 3 days, during which time rapid cell division (mitosis) is taking
place. The developing cells are now called blastomere and when there are
already 16 blastomeres, it is now terms a morula. In this morula form, it will start
to travel (by ciliary action and peristaltic contractions of the Fallopian tube) to the
uterus where it will stay for another 3-4 days. When there is already a cavity
formed in the morula, it is now called blastocyst. Fingerlike projections, called
trophoblasts, form around the blastocyst and these trophoblast are the once
which will implant high on trophoblasts or posterior surface of the uterus. Thus,
implantation, also called nidation, takes place about a week after fertilization.

General Consideration:
A. Once implantation has taken place, the uterine endothelium is now termed
decidua
B. Occasionally, a small amount of vaginal spotting appears with implantation
because capillaries are ruptured by the implanting throphoblasts =
implantation bleeding. Implication: this should not be mistaken for the
Last Menstrual Period (LMP).

Table 1. Outline of Trophoblast Differentiation

I. Cytotrophoblast – the inner layer

II. Syncytiotrophoblast – the outer layer containing fingerlike projections
called chorionic villi:
A. Langhan’s layer – believed to protect the fetus against
Treponema Pallidum (etiologic agent of syphilis). Present only during the
second trimester of pregnancy.
B. Syncytial layer – gives rise to the fetal membranes:
1. Amnion – inner layer which gives rise to:
a. Umbilical cord/funis – contains 2 arteries and one vein,
which are supported by the Wharton’s jelly
b. Amniotic fluid – clear, albuminous fluid in which the
baby floats. Begins to form at 11-15 weeks gestation.
Approximates water in specific gravity (1.007-1.025) and
is neutral to slightly alkaline (pH=7.0-7.25. Note: the
higher the pH, the more alkaline; the lower the pH, the
more acidic). Near term, is clear, colorless, containing
little white specks of vernix caseosa and other solid
particles. Produced at a rate of 500 ml in 24 hours and
fetus swallows it at an equally rapid rate. By the 4 th lunar
month, urine is added to the amount of amniotic fluid. It
is, therefore, derived chiefly from maternal serum and
fetal urine. (Implication: a case of polyhydramnios =
more than 1500 ml of aminiotic fluid, stems from inability
of the fetus to swallow amniotic rapidly, as in
Tracheoesophageal fistuli; while oligo-hydramnios =
amniotic fluid less than 500 ml, results when kidneys are
not functioning normally, as in congenital renal anomaly.)
Also know as bag of waters (BOW), it serves the
following purposes:
• Protection:
 * Shields the fetus against blows or pressure
on the mother’s abdomen
* Protects the fetus against sudden change sin
temperature because liquid changes temperature
more slowly than air
* Protects the fetus against certain infections
• Diagnosis:
* As in amniocentesis
* Meconium-stained amniotic fluid means
fetal distress
• Aids in descent of the fetus during active labor

2. Chorion – together with the deciduas basalis gives rise to the placenta,
which starts to form on the 8th week of gestation. Develops into
15-20 subdivision called cotyledons. Placenta serves the
following purposes:
a. Respiratory system – exchange of gases takes place in the placenta,
not in the fetal lungs
b. Renal system – waste products are being excreted through the
placenta (Note: it is the mother’s liver which detoxifies the fetal waste
products).
c. Gastrointestinal system – nutrients pass to the fetus via the placenta
by diffusion through the placental tissues.
d. Circulatory system – feto-placental circulation is established by
selective osmosis
e. Endocrine system – it produces the following hormones (before 8
weeks gestation, the corpus luteum is the one producing these
hormones):
Human chronionic gonadotropin (HCG) – “order’s the corpus
luteum to keep on producing estrogen and progesterone that is why
menstruation does not ta ke place during pregnancy. It is also the
basis for pregnancy test.
Human placental lactogen (HPL)/human chronionic
somatomammotropin – promotes growth of the mammary glands
necessary for lactation. Also has growth-stimulating properties
Estrogen
Progesterone
f. Protective barrier – inhibit passage of some bacteria and large
molecules.

3. Stage of human prenatal development:

a. First 12-14 days = zygote
b. From 15th day up to the 8th week = embryo
c. From 8th week up to the time of birth = fetus
IV. Fetal Development

A. First Lunar Month

1. Germ layers differentiate by the 2nd week (In cases of multiple
congenital anomalies, the structures that will be affected are those that
arise out of the same germ layer.)
a. Entoderm – develops into the lining of the GIT, the respiratory tract,
tonsils, thyroid (for basal metabolism), parathyroid (for calcium
metabolism), thymus glands (for development of immunity), bladder
and urethra
b. Mesoderm – forms into the supporting structures of the body
(connective tissues, bones, cartilage, muscles and tendons), heart,
circulatory system, blood cells, reproductive system, kidneys and
ureters
c. Ectoderm – responsible for the formation of the nervous system,
the skin, hair and nails, the sense organs and mucous membrane
of the anus and mouth.
2. Fetal membranes (amnion and chorion) appear by the second week
3. Nervous system very rapidly develops by the 3rd week (Dizziness is
said to be the earliest sign of pregnancy because as the fetal brain
rapidly develops, glucose stores of the mother are depleted, thus
causing hypoglycemia in the latter)
4. Fetal heart begins to form as early as the 16th day of life (To the
question, “When does the fetal heart begin to beat?”, the answer is the
first lunar month. But to the question “When can fetal heart tones be
first heard?”, the answer is fifth month.)
5. The digestive and respiratory tracts exist as a single tube until the
3rd week of life when they start to separate.
B. Second Lunar Month
1. All vital organs are formed by the end of the 8th week.
2. Placenta develops fully.
3. Sex organs (ovaries and testes) are formed by the 8th week. (To the
question, “When is sex determined?”, the answer is at the time of
conception.)
4. Meconium (first stools) are formed in the intestines by the 5th-8th week.
C. Third Lunar Month
1. Kidneys are able to function – urine formed by the 12th week
2. Buds of milk teeth form
3. Beginning bone ossification
4. Fetus swallows amniotic fluid
5. Feto-placental circulation is established by selective osmosis; no
direct exchange between fetal and maternal blood
D. Fourth Lunar Month
1. Lanugo appears
2. Buds of permanent teeth form
 3. Hearth beats audible with fetoscope
E. Fifth Lunar Month
1. Vernix caseosa appears
2. Lanugo covers entire body
3. Quickening (fetal movements) felt
4. Fetal heart beats very audible
F. Sixth Lunar Month
1. Skin markedly wrinkled
2. Attains proportions of full term baby
G. Seventh Lunar Month
1. Alveoli begin to form (28th weeks gestation is said to be the lower limit
of prematurity; if born, cries, breathes, but usually dies)
H. Eighth Lunar Month
1. Fetus is viable
2. Lanugo begins to disappear
3. Nails extend to ends of fingers
4. Subcutaneous fat deposition begins
I. Night Lunar Month
1. Lanugo and vernix disappear
2. Amniotic fluid volume somewhat decreases
J. Tenth Lunar Month – all characteristics of the normal newborn

V. Focus of Fetal Development

A. First trimester - organogenesis

B. Second trimester – period of continued fetal growth and development;
rapid increase in fetal length
C. Third trimester – period of most rapid growth and development because of
rapid deposition of subcutaneous fat

VI. Normal Adaptation in Pregnancy

A. Systemic Changes
1. Circulatory/Cardiovascular
a. Beginning the end of the first trimester, there is gradual increase of
about 30%-50% in total cardiac volume, reaching its peak during
the 6th month. This causes a drop in hemoglobin and hematocrit
values since the increase is only in the plasma volume=physiologic
anemia of pregnancy. Consequences of increased total cardiac
volume are:
Easy fatigability and shortness of breath because of increased
workload of the heart
Slight hypertrophy of the heart, causing it to be displaced to the
left, resulting in torsion on the great vessels (the aorta and
pulmonary artery)
Systolic murmurs are common due to lowered blood viscosity
 Nosebleeds may occur because of marked congestion of the
nasopharynx as pregnancy progresses
b. Palpitations due to:
Sympathetic nervous system stimulation during first half of
pregnancy
Increased pressure of uterus against the diaphragm during 2nd
half of pregnancy
c. Because of poor circulation resulting from pressure of the gravid
uterus on the blood vessels of the lower extremities:
Edema of the lower extremities occurs.
Management: raise legs above hip level
Important: Edema of the lower extremities is NOT a sign of
toxemia.
Varicosities of the lower extremities can also occur.
Management:
• Use/wear support hose or elastic stocking to
promote venous flow, thus preventive stasis in the
lower extremities
• Apply elastic bandage – start at the distal end of
the extremity and work toward the trunk to avoid
congestion and impaired circulation in the distal
part; do not wrap toes so as to be able to
determine the adequacy of circulation (Principle
behind bandaging: blood flow thru tissues is
decreased by applying excessive pressure on
blood vessels)
• Avoid use of constricting garters, e.g., knee-high
socks
d. Because of poor circulation in the blood vessels of the genitalia due
to pressure of the gravid uterus, varicosities of the vulva and
rectum can occur. Management:
Side-lying position with hips elevated on pillows
Advise modified knee-chest position
e. There is increased level of circulating fibrinogen, that is why
pregnant women are normally safeguarded against undue bleeding.
However, this also predisposes them to formation of blood clots
(thrombi). The implication is that pregnant women should not be
massaged since blood clots can be released an cause
thromboembolism.

2. Gastrointestinal changes
a. Morning sickness (-nausea and vomiting during the first trimester) is
due to increased human chorionic genadotropin (HCC). It may also
be due to increased acidity or even to emotional factors.
Management:
 Eat dry toast or crackers 30 minutes before arising in the
morning (or dry, high carbohydrate, low fat and low spices in the
diet).
Hyperemesis gravidarum – excessive nausea and vomiting
which persists beyond 3 months; will result in dehydration,
starvation and acidosis. Management
• D10 NSS 3000 ml in 24 hours is the priority of treatment
• Complete bed rest is also an important
b. Constipation and flatulence are due to the displacement of the
stomach and intestines, thus slowing peristalsis and gastric-
emptying time; may also be due to increased progesterone during
pregnancy. Management:
Increase fluids and roughage in the diet
Establish regular elimination time
Increase exercise
Avoid enemas
Avoid harsh laxatives like Dulcolax; stool softeners, e.g.
Colace, are better
Mineral oil should not be taken because it interferes with
absorption of fat-soluble vitamins
c. Hemorrhoids are due to pressure of enlarged uterus. Management:
Cold compress with witch hazel or Epsom salts.
d. Heartburn, especially during the last trimester, is due to increased
progesterone which decreases gastric motility, thereby causing
reverse peristaltic waves which lead to regurgitation of stomach
contents through the cardiac sphincter into the esophagus, causing
irritation.
Management:
Pats of butter before meals
Avoid fried, fatty foods
Sips of milk at frequent intervals
Small, frequent meals taken slowly
Bend at the knees, not at the waist
Take antacids (e.g. Milk of Magnesia) but NEVER sodium
bicarbonate (e.g. Alka Seltzer or baking soda) because it
promotes fluid retention.

3. Respiratory changes – there is shortness of breath

a. Causes
Increased oxygen consumption and production of carbon
dioxide during the first trimester
Increased uterine size causes diaphragm to be pushed or
displaced, thus crowding chest cavity
 b. Management: Lateral expansion of the chest to compensate for
shortness of breath increases oxygen supply and vital lung
capacity.
4. Urinary changes
a. Urinary frequency, the only sign in pregnancy seen during the first
trimester, disappear during the second and reappear during the
third trimester, is due to increased blood supply in the kidneys and
to the uterus rising out of the pelvic cavity; on the last trimester, is
due to pressure of enlarged uterus on the bladder, especially with
lightening.
b. Decreased renal threshold for sugar due to increased production of
glucocorticoids which cause lactose and dextrose to spill into the
urine; also an effect of the increase in progesterone. (Implication: It
would be difficult to diagnose diabetes in pregnancy based on the
urine sample alone because all pregnant women have sugar in
their urine)

5. Musculoskeletal changes
a. Because of the pregnant woman’s attempt to change her center of
gravity, she makes ambulation easier by standing more straight and
taller, resulting in a lordotic position (“pride of pregnancy”)
b. Due to increased production of the hormone relaxin, pelvic bones
become more supple and movable, increasing the incidence of
accidental falls due to the wobbly gait.
Implication: Advise use of low-heeled shoes after the first trimester.
c. Leg cramps are caused by:
Increased pressure of gravid uterus on lower extremities
Fatigue
Chills
Muscle tenseness
Low calcium high phosphorus intake
Management:
Frequent rest periods with feet elevated
Wear warm, more comfortable clothing
Increase calcium intake (calcium tablets and diet)
Do not massage – blood clots can cause embolism
Most effective relief: Press knee of the affected leg and
dorsiflex the foot

6. Temperature – slight increase in body temperature due to increased

progesterone, but the body adapts after the 4th month

7. Endocrine changes
a. Addition of the placenta as an endocrine organ, producing large
amounts of estrogen, progesterone, HCG and HPL
 b. Moderate enlargement of the thyroid gland due to hyperplasia of
the glandular tissues and increased vascularity. Could also be
due to increased basal metabolic activity of the products of
conception.
c. Increased size of the parathyroids, probably to satisfy the
increased need of the fetus for calcium
d. Increased size and activity of the adrenal cortex, thus increasing
the amount of circulating cortisol, aldosterone and ADH, all of
which affect carbohydrate and fat metabolism
e. Gradual increase in insulin production but the body’s sensitivity
to insulin is decreased during pregnancy

8. Weight
a. During first trimester, weight gain of 1.5 – 3 lbs
b. On 2nd trimester and 3rd trimesters, weight gain of 10-11 pounds
per trimester is recommended
c. Total allowable weight gain during entire period of pregnancy is
20 - 25 lbs ( = 10 – 12 kgs)
d. Pattern of weight gain is more important than the amount of
weight gained
e. Distribution of weight gain during pregnancy:
Fetus 7 lbs
Placenta 1 lb
Amniotic fluid 1 ½ lbs
Increased weight of uterus 2 lbs
Increased blood volume 1 lb
Increased weight of the breast 1 ½ - 3 lbs
Weight of additional fluid 2 lbs
Fat fluid accumulation 4 – 6 lbs
Characteristic of pregnancy _________

TOTAL = 20 – 25 lbs

9. Emotional responses
a. First trimester: the fetus is an unidentified concept with great
future implications but without tangible evidence of reality.
Some degree of rejection, denial and disbelief, even repression.
(Implication: when giving health teachings, be sure to
emphasize the bodily changes in pregnancy)
b. Second trimester: fetus is perceived as a separate entity.
Fantasizes appearance of the baby
c. Third trimester: has personal identification with a real baby
about to be born and realistic plans for future child care
responsibilities. Best time to talk about preparation of layette
and infant feeding method. Fear of death, though, is prominent
 (To allay fears, let pregnant woman listen to the fetal heart
tones).

B. Local Changes
1. Uterus
a. Weight in crease to about 1,000 grams at full term; due to
increase in the amount of fibrous and elastic tissues.
b. Change in shape from pear-like to ovoid
c. Change in consistency of the lower uterine segment causes
extreme softening, known as Hegar’s sign, seen at about the 6th
week
d. Mucous plugs in the cervix, called operculum, are produced to
seal out bacteria
e. Cervix becomes more vascular and edematous, resembling the
consistency of an earlobe, known as Goodell’s sign.

2. Vagina
a. Increased vascularity causes change in color from light pink to
deep purple or violet known as Chadwick’s sign
To prevent confusion as to pregnancy signs arrange the
body “out to xxx” and the different signs alphabetically. Thus:
Vagina - Chadwick’s sign
Cervix - Goodell’s sign
Uterus - Hegar’s sign
b. Due to increase estrogen, activity of the epithelial cells
increases, thus increasing amount of vaginal discharges called
leukorrhea. As long as the discharges are not smelling or
irritatingly itchy, it is normal. Management: Maintain or increase
cleanliness by taking twice daily shower baths using cool water.
c. pH of vagina changes from the normally acidic (because of the
presence of the Doderlein bacilli) to alkaline (because of
increased estrogen). Alkaline vaginal environment is supposed
to protect against bacterial infection, however, there are two
microorganisms which love to thrive in an alkaline environment:
Trichomonas, a protozoa or flagellate. The condition is called
trichomonas vaginalis or trichomonas vaginitis or
trichomoniasis. Symptoms are:
Frothy, cream-colored, irritatingly itchy, foul-smelling
discharges
Vulvar edema and hyperemia due to irritation from the
discharges
Treatment:
Flagyl for 10 days p.o. or vaginal suppositories of
Trichomonicidal compounds (e.g., Tricefuron, Vagisec,
Devegan). Note: Is carcinogenic during the first trimester.
Treat male partner also, with Flagyl. (Important: avoid
 alcoholic drinks when taking Flagyl – can cause
Antabuse-like reactions: vomiting, flushed face and
abdominal cramps.) Dark brown urine a minor side effect-
no need to discontinue the drug.
Acidic vaginal douche (1 tbsp. white vinegar to 1 quart of
water or 15 ml white vinegar in 1000 ml water) to
counteract alkaline-preferred environment of the
protozoa.
Avoid intercourse to prevent re-infection.
Monilia, a fungus called Candida albicans. The condition is
called Moniliasis or Candidiasis. Fungus also lives to thrive
in environment right in carbohydrates (that is why it is
common among poorly-controlled diabetics) and in those on
steroid and antibiotic therapy when acidic environment is
altered.
Symptoms:
White, patchy, cheese-like particles that adhere to
vaginal walls. Irritatingly itchy and foul-smelling vaginal
discharges
Treatment:
 Mycostatin/Nystatin p.o. or vaginal
suppositories/pessaries (100,000 U) twice a day for 15
days
Gentian violet swab to vagina (use panty shields to
prevent staining of clothes or underwear)
Correct diabetes
Avoid intercourse
Acidic vaginal douche
Moniliasis is seen as oral thrush in the newborn when
transmitted during delivery through the birth canal of the
infected mother.

3. Abdominal Wall
a. Striae gravidarum – increased uterine size results in rupture
and atrophy of the connective tissue layers, seen as pink or
reddish streaks (gently rubbing oil on the skin helps prevent
diastasis)
b. Umbilicus pushed out

4. Skin
a. Linea nigra – brown line running from umbilicus to symphysis
pubis
b. Melasma or chloasma – extra pigmentation on cheeks and
across the nose due to the increased production of
melanocytes by the pituitary gland
c. Sweat glands unduly activated
 5. Breasts
a. All changes due to increased estrogen
b. Increase in size due to hyperplasia of mammary alveoli and
fat deposits. Proper breast support with well-fitting brassiere
necessary to prevent sagging
c. Feeling of fullness and tingling sensation in the breasts
d. Nipples more erect (For mothers who intend to breastfeed,
advise nipple rolling, drying nipples with rough towel to help
toughen the nipples and not to use soap or alcohol so as to
prevent drying which could lead to sore nipples).
e. Montgomery glands become bigger and more protruberant
f. Areolae become darker and diameter increase
g. Skin surrounding areolas turns dark
h. By the fourth month, a thin, watery, high-protein fluid, called
colostrums, is formed. It is the precursor of breast milk.

6. Ovaries – no activity whatsoever, since ovulation does not take

place during pregnancy and progesterone and estrogen are
being produced by the placenta.

Table 2. Signs Of Pregnancy

STAGE PRESUMPTIVE PROBABLE POSITIVE

First Trimester Amenorrhea Chadwick’s Ultrasound evidence
Morning sickness Goodell’s
Breast changes Hegar’s
Fatigue Positive HCG
Urinary frequency Elevation of basal
Enlarging uterus body temperature
Second Trimester Quickening Enlarged abdomen Fetal heart tones
Increased skin Braxton Hicks Fetal movements
pigmentation: Ballotement Fetal outline on
Chloasma X-ray
Linea nigra
Striae gravidarum

VII. The Prenatal Visit

The provision of prenatal care is the primary factor in the improvement of

maternal morbidity and mortality statistics. To ensure the success of the prenatal
care programs, it should be remembered that the patient’s understanding of the
modalities of care is basic to cooperative action.
The duration of normal pregnancy is 266-280 days or 38-42 weeks
(average is 40 weeks) or 9 calendar months or 10 lunar months. Any baby,
therefore, who is born before the 38th week of gestation is called preterm and a
baby born after the 42nd week of gestation is said to be post term.

A. Diagnosis of Pregnancy
1. Urine examination – human chorionic gonadotropin (HCG) in the urine
is the basis for pregnancy tests. It is present from the 40th day
through the 100th day, reaching a peak level on the 60th day. HCG,
therefore, is most correct 6 weeks after the LMP. When collecting
urine for pregnancy testing:
a. No water taken after 8 PM the night before urine collection in order
to concentrate urine
b. First morning urine, midstream, should be collected in a clean, dry
jar
c. If more than 1 hour would lapse before being tested, refrigerate
specimen because HCG is unstable under room temperature
d. Types of urine exams for pregnancy:
Biological tests – presence of HCG will produce hemorrhagic
changes in the ovaries/testes of the animal when the urine of a
pregnant woman is injected.
E.g. Ascheim-Zondek – mice; Freidman – rabbit; Frank Berman
– rat; Hogben – toad; male frog. Is actually obsolete.
Immunodiagnostic tests – antigen-antibody reaction. Widely
used at present because results are obtained faster and do not
involved the sacrifice of an animal. E.g. Gravindex; Pregnex;
Prognosticon
2. Progesterone Withdrawal Test – also a test to diagnose pregnancy. A
contraceptive pill is taken by the woman three times a day for 3 days
pregnancy test pill (Gestex) is taken once. If menstruation occurs
within 10-15 days after, the woman is not pregnant. If pregnant,
there will be no menstruation because the corpus luteum produces
enough hormones to neutralize the effect of withdrawn synthetic
progesterone.

B. Components of a prenatal visit

1. History-taking
a. Personal data – patient’s name, age, address, civil status (an
unwed pregnancy is a risk pregnancy) and family history (with
whom does she live? Are there familial disease that could
possible affect the pregnancy?)
b. Obstetrical data
 Gravida – number of pregnancies a woman has had
 Para – number of viable deliveries, regardless of number and
outcome
 TPAL score – (_ _ _ _) – number of full term babies; premature
babies; abortions; living children
  Past pregnancies
o Method of delivery – normal spontaneous vaginal?
Cesarean section (CS)? Indication for past CS?
o Where – At home? In the hospital?
o Risks involved – Prematurity? Toxemia?
Present pregnancy
o Chief concern – Is there nausea and vomiting?
o Danger signals:
Vaginal bleeding, no matter how slight
Swelling of face or fingers
Severe continuous headache
Dimness or blurring of vision
Flashes of light or dots before the eyes
Pain in the abdomen
Persistent vomiting
Chills and fever
Sudden escape of fluids from the vagina
Absence of fetal heart sounds after they have been
initially auscultated on the 4th or 5th month
c. Medical data – Is there a history of kidney, cardiac or liver disease;
hypertension; tuberculosis; sexually-transmitted disease
(STDs)?
2. Assessment
a. Physical examination – a review of systems is indicated, including
inspection of the teeth because they are common foci of infection
b. Pelvic examination (Cardinal rule: Empty the bladder first)
Internal Exam (IE) to determine Hegar’s, Chadwick’s and
Goodell’s
Ballotement – fetus will bounce when lower uterine segment is
tapped sharply (on 5th month of pregnancy)
Papanicolau smear (Pap smear) – cytological examination to
diagnose cervical carcinoma.
Classification of findings:
Class 1 – absence of atypical or abnormal cells (normal)
Class 2 – atypical cytology but no evidence of malignancy
Class 3 – cytology suggestive of malignancy
Class 4 – cytology strongly suggestive of malignancy
Class 5 – conclusive for malignancy
Clinical stages that reflects localization or spread of
malignant changes:
Stage 1 – CA confined to the cervix
Stage 2 – CA extends beyond cervix into the vagina, but
not into pelvic wall or lower 1/3 of the vagina
Stage 3 – metastasis to the pelvic wall
 Stage 4 – metastasis beyond pelvic wall into the bladder
and rectum
Pelvic measurements are preferably done after 6th lunar month.
X-ray pelvimetry (several flat plate X-ray pictures of the pelvis are
taken from different angels), however, is the most effective
method of diagnosing cephalopelvic disproportion (CPD). But
since X-rays are teratogenic, the procedure can be done only 2
weeks before EDC.
Leopold’s maneuvers – to determine presentation, position and
attitude; estimate fetal size and locate fetal parts.
o Preparatory steps:
Palpate with warm hands xxx cold hands cause
abdominal muscles to contract
Use palms not fingertips
Position patient on supine, with knees flexed slightly
(-dorsal recumbent position) so as to relax abdominal
muscles
Use gentle but firm motions
o Procedure:
First maneuver: Facing head part of pregnant woman,
palpate for the fetal part found in the fundus to
determine presentation (a hard, smooth, round,
ballotable mass at the fundus means the fetus is in
breech presentation
Second maneuver: Palpate sides of the uterus to
determine the location of the fetal back and the small
fetal parts
Third maneuver: Grasp lower portion of abdomen just
above the symphysis pubis to find out degree of
engagement
Fourth maneuver: Facing the feet part of the patient,
press fingers downward on both sides of the uterus
above the inguinal ligaments to determine attitude
(-degree of flexion of fetal head)
c. Vital signs – temperature and pulse and respiratory rates are
important especially during the initial prenatal visit.
But certainly more important are the weight and blood
pressure as baseline data to determine any significant
increases.
d. Blood studies
Blood typing
Complete blood count, including Hgb and Hct, to determine
anemia
Serological tests (VDRL and Kahn & Wasserman) to diagnose for
syphilis
e. Urine examinations
 Heat and acetic acid test to determine albuminuria. Any sign of
albumin in the urine should be reported immediately because it is
a serious sign of toxemia
Benedict’s test for glycosuria, a sign of possible gestational
diabetes. Specimen should be taken before breakfast to avoid
false positive results. Should not be more than +1 sugar.
Determination of pyuria. Urinary tract infection has been found to
be a common cause of premature delivery.

3. Important Estimates
a. Estimates of age of gestation (AOG):
Naegele’s Rule – calculation of expected date of confinement
(EDC). Count back three months from the first day of the last
menstrual period (LMP) then add 7 days. Substitute number for
month for easy computation.
McDonald’s Method – determines age of gestation by measuring
from the fundus to the symphysis pubis (in cm.) then divide by 4 =
AOG in months. E.g., fundic height of 16 cm. divided by 4 = 4
months AOG = 16 weeks AOG.
Bartholomew’s Rule – estimates AOG by the relative position of
the uterus in the abdominal cavity.
o By the 3rd lunar month, the fundus is palpable slightly
above the symphysis pubis
o On the 5th lunar month, the fundus is at the level of the
umbilicus
o On the 9th lunar month, the fundus is below the xiphoid
process
b. Arey’s Rule – determines the length of the fetus in centimeters.
During the first half of pregnancy, square the number of the
month (E.g., first lunar month: 1 x 1 = 1 cm.)
During the second half of pregnancy, multiply the month by 5
(E.g., 6th lunar month: 6 x 5 = 30 cm.)
o Vitamin D – fish, liver, eggs, milk (excess Vit. D during
pregnancy can lead to fetal cardiac problems
o Vitamin E – green leafy vegetables, fish
o Vitamin C – tomatoes, guava, papaya
o Vitamin B – foods rich in proteins
o Calcium/phosphorus – milk, cheese
o Iron – especially important during the last trimester when
the pregnant woman is going to transfer her iron stores
from herself to her fetus so that the baby has enough iron
stores during the first 3 months of life when all he takes is
milk (which is deficient in iron). Iron has a very low
absorption rate; only 10% of the iron intake can be
absorbed by the body. Thus, for optimum absorption,
 give Vitamin C. Iron should be given after meals
because it is irritating to the gastric mucosa. Sources:
liver and other internal organs camote tops, kangkong,
egg yolk, ampalaya.

Table 4. Quantities of Food Necessary During Pregnancy

NUTRIENTS ACTIVE NON-PREGNANT PREGNANT

Meat 2 servings of meat, fowl or 2-3 servings of meat, fowl or
fish/day; 3-5 eggs per week fish/day; 1 egg daily

Vegetables: Dark green or 1 serving (at least 3/week)

deep yellow 1 serving daily

Other vegetables 2 or more servings

2-3 servings
Fruits:
Citrus 1 serving
Other fruits 1 serving 1 serving
1 serving
Breads and cereal 4 or more servings
4 servings
Milk 1 pint (8 oz. glasses)
1 quart (4, 8 oz. glasses)
Additional fluid Ad libitum
At least 2 glasses daily

* Malnutrition during pregnancy can result in prematurity, preeclampsia,

abortion, low birth weight babies, congenital defects or even stillbirths.

b. Smoking – causes vasoconstriction, leading to low birth weight babies

and, therefore, is contraindicated during pregnancy
c. Drinking – in moderation is not contraindicated but when excessive
can cause transient respiratory depression in the newborn
and fetal withdrawal syndrome; besides, alcohol supplies
only empty calories.
d. Drugs – dangerous to fetus especially during the first trimester when
the placental barrier is still incomplete and the different body
organs are developing. Are teratogenic (can cause congenital
defects) and, therefore, contraindicated unless prescribed by
the doctor.
Thalidomide – causes amelia or phocomelia
Steroids – can cause cleft palate and even abortion
Iodides – (contained in many over-the-counter cough
suppressants) – cause enlargement of the fetal thyroid gland,
leading to tracheal decompression and dyspnea at birth
Vitamin K – causes hemolysis and hyperbilirubinemia
 Aspirin/Phenobarbital – causes bleeding disorders
Tetracycline – causes staining of long bones (not given also to
children below 8 years for the same reasons)
e. Sexual activity
Sexual desires continue throughout pregnancy, but levels
change:
o During the first trimester, there is a decrease in sexual
desires because the woman is more preoccupied with the
changes in her body
o During the second trimester, there is an improvement in
sexual desires because the woman has adapted to the
growing fetus
o During the third trimester, there is another decrease in
sexual desires because the woman is afraid of hurting the
fetus
Sex in moderation is permitted during pregnancy but not during
the last 6 weeks of pregnancy because it has been found out
that there is increased incidence of postpartum infection in
women who engage in sex during the last 6 weeks. Counsel the
couple to look for more comfortable positions.
Sex is contraindicated in the following situations:
o Spotting or bleeding
o Incompetent cervical os
o Ruptured BOW
o Deeply engaged presenting part
f. Employment – as long as the job does not entail handling toxic
substances, or lifting heavy objects, or excessive physical or
emotional strain, there is no contraindication to working. Advise
pregnant women to walk about every few hours of her work day
during long periods of standing or sitting to promote circulation.
g. Traveling – no travel restrictions, but postpone a trip during the last
trimester. On long rides, 15-20 minute rest periods every 2-3 hours
to walk about or empty the bladder is advisable.
h. Exercises
Chief aim: To strengthen the muscles used in labor and
delivery
Should be done in moderation
Should be individualized: according to age, physical condition,
customary amount of exercise (swimming or tennis not
contraindicated unless done for the first time) and the stage of
pregnancy
Recommended exercises:
o Squatting and tailor-sitting – help stretch and strengthen
perineal muscles; increase circulation in the perineum;
make pelvic joints more pliable. When standing from the
 squatting position, raise buttocks first before raising the
head to prevent postural hypotension.
o Pelvic rock – maintain good posture; relieves abdominal
pressure and low backaches; strengthens abdominal
muscles following delivery
o Modified knee-chest position – relieves pelvic pressure and
cramps in the thighs or buttocks; relieves discomfort from
hemorrhoids
o Shoulder-circling – strengthens muscles of the chest
o Walking – said to be the best exercise
o Kegel – relieves congestion and discomfort in pelvic
region; tones up pelvic floor muscles
i. Prepared Childbirth/Childbirth Education – preparing the
pregnant couple for child-bearing
Operates basically on the “Gate Control Theory” of pain: Pain is
controlled in the spinal cord. To ease pain in one body part, the
“gate” to this pain should be “closed”.
Premises:
o Discomfort during labor can be minimized if the woman
comes into labor informed about what is happening and
prepared with breathing exercises to use during labor
o Discomfort during labor can be minimized if the woman’s
abdomen is relaxed and the uterus is allowed to rise freely
against the abdominal wall with contractions.
Major approaches to prepared childbirth-pregnant couples are
taught about anatomy, pregnancy, labor and delivery, relaxation
techniques, breathing exercises, hygiene, diet, comfort measures:
o Grantly-Dick Read Method: Fear leads to tension and
tension leads to pain.
o Lamaze – psychoprophylactic method; based on the
stimulus-response conditioning. To be effective, full
concentration on breathing exercises during labor should be
observed. (Implication: Nurse should not interrupt the couple
doing breathing exercises.)
j. Tetanus immunization – given 0.5 ml IM (deltoid region of the upper
arm) to all pregnant women any time during pregnancy. It shall be
given in two doses at least 4 weeks apart, with the second dose at
least 3 weeks before delivery. Booster doses shall be given during
succeeding pregnancies regardless of the interval. Three booster
doses will confer a lifelong immunity.
k. Clinic appointments:
First 7 lunar months – every month
On 8th and 9th lunar months – every other week – twice a month
On 10th lunar month – every week until labor pains set in
LABOR AND DELIVERY

I. The Fetal Skull

A. Importance – From an obstetrical point of view the fetal skull is the most
important part of the fetus because:
1. It is the largest part of the body
2. It is the most frequent presenting part
3. It is the least compressible of all parts

B. Cranial bones – the first 3 are not important because they lie at the base
of the cranium and, therefore, are never the presenting parts:
1. Sphenoid
2. Ethmoid
3. Temporal
4. Frontal
5. Occipital
6. Parietal

C. Membrane spaces – suture lines are important because they allow the
bones to move and overlap; changing the shape of the fetal head in
order to fit through the birth canal, a process called molding:
1. Sagittal suture line – the membranous interspace which joins the 2
parietal bones
2. Coronal suture line – the membranous inter-space which joins the
frontal bone and the parietal bones
3. Lambdoid suture line – the membranous inter-space which joins the
occiput and the parietals

D. Fontanelles – membrane-covered spaces at the junction of the main

suture lines:
1. Anterior fontanelle – the larger, diamond-shaped fontanelle which
closes between 12-18 months in an infant
2. Posterior fontanelle – the smaller, triangular shaped fontanelle which
closes between 2-3 months in the infant
E. Measurements – the shape of the fetal skull causes it to be wider in its
anteroposterior (AP) diameter that in its transverse diameter:
1. Transverse diameters of the fetal skull:
a. Biparietal = 9.25 cm.
b. Bitemporal = 8 cm.
c. Bimastoid = 7 cm.
 2. Anteroposterior diameter:
a. Suboccipitobregmatic – from below the occiput to the anterior
fontanelle = 9.5 cm (the narrowest AP
diameter)
b. Occipitofrontal – from the occiput to the mid-frontal bone = 12 cm.
c. Occipitomental – from the occiput to the chin = 13.5 cm (the widest
AP diameter)

Which one of these diameters is presented at the birth canal depends

on the degree of flexion (known as attitude) the fetal head assumes prior to
delivery. In full flexion (very good attitude when the chin is flexed on the chest),
the smallest suboccipitobregmatic diameter is the one presented at the birth
canal. If in poor flexion, the widest occipitomental diameter will be the one
presented and will give mother and baby more problems

II. Theories of Labor Onset

A. Uterine Stretch Theory – any hollow body organ when stretched to
capacity will necessarily contract and empty.

B. Oxytocin theory – labor, being considered a stressful event, stimulate s the

hypophysis to produce oxytocin from the posterior pituitary gland.
Oxytocin causes contraction of the smooth muscles of the body, e.g.,
uterine muscles.

C. Progesterone Deprivation theory – progesterone, being the hormone

designed to promote pregnancy, is believed to inhibit uterine motility.
Thus, if its amount decreases, labor pains can occur.

D. Prostaglandin theory – initiation of labor is said to result from the release

of arachidonic an acid produced by steroid action on lipid precursors.
Arachidonic acid, is said to increase prostaglandin synthesis which,
in turn, causes uterine contractions.

E. Theory of Aging Placenta – because of the decreased blood supply, the

uterus contracts.

III. Preliminary/prodromal Signs of Labor

A. Lightening – the settling of the fetal head into the pelvic brim. In primis, it
occur 2 weeks before EDC; in multis, on or before labor
onset.
Results of lightening:
1. Increase in urinary frequency
2. Relief of abdominal tightness and diaphragmatic pressure
3. Shooting pains down to legs because of pressure on the sciatic nerve
4. Increase in the amount of vaginal discharges.
 5. Lightening should not be confused with engagement. Engagement
occurs when the presenting part has descended into the pelvic inlet.

B. Increased Activity Level – due to increase in epinephrine secreted to

prepare the body for the coming “work” ahead. Advise the pregnant
woman not to use this increased energy for doing household chores.

C. Loss of weight – of about 2-3 lbs 1 to 2 days before labor onset, probably
due to decrease in progesterone production, leading to
decrease in fluid retention.

D. Braxton Hicks contractions – painless, irregular practice contractions

E. Ripening of the cervix – from Goodell’s sign, the cervix becomes “butter-
soft”.

F. Rupture of the membranes – it is IMPORTANT to remember that once

membranes that once membranes (BOW) have ruptured:
1. Labor is inevitable. It will occur within 24 hours
2. The integrity of the uterus has been destroyed. Infection, therefore,
can easily set in. That is why once membranes have ruptured, aseptic
techniques should be observed in al procedures, doctors do less
obstetric manipulations (e.g., IE) and enema is no longer ordered.
3. Umbilical cord compression and/or cord prolapse can occur (especially
in breech presentation). Nursing action depends on the specific
situation.
a. A woman in labor seeking admission to the hospital and saying that
her BOW has ruptured should be put to bed immediately and the
fetal heart tones taken consequently.
b. If a woman in the Labor Room says that her membranes have
ruptured, the initial nursing action is to take the fetal heart tones.
c. If a woman in labor says that she feels a loop of the cord coming out
of the vagina (cord prolapse), the first nursing action is to put her on
Trendelenburg position (lower the head of the bed) in order to
reduce pressure on the cord (REMEMBER: Only 5 minutes of cord
compression can already lead to irreversible brain damage or even
death). In addition, apply a warm saline-saturated OS on the
prolapsed cord to prevent drying of the cord.
G. Show – due to pressure of the descending presenting part of the fetus
which causes rupture of minute capillaries in the mucous
membrane of the cervix. Blood mixes with mucus when
operculum is released. Show, therefore, is only a pinkish vaginal
discharge.

IV. Signs of True Labor

 A. Uterine Contractions – the surest sign that labor has begun is the initiation
of effective, productive uterine contractions.
1. Pain in uterine contractions results from:
a. Contraction of uterine muscles when in an ischemic state
b. Pressure on nerve ganglia in the cervix and lower uterine segment
c. Stretching of ligaments adjacent to the uterus and in the pelvic joints
d. Stretching and displacement of the tissues of the vulva and
perineum
2. Phases of uterine contractions
a. Increment – first phase during which the intensity of contraction
increases; also known as crescendo
b. Acme – the height of the uterine contraction; also know as apex
c. Decrement – last phase during which intensity of contraction
decreases; also known as decrescendo

Table 5. Differences Between False and True Labor Pains

FALSE LABOR PAINS TRUE LABOR PAINS

1. Remain irregular 1. May be slightly irregular at first but
become regular and predictable in a
matter of hours.

2. Generally confined to the abdomen 2. First felt in the lower back and
sweep around to the abdomen in a
girdle-like fashion

3. No increase in duration, frequency 3. Increase in duration, frequency and

and intensity intensity

4. Often disappears if the woman 4. Continue no matter what the

ambulates woman’s level of activity is.

5. Absent cervical changes 5. Accompanied by cervical

effacement & dilatation

B. Effacement – shortening and thinning of the cervical canal from 1-2 cm. to
one in which no canal as distinct from the uterus exists. It is
expressed in percentage.

C. Dilatation – enlargement of the external cervical os to 10 cm. primarily as a

result of uterine contractions and, secondarily, as a result of
pressure of the presenting part and the BOW.
 D. Uterine Changes – the uterus is gradually differentiated into 2 distinct
portions:
1. Upper uterine segment – becomes thick and active to expel out fetus
2. Lower uterine segment – becomes thin-walled, supple and passive so
that fetus can be pushed out easily.
Physiological retraction ring is formed at the boundary of the upper and
lower uterine segments. In difficult labor when fetus is larger than the
birth canal, the round ligaments of the uterus become tense during
dilatation and expulsion, causing an abdominal indentation called
Bandl’s pathological retraction ring, a danger sign of labor signifying
impending rupture of the uterus if the obstruction is not relieved.

V. Length of Normal Labor

Primis Multis

First Stage 12 ½ hours 7 hours, 20 minutes

Second Stage 80 minutes 30 minutes
Third Stage 10 minutes 10 minutes
_________ _________
Total = 14 hours 8 hours

VI. Stages of Labor

A. First Stage (Stage of Dilatation) – begins with true labor pains and ends
with complete dilatation of the cervix.
1. Power/Forces: Involuntary uterine contractions
2. Phases:
a. Latent – early time in labor
Cervical dilatation is minimal because effacement is occurring
Cervix dilates 3-4 cm. only
Contractions are of short duration and occur regularly 5-10
minutes apart (during which time the pregnant woman may seek
admission to the hospital)
Mother is excited, with some degree of apprehension but still with
ability to communicated
Takes up 8 of the 12-hour first stage
b. Active/accelerated
Cervical dilatation reaches 4-8 cm.
Rapid increase in duration, frequency and intensity of contractions
Mother fears losing control of herself
2. Nursing Care
a. Hospital admission – provide privacy and reassurance from the very
start
Personal data – name, age, address, civil status
 Obstetrical data – determine EDC; obstetrical score; amount and
character of show; and whether or not membranes have ruptured
b. General physical examination, internal exam and Leopold’s
maneuvers are done to determine:
Effacement and dilatation
Station – relationship of the fetal presenting part to the level of the
ischial spines
Station 0 – at the level of the ischial spines; synonymous to
engagement
Station -1 – presenting part above the level of the ischial
spines
Station +1 – presenting part below the level of the ischial
spines
Station +3 or +4 – synonymous to crowning (= encirclement of
the largest diameter of the fetal had by the vulvar ring)
Presentation – relationship of the long axis of the fetus to the long
axis of the mother; also known as lie
Presenting part – the fetal part which enter the pelvis first and
covers the internal cervical os

Table 6. Types of Presentation

I. VERTICAL
A. Cephalic – he is the presenting part
1. Vertex – head sharply flexed, making the parietal bone the presenting
part
2. Face)
3. Brow) if in poor flexion
4. Chin )

B. Breech – buttocks are the presenting parts

1. Complete – thighs flexed on the abdomen and legs are on thighs
2. Frank – thighs are flexed and legs are extended, resting on the anterior
surface of the body
3. Footling
a. Single – one leg unflexed and extended; one foot presenting
b. Double – legs unflexed and extended; feet are presenting

II. HORIZONTAL – Transverse lie – Shoulder presentation

In vertex and breech presentations, fetal heart sounds are best heard,
at the area of the fetal back; in face presentations, at the area of the
fetal chest
 In vertex presentations, FHS are usually located in either the left or
right lower quadrant (RLQ or LLQ); in breech presentation, at or above
the level of the umbilicus (RUQ or LUQ)
Hazards of breech delivery:
o Cord compression
o Abruptio placenta
o Erb-duchenne paralysis
Horizontal lie is very rare (1%) and maybe due to a relaxed abdominal
wall because of multiparity, pelvic contraction or placenta previa
Position – relationship of the fetal presenting part to a specific quadrant
of the mother’s pelvis
The pelvis is divided into four quadrants
o Right anterior
o Right posterior
o Left anterior
o Left posterior
o Posteriors positions result in more backaches because of
pressure fetal presenting part on the maternal sacrum
Points of direction in the fetus:
o Occiput – in vertex presentations
o Chin (mentum) – in face presentations
o Buttocks/feet – in breech presentations
o Scapula (acromic) – in horizontal presentation
Possible fetal positions
o Vertex
LOA – left occipitoancetior (most common and favorable
position at birth)
LOP – left occipitoposterior
LOT – left occipitoetransverse
ROA – right occipitoanterior
ROP – right occipitoposterior
ROT – right occipitotransverse
o Breech
LSA – left sacroanterior
LSP – left sacroposterior
LST – left sacrotransverse
RSA – right sacroanterior
RSP – right sacroposterior
RST – right sacrotransverse
o Face
LMA – left mentoanterior
LMP – left mentoposterior
LMT – left mentotransverse
RMA – right mentoanterior
RMP – right mentoposterior
 RMT – right mentotransverse
o Shoulder
LADA – left acromiodorsoanterior
LADP – left acromiodorsoposterior
RADA – right acromiodorsoanterior
RADP – right acromiodorsotransverse

c. Monitoring and evaluation of important aspects

Uterine contractions – fingers should be spread lightly over the fundus
o Duration – from the beginning of one contraction to the end of the
same contraction (A to B)
Duration during early labor – 20-30 seconds
Duration late in labor – 60 to 70 seconds (SHOULD NEVER
BE LONGER)
o Interval – from the end of one contraction to the beginning of the
next contraction (B to C)
Interval early in labor – 40-45 minutes
Interval late in labor – 2-3 minutes
o Frequency – from the beginning of one contraction to the
beginning of the next contraction (A to C) Time 3-4 contractions
to have a good picture of the frequency of contractions
o Intensity – strength of contractions. May be mild, moderate or
string. Intensity is measured by the consistency of the fundus at
the acme of the contraction. When estimating intensity, check
fundus at the end of contractions to determine whether it relaxes.
o Blood pressure – should not be taken during a contraction as it
tends to increase. Because no blood supply goes to the placenta
during a contraction, all of the blood is in the periphery that is why
there is increased BP during uterine contractions.
BP readings should be taken at least every half hour during
active labor
When a woman in labor complains of a headache, the first
nursing action is to take the BP. If it is normal, it is only stress
headache; if the BP is increased, refer immediately to the doctor
(it could be a sign of toxemia)
o Fetal heart rate – should not be mistaken for uterine soufflé
(synchronizes with maternal pulse rate)
Normally 120-160 per minute
Should not be taken also during a uterine contraction because
it tends to decrease. Compression of the fetal head when the
uterus contracts stimulates the vagal reflex which, in turn,
caused bradycardia
Should be taken every hour during the latest phase of labor;
every half hour during the active phase and every 15 minutes
during the transition phase
 For any abnormality in FHR, the initial nursing action is to
change the mother’s position.
Signs of fetal distress:
o Bradycardia (= FHR less than 100/minute) or
tachycardia (=FHR more than 180/minute)
o Meconium-stained amniotic fluid in non-breech
presentation
o Fetal thrashing – hyperactivity of the fetus as it
struggles for more oxygen
d. Emotional support is provided for the woman in labor by keeping her
constantly informed of the progress in labor.
e. Healthy Teachings
Bath – is advisable if contractions are tolerable or not too close to one
another. Will make the mother feel more comfortable
Ambulation – during the latent phase of labor helps shorten the first
stage of labor. But definitely not allowed anymore if membranes have
ruptured.
Solid or liquid foods are to be avoided because:
o Digestion is delayed during labor
o A full stomach interferes with proper bearing down
o May vomit and cause aspiration
Enema – NOT a routine procedure
o Purposes:
 A full bowel hinders the progress of labor- effectiveness
of enema in labor is shown by evaluating change in
uterine tone and amount of show
 Expulsion of feces during second stage of labor
predisposes mother and baby to infection.
 Full bowel predisposes to post-partum discomfort
o Procedure of enema administration
 Enema solution may either be soap suds or fleet enema
 Optimal temperature of the enema solution – 105oF to
115oF ( 40.5oC – 46.1oC)
 Patient on side-lying position
 When there is resistance while inserting the rectal
catheter, withdraw the tube slightly while letting a small
amount of solution enter
 Clamp rectal tube during s contraction
 Important nursing action: Check FHR after enema
administration to determine fetal distress
o Contraindications to enema in labor :

 Vaginal bleeding
 Premature labor
  Abnormal fetal presentation or position
 Ruptured membranes
 Crowning
 Encourage the mother to void very 2-3 hours by offering the
bedpan because:

 A full bladder retards fetal descent

 Urinary stasis can lead to urinary tract infection
 A full bladder can be traumatized during delivery
 Perineal Prep – done aseptically
Use “No.7” method, always from front to back.
 Perineal shave – maybe done to provide a clean area for delivery.
Muscles at the symphysis pubis should be kept taut and razor
moved along the direction of hair growth
 Encourage Sim’s position because :

 It favors anterior rotation of the fetal head

 It promotes relaxation between contractions
 It prevents continual pressure of the gravid uterus on the
inferior vena cava ( the blood vessel which brings
unoxygenated blood back to the heart), pressure results
in Supine Hypotensive Syndrome, also called Vena Cava
Syndrome. Hypotension is due to the reduced venous
return resulting in decreased cardiac output and
therefore, a fall in arterial BP.

 Woman in labor should not be allowed to push or bear down

unnecessarily during contractions of the first stage because:

 It leads to unnecessary exhaustion

 Repeated strong pounding of the fetus against the pelvic
floor will lead to cervical edema, thus interfering with
dilatation
 Abdominal breathing – is advised for contractions during the first
stage in order to reduce tension and prevent hyperventilation.
f. Administer analgesics as ordered. The dosage is based on the patient’s
weight, status of labor and size and stage of gestation.
 Narcotics are the most commonly used, specifically Demerol.
 Pharmacologic effect: Depresses the sensory portion of the
cerebral cortex. It is not only a potent analgesic, it is also a
sedative and an antispasmodic.
 It is not given early in labor because it can retard labor
progress ( is an antispasmodic), but cannot also be given if
delivery is only one hour away because it causes
respiratory depression in the newborn ( that is why it can
be given only if cervical dilatation is 6-8cm.)
  Given 25-100mg.,depending on the body weight
 Takes effect in 20 minutes – patient experiences a sense of
well-being and euphoria
 Narcotic antagonists (e.g. Narcan or Nalline) are given to
counteract the toxic effects of Demerol
g. Assist in administration of regional anesthesia – preferred over any
other form of anesthesia because it does not enter maternal circulation
and thus does not affect the fetus. Patient is completely awake and
aware of what is happening. Does not depress uterine tone, thus optimal
uterine contraction is achieved.
 Xylocaine is anesthesia of choice
 Patient on NPO with IV to prevent dehydration, exhaustion
and aspiration and because glucose aids uterine muscles in
proper functioning.
 Types of Anesthesia:
 Paracervical – transvaginal injection into either side
of the cervix. Patient on lithotomy position. Coupled
with a local anesthetic, results in “painless childbirth”
( uterine contractions are not felt by mother)
 Pudendal – through the sacro-spinous ligament into
the posterior areolar tissues to reduce perception of
pain during second stage and make mother
comfortable. Patient on lithotomy. Side effect : an
ecchymotic (purplish discoloration of the skin due to
blood in the subcutaneous tissues) area or
hematoma in the right of the perineum may be an
aftermath. No special treatment is needed: ice bag
applied to the area on the first day may reduce the
swelling
 Low Spinal
 Epidural – injection of local anesthetic at the
lumbar level outside the dura mater
 Saddle block – injection into the 5th lumbar
space, causing anesthesia into the parts of the
body that come in contact with a saddle
(perineum, upper thighs and lower pelvis).
Blocks nerves that transmit pain of first stage
of labor. In sitting or side-lying position, with
back flexed.

 Forceps are generally needed in delivery of patient under

anesthesia because of loss of coordination in second-stage
pushing
 Postspinal headaches maybe due to leakage of anesthetic into
the CSF or injection of air at time of needle insertion.
Management : Flat on bed for 12 hours and increase fluid intake
  Common side-effects:
 Hypotension – because Xylocaine is a vasodilator.
Management : turn to side; prompt elevation of legs;
administration of vasopressor and oxygen, as ordered
 Fetal bradycardia
 Decreased maternal respirations
h. A sure sign that the baby is about to be born is the bulging of the
perineum. In general, primigravidas are transported from LR to the DR
when the cervix is fully dilated or when there is bulging of the perineum;
multiparas are transported at 7-8cm cervical dilatation.

B. Transition Period – when the mood of the woman suddenly changes and the
nature of the contractions intensify.
1. Characteristics :
a) If membranes are still intact, this period is marked by a
sudden gush of amniotic fluid as fetus is pushed into the
birth canal. If spontaneous rupture does not occur,
amniotomy (snipping of BOW with a sterile pointed
instrument e.g. Kelly or Allis forceps or amniohook to allow
amniotic fluid to drain), is done to prevent fetus from
aspirating the amniotic fluid as it makes its different fetal
position changes. Amniotomy, however cannot be if station
is still “minus” as this (can lead to cord compression).
b) Show becomes prominent.
c) There is an uncontrollable urge to push with contractions, a
sign of impending second stage of labor. Profuse
perspiration and distention of neck veins are seen.
d) Nausea and vomiting is a reflex reaction due to decreased
gastric motility and absorption.
e) In primis, baby is delivered within 20 contractions (=40
minutes); in multis, in 10 contractions (=20 mintues)

2. Nursing actions are primarily comfort measures:

a) Sacral pressure ( applying pressure with the heel of the hand
on the sacrum) relieves discomfort from contractions
b) Proper bearing down techniques: push with contractions
c) Controlled chest ( costal) breathing during contractions
d) Emotional support

C. Second Stage ( stage of Expulsion) – begins with complete dilatation of

the cervix and ends with delivery of the baby.
1. Power/forces : In voluntary uterine contractions and contractions
of the diaphragmatic and abdominal muscles
2. Mechanisms of Labor/ Fetal Position Changes : (D FIRE ERE)

a. Descent ( may be preceded by engagement)

 b. Flexion – as descant occurs, pressure from the pelvic floor
causes the chin to bend forward onto the chest
c. Internal Rotation – from AP to transverse, then AP to AP
d. Extension – as head comes out, the back of the neck stops
beneath the pubic arch. The head extends and the forehead,
nose, mouth and chin appear
e. External Rotation ( also called restitution - anterior shoulder
rotates externally to the AP position
f. Expulsion – delivery of the rest of the body

3. Nursing Care
a. When positioning legs or lithotomy, put them up at the same
time to prevent injury to the uterine ligaments
b. As soon as the fetal head crowns, instruct mother not to
push, but to pant instead ( rapid and shallow breathing) to
prevent rapid expulsion of the baby. If panting is deep and
rapid, called hyperventilation the patient will experience light-
headedness and tingling sensation of the fingers leading to
carpopedal spasms, because of respiratory alkalosis.
Management: let the patient breath into brown paper bag to
recover lost carbon dioxide; a cupped hand will serve the
same purpose.
c. Assist in episiotomy – incision made in the perineum
primarily to prevent lacerations.
Other purpose of episiotomy:
o Prevent prolonged and severe stretching of muscles
supporting bladder or rectum
o Reduce duration of second stage when there is
hypertension or fetal distress
o Enlarge outlet, as in breech presentation or forceps
delivery
Types of episiotomy:
o Median – from middle portion of the lower vaginal
border directed towards the anus
o Mediolateral – begun in the midline but directed
laterally away from the anus
Natural anesthesia is used in episiotomy, i.e., no
anesthetic is injected because pressure of fetal presenting
part against the perineum is so intense that nerve endings
for pain are momentarily deadened.
d. Apply the Modified Ritgen’s Maneuver:
Cover the anus with sterile towel and exert upward and
forward pressure on the fetal chin, while exerting gentle
pressure with two fingers on the head to control emerging
head. This will not only support the perineum, thus
preventing lacerations, but will also favor flexion so that the
 smallest sub-occipitobregmatic diameter of the fetal head
is presented.
Ease the head out and immediately wipe the nose and
mouth of secretions to establish and maintain a patent
airway (REMEMBER: the first principle in the care of the
newborn is establish and maintain a patent airway). (The
head should be delivered in between contractions.)
Insert 2 fingers into the vagina so as to feel for the
presence of a cord looped around the neck (nuchal cord).
If so, but loose, slip it down the shoulders or up over the
head; but if tight; clamp cord twice, an inch apart, and then
cut in between.
As the head rotates, deliver the anterior shoulder by
exerting a gentle downward push and then slowly give an
upward lift to deliver the posterior shoulder
While supporting the head and the neck, deliver the rest
of the body. Take note of the exact time of delivery of the
baby.
e. Immediately after delivery, newborn should be held below the
level of the mother’s vulva for a few minutes to encourage
flow of blood from the placenta to the baby.
f. The infant is held with his head in a dependent position (-head
lower than the rest of the body) to allow for drainage of
secretions. REMEMBER: Never stimulate a baby to cry
unless you have drained him out of his secretions first.
g. Wrap the bay in a sterile diaper to keep him warm.
REMEMBER: Chilling increases the body’s need for oxygen.
h. Put the bay on the mother’s abdomen. The weight of the
baby will help contract the uterus.
i. Cutting of the cord is postponed until the pulsations have
stopped because it is believe that 50 – 100 ml of blood is
flowing from the placenta to the baby at this time. After cord
pulsations have stopped, clamp it twice, an inch apart, and
then cut in between
j. Show the baby to the mother, inform her of the sex and time of
delivery then give the baby to the circulating nurse.

D. Third Stage (Placental Stage) – begins with the delivery of the baby and
ends with the delivery of the placenta.
1. Signs of placental separation:
a. Uterus becoming round and firm again, rising high to the level
of the umbilicus (Calkin’s sign) – the earliest sign of
placental separation
b. Sudden gush of blood from the vagina
c. Lengthening of the cord from the vagina
2. Types of placental delivery:
 a. Schultz – if placenta separates first at its center and last at
its edges, it tends to fold on itself like an umbrella and
presents the fetal surface which is shiny. 80% of placentas
separate in this manner (“Shiny” for Schultz)
b. Duncan – if placenta separates first at its edges, it slides
along the uterine surface and presents with the maternal
surface which is raw, red, beefy, irregular and “dirty”. Only
about 20% of placentas separate this way. (”Dirty” of
Duncan)
3. Nursing Care
a. Do not hurry the expulsion of the placenta by forcefully pulling
out the cord or doing vigorous fundal push as this can cause
uterine inversion. Just watch for the signs of placental
separation.
b. Tract the cord slowly, winding it around the clamp until
placenta spontaneously comes out, rotating it slowly so that
no membranes are left inside the uterus, a method called
Brandt-Andrews maneuver.
c. Take not of the time of placental delivery; it should be
delivered within 20 minutes after the delivery of the baby.
Otherwise, refer immediately to the doctor as this can cause
severe bleeding in the mother.
d. Inspect for completeness of cotyledons; any placental
fragment retained can also cause severe bleeding and
possible death
e. Palpate the uterus to determine degree of contraction. If
relaxed, boggy or non-contracted, first nursing action is to
massage gently and properly. An ice cap over the abdomen
will also help contract the uterus since cold causes
vasoconstriction.
f. Inject oxytocin (Methergin – 0.2. mg/ml or Syntocinon = 10
U/ml) – IM to maintain uterine contractions, thus prevent
hemorrhage. Note: oxytocins are not given before placental
delivery because placental entrapment can occur.
 Categories of lacerations (tend to heal more slowly
because of ragged edges):
o First degree – involves the vaginal mucous membranes
and skin
o Second degree – involves not only the vaginal mucous
membranes and skin, but also the muscles
o Third degree – involves not only the muscles, vaginal
mucous membranes and skin, but also the external
sphincter of the rectum
o Fourth degree – involves not only the external sphincter
of the rectum, the muscles, vaginal mucous
 membranes and skin, but also the mucous membranes
of the rectum
 Assist the doctor in doing episiorrhaphy (- repair of
episiotomy or lacerations). In vaginal episiorrhaphy,
packing is done to maintain pressure on the suture line,
thus prevent further bleeding. Note: Vaginal packs have to
be removed after 24 – 48 hours
g. Make mother comfortable by perineal care and applying clean
sanitary napkin snugly to prevent its moving forward from the
anus to the vagina. Soiled napkins should be removed from
front to back.
h. Position the newly-delivered mother flat on bed without pillows to
prevent dizziness due to decrease in intra-abdominal pressure.
i. The newly-delivered mother may suddenly complain of chills due
to the rapid decrease of pressure, fatigue or cold temperature in
the delivery room. Management: Provide additional blankets to
keep her warm.
j. May give initial nourishment, e.g., milk, coffee, or tea
k. Allow patient to sleep in order to regain lost energy

E. Fourth Stage – first 1 – 2 hours after delivery which is said to be the

most critical stage for the mother because of unstable vital signs.
1. Assessment:
a. Fundus – should be checked every 15 minutes for 1 hour then
every 30 minutes for the next 4 hours. Fundus should be firm,
in the midline and, during the first 12 hours postpartum, is a little
above the umbilicus. First nursing action for a non-contracted
uterus: massage.
b. Lochia – should be moderate in amount. Immediately after
delivery, a perineal pad can be completely saturated after 30
minutes.
c. Bladder – a full bladder is evidenced by a fundus which is to the
right of the midline, dark-red bleeding with some clots.
d. Perineum – is normally tender, discolored and edematous. It
should be clean, with intact sutures.
e. Blood pressure and pulse rate – may be slightly increased from
excitement and effort of delivery, but normalize within one hour.
2. Lactation-suppressing agents – estrogen-androgen preparation given
within the first hours postpartum to prevent breastmilk production in
mothers who will not (or cannot) breastfeed. E.g., diethylstilbestrol,
TACE or deladumone. These drugs tend to increase uterine bleeding
and retard menstrual return.
3. Rooming-in concept – mother and baby are together while in the
hospital. The concept of a family, therefore, is felt at the very
beginning because parents have the baby with them, thus providing
opportunities for developing a positive relationship between parents
 and newborn. Eye-to-eye contact is immediately established,
releasing maternal caretaking responses.

VII. Dystocia – bread term for abnormal or difficult labor and delivery.

A. Uterine Inertia – sluggishness of contractions.

1. Causes:
a. Inappropriate use of analgesics
b. Pelvic bone contraction
c. Poor fetal position
d. Overdistention – due to multiparity, multiple pregnancy,
polyhydramnios or excessively large fetus
2. Types:
a. Primary (hypertonic) Uterine Dysfunction relaxations are
inadequate and mild, this are ineffective. Since uterine
muscles are in a state of greater than normal tension, latest
phase of the first stage of labor is prolonged. Treatment:
secure the patient
b. Secondary (hypotonic) Uterine Dysfunction – contractions have
been good but gradually become infrequent and of poor
quality and dilatation steps. Treatment: stimulation of labor
either by oxytocin administration or amniotomy.

B. Precipitate Delivery – labor and delivery that is completed in less than 3

hours after the onset of true labor pains. Probably due to
multiparity or following oxytocin administration or
aminiotomy. Dangers imposed by precipitate delivery:
Extensive lacerations; abruptio placenta; or hemorrhage due
to sudden release of pressure, leading to shock.

C. Prolonged Labor – in primis, labor more than 18 hours and in multis,

more than 12 hours. Dangers: maternal exhaustion, uterine
atony or caput succedaneum.

D. Uterine Rupture – occurs when the uterus undergoes more strain that it
is capable of sustaining.
1. Causes:
a. Scar from a previous classic Cesarean Section (CS)
b. Unwise use of oxytocins
c. Overdistention
d. Faulty presentation or prolonged labor
2. Signs and symptoms:
a. Sudden, severe pain
b. Hemorrhage and clinical signs of shock (restlessness, pallor,
decreasing BP, increasing respiratory and pulse rates)
 c. Changing abdominal contour, with two swellings on the
abdomen, the retracted uterus and the extrauterine fetus
3. Management: hysterectomy

E. Uterine Inversion – fundus is forced through the cervix so that the uterus
is turned inside out
1. Causes:
a. Insertion of placenta at the fundus, so that as fetus is rapidly
delivered, especially if unsupported, the fundus is pulled down
b. Strong fundal push when mother fails to bear down properly
c. Attempts to deliver the placenta before signs of placental
separation appear.
2. Management: hysterectomy

F. Amniotic Fluid Embolism – occurs when amniotic fluid is forced into an

open maternal uterine blood sinus through some defect in the
membranes or after partial premature separation of the placenta. Solid
particles in the amniotic fluid enter the maternal circulation and reach the
lungs as emboli.
1. Signs and symptoms – are dramatic:
a. Woman in labor suddenly sits up and grasps her chest because
of inability to breathe and sharp pain
b. Turns pale and then the typical bluish-gray color associated with
pulmonary embolism
c. Death may occur in few minutes
2. Management:
a. Emergency measures to maintain life: IV, oxygen, CPR
b. Provide intensive care in the ICU
c. Keep family informed and provide emotional support

G. Trial Labor – if a woman has borderline (just adequate) pelvic

measurements but fetal position and presentation are good. Maybe
continued for as long as there is progressive fetal descent of the
presenting part and cervical dilatation.
1. Management:
a. Monitor FHRs and uterine contractions
b. Keep bladder empty to allow all available space to be used by
the fetus
c. Emotional support

H. Premature Labor and Delivery – if uterine contractions occur before the

38th week of gestation
1. If there is no bleeding and cervical dilatation and fetal heart sounds
are good, premature uterine contractions can be stopped by drugs:
 a. Ethyl alcohol (ethanol) IV – blocks the release of oxytocin. Side
effects: Nausea and vomiting, mental confusion, etc. (same side
effects when alcohol is taken orally in excessive amounts)
b. Vasodilan IV – a vasodilator. Side effects: hypotension and
tachycardia
c. Ritodrine – a muscle relaxant given orally
d. Bricanyl – a known bronchodilator
2. If premature uterine contractions are accompanied by progressive
fetal descent and cervical dilatation, premature delivery is inevitable.
a. Not necessarily shorter than full term labor
b. Pain medications are kept to a minimum because analgesics are
know to cause respiratory depression. As it is, premature
babies already have enough difficulty breathing on their own;
giving analgesics, therefore, would add up to the problem.
Implication: give emotional support to the mother such that she
focuses her attention not on her own need, but those of her
baby.
c. Steroids (glucocorticoids) are given to the mother to help in
maturation of fetal lungs by hastening production of surfactants.
d. Caudal, spinal or infiltration anesthesia is preferred because it
does not compromise fetal respiration.
e. Episiotomy may not necessarily be smaller than in full-term
deliveries; may even be larger so that the preemie can be
delivered the shortest possible time, since excessive pressure
on the fragile preemie’s had can cause subarachnoid
hemorrhage that could be fatal.
f. Forceps may be applied gently.
g. Cord is cut immediately, rather than waiting for pulsations to
stop, because preemies have difficult time excreting large
amount of bilirubin that will be formed from the extra amount of
blood.
PUERPERIUM

I. Definitions

A. Puerperium/Postpartum – refers to the six-week period after delivery of

the baby
B. Involution – the return of the reproductive organs to their prepregnant
state

II. Principles of Postpartum Care

A. Promote healing and return to normal (involution) of the different parts of

the body.
1. Vascular Changes
a. The 30 – 50% increase in total cardiac volume during pregnancy
will be reabsorbed into the general circulation within 5-10
minutes after placental delivery. Implication: the first 5-10
minutes after placental delivery is crucial to gravido-cardiacs
because the weak heart may not be able to handle such
workload.
b. White blood cell (WBC) count increases to 20,000-30,000/rm3.
Implication: WBC count, therefore, cannot be sued as an
indicator of postpartum infection.
c. There is extensive activation of the clotting factors, which
encourages thrombo-embolization. This is the reason why:
• Ambulation is done early – after 4-8 hours in normal vaginal
delivery. When ambulating the newly-delivered patient for the
first time, the nurse should hold on to the patient’s arm.
• Exercises are recommended:
• Kegel and abdominal breathing on postpartum day 1 (PPD
1)
• Chin-to-chest – on second day to tight on and firm up
abdominal muscles
• Knee-to-abdomen – when perineum has healed, to
strengthen abdominal and gluteal muscles.
• Massage is contraindicated
d. All blood values are back to prenatal levels by the third or fourth
week postpartum
2. Genital changes
a. Uterine involution is assessed by measuring the fundus by
fingerbreadths (= 1 cm). On PPD 1 – fundus is one
fingerbreadth below the umbilicus; on PPD 2, 2 fingerbreadths
below umbilicus and so forth until on the 10th day postpartum, it
can no longer be palpated because it is already behind the
symphysis pubis.
 • Subinvoluted uterus – a big uterus and vaginal bleeding with
clots. Since blood clots are good media for bacteria, it is,
therefore, a sign of puerperal sepsis.
b. To encourage return of the uterus to its usual anteflexed position,
prone and knee-chest positions are advised.
c. Afterpains/after birth pains – strong uterine contractions felt more
particularly by multis, those who delivered large babies or twins
and those who breastfeed.
• Management:
• NEVER apply heat on abdomen
• Give analgesics, as ordered
• Explain that it is normal and rarely lasts for more than 3
days
d. Lochia – uterine discharge consisting of blood, decidua, WBC
mucus and some bacteria
• Pattern:
• Rubra – first 3 days postpartum; red and moderate in
amount
• Serosa – next 4-9 days; pink or brownish and decreased in
amount
• Alba – from 10th day up to 3-6 weeks; colorless and minimal
in amount
• Characteristics:
• Pattern should not reverse
• It should approximate menstrual flow (However, it increases
with activity and decreases with breastfeeding)
• It should not have any offensive odor. It has the same
fleshy odor as menstrual blood. Otherwise, it means either
poor hygiene or infection
• It should not contain large clots
• It should never be absent, regardless of method of delivery.
Lochia has the same pattern and amount, whether CS or
normal vaginal delivery.
e. Pain in perineal region may be relieved by:
• Sim’s position – minimizes strain on the suture line
• Perineal heat lamp or warm Sitz baths twice a day –
vasodilatation increases blood supply and, therefore, promotes
healing
• Application of topical analgesics or administration of mild oral
analgesics, as ordered
f. Sexual activity – maybe resumed by the third or fourth week
postpartum if bleeding has stopped and episiorrhaphy has
haled. Decreased physiologic reactions to sexual stimulation
are expected for the first 3 months and emotional factors
 g. Menstruation – if not breastfeeding, return of menstrual flow is
expected within 8 weeks after delivery. If breastfeeding,
menstrual return is expected in 3-4 months; in some women, no
menstruation occurs during the entire lactation period
(IMPORTANT: Amenorrhea during lactation is no guarantee that
the woman will not become pregnant. She may be ovulating
and the absence of menstruation may be her body’s way of
conserving fluids for lactation. Implication: She should be
protected against a subsequent pregnancy by observing a
method of contraception but not the pill.)
h. Postpartum check-up – should be done after the 6th week
postpartum to assess involution.
3. Urinary changes
a. There is marked diuresis within 12 hours postpartum to eliminate
excess tissue fluid accumulation during pregnancy.
b. Some newly delivered mothers may complain of frequent
urination in small amounts; explain that it is due to urinary
retention with overflow. Others, on the other hand, may have
difficulty voiding because of decreased abdominal pressure or
trauma to the trigone of the bladder. Voiding maybe initiated by
pouring warm and cold water alternately over the vulva,
encouraging patient to go to the comfort room and let her listen
to the sound of running water. If these measures fail,
catheterization, done gently and aseptically, is the last resort on
doctor’s order. (If there is resistance to the catheter when it
reaches the internal sphincter, ask patient to breathe through
the mouth while rotating the catheter before moving it inward
again.)
4. Gastrointestinal changes – delayed bowel evacuation postpartally
may be due to:
a. Decrease muscle tone
b. Lack of food + enema during labor
c. Dehydration
d. Fear of pain from perineal tenderness due to episiotomy,
lacerations or hemorrhoids
5. Vital Signs
a. Temperature may increase because of the dehydrating effects of
labor. Implication: Any increase in body temperature during the
first 24 hours postpartum is not necessarily a sign of postpartum
infection.
b. Bradycardia ( = heart rate of 50-70 per minute) is common for 6-
8 days postpartum.
c. There is no change in respiratory rate.
6. Weight – there is an immediate weight loss of 10-12 lbs representing
the weights of the fetus, placenta, amniotic fluid and blood. Further
weight loss will occur during the next days due to diaphoresis.
 7. Psychologic phases

B. Provide emotional support – the psychological phases during the postpartum

period are:
1.Taking-in phase – first 1-2 days postpartum when mother is passive
and relies on others to care for her and her newborn. She keeps
on verbalizing her feelings regarding the recent delivery for her to
be able to integrate the experience into herself.
2. Taking-hold phase – begins to initiate action and make decisions.
Postpartum blues ( - an overwhelming feeling of sadness that
cannot be accounted for) may be observed. Could be due to
hormonal changes, fatigue or feelings of inadequacy in taking care
of a new baby. Management: Explain that it is normal and that
crying is therapeutic, in fact.

C. Prevent postpartum complications

1. Hemorrhage – blood loss of more than 500 cc. (normal blood loss
during labor and delivery is 250-350 cc); leading cause of maternal
mortality associated with childbearing

Table 7. Classification of Postpartum Hemorrhage

I. Early postpartum hemorrhage – occurs during he first 24 hours postpartum

A. Uterine Atony – uterus is not well contracted, relaxed or boggy; most
frequent cause
1. Predisposing factors:
a. Overdistention of the uterus – e.g., multiple pregnancy,
multiparity, excessively large baby, polyhydramnios
b. Cesarean section
c. Placental accidents (previa or abruptio)
d. Prolonged and difficult labor
2. Management:
a. Massage – first nursing action
b. Ice compress
c. Oxytocin administration
d. Emptying the bladder
e. Bimanual compression to explore retained placental fragments
f. Hysterectomy – last resort
B. Lacerations
C. Hypofibrinoginemia – a clotting defect

II. Late postpartum hemorrhage

A. Retained placental fragments – Management: dilatation and curettage
(D&C)
B. Hematoma – due injury to blood vessels during delivery
1. Incidence: Commonly seen in precipitate delivery and those with
perineal varicosities
2. Treatment:
a. Ice compress during the first 24 hours
b. Oral analgesic, as ordered
c. Site is incised and bleeding vessel is ligated

2. Infection
a. Sources:
• Endogenous (primary) sources – bacteria in the normal flora
become virulent when tissues are traumatized and general
resistance is lowered
• Exogenous sources – pathogens introduced from external
sources. Organism most frequently responsible for postpartum
infections: Anaerobic streptococci.
• Common exogenous sources:
• Hospital personnel
• Excessive obstetric manipulations
• Breaks in aseptic techniques – faulty hand washing,
unsterile equipments and supplies
• Coitus in late pregnancy
• Premature rupture of the membranes
b. General symptoms: malaise, anorexia, fever, chills and headache
c. General management: complete bed rest (CBR), proper nutrition,
increased fluid intake, analgesics, antipyretics and antibiotics, as
ordered
d. Types of infection:
A. Infection of the perineum
• Specific symptoms:
• Pain, heat and feeling of pressure in the perineum
• Inflammation of the suture line, with 1 or 2 stitches
sloughed off
• With or without elevated temperature
• Specific management:
• Doctor removes sutures to drain area and re-sutures
• Hot Sitz bath or warm compress
B. Endometritis – inflammation/infection of the lining of the
uterus
• Specific symptoms:
• Oxytocin
• Fowler’s position to drain out lochia and prevent pooling
of infected discharge
C. Thrombophlebitis – infection of the lining of a blood vessel
with formation of clots; usually an extension of endometritis
 • Specific symptoms:
• Pain, stiffness and redness in the affected part of the leg
• Leg beings to swell below the lesion because venous
circulation has been blocked
• Skin is stretched to a point to shiny whiteness, called
milk leg – phlegmasia alba dolens
• Positive Homan’s Sign – pain in the calf when the foot is
dorsiflexed
• Specific management:
• Bed rest with affected leg elevated
• Anticoagulants, e.g., Dicumarol or Heparin, to prevent
further clot formation or extension of a thrombus
Side effects: hematuria & increased lochia
• Considerations:
• Discontinue breastfeeding
• Monitor prothrombin time
• Always have Protamin sulfate or Vitamin at
bedside to counteract toxicity
• Analgesics are given but NEVER Aspirin because it
inhibits prothrombin formation; since patient is already
receiving an anticoagulant, bleeding may occur

D. Establish successful lactation

Table 8. Physiology of Breastmilk Production

DECREASED ESTROGEN AND PROGESTERONE levels after the

delivery of the placenta ---------------------stimulates anterior pituitary gland
to produce prolactin ------------------- acts on acinar cells to produce
foremilk -----------------stored in collecting tubules.

WHEN INFANT SUCKS ----------------- posterior pituitary gland is

stimulated to produce oxytocin --------------- causes contraction of smooth
muscles of collecting tubules ---------- milk ejected forward ---------------
LET-DOWN or MILK EJECTION REFLEX --------------hindmilk is
produced

1. Implications of physiology of breastmilk production:

a. Regardless of the mother’s physical condition, method of
delivery or breast size, condition, milk will be produced.
b. Lactation does not occur during pregnancy because estrogen
and progesterone are present and therefore, inhibit prolactin
production.
c. Lactation-suppressing agents are to be given immediately
after placental delivery to be effective
 d. Oral contraceptives are contraindicated in lactating mothers
because they decrease milk supply
e. After pains are felt more by breastfeeding women because of
oxytocin production; they also have less lochia and
experience more rapid involution
f. If emergency delivery when the uterus does not contract, put
the infant to the breast.
• During initial contact in emergency delivery, determine
whether the woman in labor is a primi or a multi, the EDC
and also assess the stage of labor. And if not sterile
equipment is available to cut the cord, wrap the baby and
the placenta together; never cut the cord unless sterile
equipments are available.
2. Advantages of breastfeeding
a. For mother:
• Economical in terms of time, money and effort
• More rapid involution
• Less incidence of cancer of the breast, according to some
studies
b. For the baby:
• Closer mother-infant relationship
• Contains antibodies that protect against common illnesses
• Less incidence of gastrointestinal diseases
• Always available at the right temperature
3. Health Teachings
a. Hygiene
• Wash breasts daily at bath or shower time
• Soap or alcohol should never be used on the breasts as
they tend to dry and crack the nipples and cause sore
nipples
• Wash hands before and after every feeding
• Insert clean OS squares or piece of cloth in the brassiere to
absorb moisture when there is considerable breast
discharge
b. Method – as suggested by the La Leche League
• Side-lying position with a pillow under the mother’s head
while holding the bulk of breast tissues way from the
infant’s nose
• Stimulate the baby to open his mouth to grasp the nipples
by means of the rooting reflex
• Infant should grasp not only the nipple but also the areola
for effective sucking motion. Effectiveness is ensured
when:
• The baby’s mouth parts “make well up” into the areola
 • The mother feels after pain as the baby sucks
• The other nipple flows with milk while baby is feeding on
the other breast
• To prevent nipples from becoming sore and cracked,
infant should be introduced to the beast gradually. The
baby should be fed for only 5 minutes at each beast at
each feeding on the first day, increasing the time at each
beast by 1 minute per day until the infant is nursing for
10 minutes at each breast each feeding, making a total
feeding time of twenty minutes per feeding.
• For continuous milk production, at each feeding, the
infant should be placed first on the breast he fed last in
the previous feeding. This ensures that each breast will
be completely emptied at every other feeding. If breasts
are completely emptied, they completely refill again; if
only half-emptied, will half-refill and after some time, will
become insufficient.
• To break away from the closed suction at the breast
after feeding, insert a clean finger in the corner of the
infant’s mouth to release the suction, then pull the chin
down. This also helps prevent sore nipples.
• Feed as often as the baby is hungry, especially during
the first few days, because he is receiving colostrums,
which is not very filling; however, it contains the only
group of substances that can never be replicated by any
artificial formula, the gamma globulins (antibodies).
• Advise the mother to learn how to relax during feedings
because tension prevents good let-down.
c. Engorgement – feeling of tension in the breasts during the
third postpartum day, sometimes accompanied by an
increase in temperature (- milk fever). The breasts become
full, feel tense and hot, with throbbing pain. It lasts for about
24 hours and is due to increased lymphatic and venous
circulation.
• Management:
• Advise use of firm-fitting brassiere for good support. It
will not only decrease the discomfort from breast
engorgement but also prevents contamination of the
nipples and the areolae.
• Cold compress is applied if mother does not intend to
breastfeed; warm compress is applied if she will
breastfeed
• Breast pump is not used more breast massage doe if
mother is not going to breastfeed, since either will only
stimulate milk production.
 • Sore nipples – are not contraindications to breastfeeding
• Management:
• Expose nipples to air by leaving bra unsnapped for 10 to
15 minutes after a feeding
• When normal air drying is not effective, exposure to a
20-watt bulb place 12-18 inches away will cause
vasodilatation, increase circulation and promote healing
• Do not use plastic liners that are found in some nursing
bras because they prevent air from circulating around
the breasts
• Use nipple shield
• Mastitis – inflammation of the breasts
• Symptoms:
• Localized pain, swelling and redness in breast tissues
• Lumps in the breast
• Milk becomes scanty
• Management:
• Antibiotics, as ordered
• Ice compress
• Proper breast support
• Discontinue breastfeeding in affected breast
d. Nutrition – lactating mothers should take 3000 calories daily and
should have larger amounts of proteins (=96 gms per day),
calcium, iron, Vitamins A, B, and C. Non-breastfeeding women
can have the same requirements as in pregnancy
e. Contraindications
• Drugs – oral contraceptives, atropine, anticoagulants,
antimetabolites, cathartics, tetracyclines. Insulin (diabetes,
therefore, is not contraindicated), epinephrine, most
antibiotics, antidiarrheal and antihistamines are generally not
contraindicated.
• Certain disease conditions, specifically tuberculosis because
of the close contact between mother and baby during
feeding. No TB germs, however, are every transmitted thru
breast milk.

E. Motivate use of family planning methods – the success of the family

planning program depends to a great extent on the motivation of both
husband and wife.
1. Physiological methods – the oral contraceptives.
a. Action: Suppresses the pituitary gland, thus inhibiting
ovulation.
b. Types:
 • Combined – estrogen and progesterone in the same
dosage each day for 20 days, starting on the fifth day of
the menstrual cycle, after which it is discontinued and
then resumed on the fifth day of the next menstrual
period.
• Sequential – estrogen alone for 15 days, then estrogen
and progesterone for 5 days.
• Mini-pill – taken continuously
c. Side effects – same complaints of pregnant women because
of estrogen and progesterone:
• Nausea and vomiting
• Headache and weight gain – both due to fluid retention
because of progesterone
• Breast tenderness
• Dizziness
• Breakthrough bleeding/spotting between periods
• Chloasma
d. Contraindications:
• Breastfeeding
• Certain diseases
• Thromboembolism – because there is increased
tendency towards clotting in the presence of estrogen
• Diabetes mellitus and liver disease – because estrogen
tends to interfere with carbohydrate metabolism
• Migraine; epilepsy; varicosities
• Cancer; renal disease; recent hepatitis
• Women who smoke more than 2 packs of cigarettes per
day
• Strong family history of heart attack
2. Mechanical methods
a. Intrauterine device (IUD)
• Specific action: Prevents implantation by setting up a
non-specific cell inflammatory reaction to the device
• Inserted during a menstruation to ensure that the woman
is not pregnant; septic abortion can result if she is
pregnant.
• Side effects:
• Increased menstrual flow
• Spotting or uterine cramps during the first 2 weeks
after insertion
• Increased risk of infection
 • When pregnancy occurs with the device in place, it need
not be removed since it stays outside the membranes,
and, therefore, will not in any way harm the fetus
b. Diaphragm
• Specific action: A circular rubber disc that fits over the
cervix and forma a barrier against the entrance of sperms
• Is initially inserted by a doctor who determines the depth
of the vagina
• May be coated with a spermicidal jelly or cream for double
protection
• Maybe washed with soap and water after use
• Sperms remain viable in the vagina for 6 hours, so
the device should be kept in place during such time,
but should not stay for more than 24 hours because
stasis of semen can lead to infection.
c. Condom
• Specific action: Sperms are deposited in the tip of the
rubber sheath placed over an erect penis prior to coitus.
Has the added potential of lessening the change of
contacting sexually-transmitted disease (STDs)
• Most common complaint of users: it interrupts the sexual
act to apply
3. Chemical methods – are spermicidals (kill sperms). E.g., jellies,
creams, foaming tablets, suppositories
4. Biological method – Rhythm/Calental/Ogino-Knause Formula
a. Specific action: the couple abstains on days that the woman
is fertile
b. Procedure
• The woman charts her menstrual cycles for 12 continuous
months in order to determine the shortest and the longest
cycles
• The first fertile day is determined by subtracting “18” from
the shortest menstrual cycle; the last fertile day is
determined by subtracting “11” from the longest menstrual
cycle.
• E.g., if a woman’s shortest menstrual cycle is 26 days
and her longest is 32 days,

26 32
- 18 - 11
8 21

her fertile period would be from the 8th to the 21st day
of her cycle, i.e., she should not have sexual intercourse
during these days
5. Natural Family Planning (NFF) – periods abstinence:
a. Cervical mucus/Billing method
• Basis: the flow of mucus from the cervix of the uterus
• Method: a woman can discern her fertile and infertile days
based on her sensory and visual observations of the
cervical mucus (when it becomes thin and watery –
spinnbarkeit), intercourse is avoided 4 days prior to and 3
days after the spinnbarkeit
b. Basal Body Temperature (BBT)
• Method: involves observing the temperature of the
woman at rest, free from any factor that may cause it to
fluctuate (immediately upon waking up, before doing
anything else). As soon as the temperature drops slightly
and then increases (which means ovulation has taken
place), she counts 3-4 days, after which sexual
intercourse may be resumed.
c. Sympto-Thermal method – fertile and infertile days are
determined after having established an accurate record of
the six immediately preceding menstrual cycles and then
watching out for BBT fluctuations.
6. Surgical methods
a. Tubal ligation – the Fallopian tubes are ligated in order to
prevent passage of sperms. Menstruation and ovulation
continue
b. Vasectomy – small incision made into each side of the
scrotum and the vas deferens is and cut and tied, blocking
passage of sperms. Sperm production continues, only
passage into the exterior is prevented. (Sperms in the vas
deferens at the time of surgery may remain viable for as long
as 6 months. Implication: couple should still observe a form
of contraception during this time to ensure protection against
a subsequent pregnancy.)
7. Social methods
a. Abstinence
b. Withdrawal or coitus interruptus
 RISK PREGNANCY

I. BLEEDING IN PREGNANCY

Table 9. Outline of Classification

I. First Trimester Bleeding

A. Abortion
1. Spontaneous
a. Threatened
b. Imminent
• Complete
• Incomplete
2. Induced
a. Therapeutic
b. Illegal
B. Ectopic Pregnancy
1. Tubal – most common
2. Cervical
3. Ovarian
4. Abdominal

II. Second Trimester Bleeding

A. Hydatidiform Mole
B. Incompetent Cervical Os

III. Third Trimester Bleeding

A. Placenta previa
B. Abruptio placenta

A. ABORTION – any interruption in pregnancy before the age of

viability.
1. Spontaneous – occurs from natural causes, blighted ovum/germ
plasma defect (most common cause – it is nature’s way of
eliminating the birth of a congenitally defective baby);
 implantation or hormonal abnormality; following trauma,
infection (e.g., rubella, influenza) or emotional problems
a. Threatened
• Symptom: bright red vaginal bleeding which is moderate
in amount
• Management:
• Complete bed rest for 24-48 hours; if bleeding will stop
it usually steps within this time
• Coitus is restricted for 2 weeks after bleeding has
stopped in order to prevent further bleeding or
infection
• Endocrine/hormonal therapy
• Advise patient to save all pads, clots and expelled
tissues
b. Imminent/inevitable
• Symptom: Bright red vaginal bleeding which is moderate
in amount and accompanied by uterine contractions and
cervical dilatation. Loss of the products of conception is
inevitable.
• Management: depends on whether it is
• Complete abortion – all products of conception are
expelled; bleeding is minimal and self-limiting. No
intervention is therefore needed.
• Incomplete abortion – part of the conceptus, usually
the fetus, is expelled, but membranes or placental
fragments are retained. D & C is indicated as
management.
c. Missed abortion – fetus dies in utero but is not expelled.
Usually discovered at a prenatal visit when fundic height is
measure and no increase is demonstrated or when
previously heard fetal heart tones are no longer present. In
2 weeks’ time, signs of abortion should occur; otherwise,
labor will have to be induced to prevent hypofibrinoginemia
or sepsis.
2. Induced – is never allowed in the Philippines
a. Therapeutic – performed by a doctor in a controlled hospital
or clinic setting for a medical or a legal reason. Also known
as medical, planned or legal abortion.
b. Illegal

B. ECTOPIC PREGNANCY – any gestation located outside the uterine

cavity.
1. Signs and symptoms – since the wall of the Fallopian tube is not
sufficiently elastic, it ruptures within the first 12 weeks of
gestation as it can no longer give way for the growing fetus:
 a. peri-umbilical colicky pain which mimics appendicitis (in
bleeding wherein there is no exit or egress of blood from the
body, pain is the outstanding symptom; this pain
differentiates ectopic pregnancy from abortion).
b. may radiate to shoulder & neck if internal bleeding reach
level of diaphragm
c. (+) xxxxxxxxx sign – xxxxxxxxxxxxxxxxx
d. Excruciating pain when cervix is moved on IE
e. Signs of shock: falling BP, tachycardia, lightheadedness
• Ruptured ectopic pregnancy is an emergency situation.
2. Diagnosis:
a. Pelvic exam-reveal adnexae or cul de sac mass/cul de sac
of Douglas
b. Culdocentesis-aspirate fluid
c. Culdotomy
d. Laparoscopy
e. D&C
3. Management:
a. Laparotomy – if Fallopian tube can still be repaired and
preserved, but the pregnancy has to be terminated
b. Salpingectomy + blood transfusion
c. Salphingo-oopherectomy
3. Nursing care – combat shock:
a. Elevate foot of the bed
b. Maintain body heat by hot water bottles and blankets

C. HYDATIDIFORM MOLE – developmental anomaly of the placenta

resulting in proliferation and degeneration of the chorionic villi
1. Incidence: it is the most common lesion anteceding
choriocarcinoma. It occurs most often in women:
a. From low socioeconomic backgrounds with low protein intake
b. Over 35 years and under 18 years of age
2. Signs and symptoms:
a. Because of rapid proliferation of placental tissues and,
therefore, high levels of HCG:
• Highly positive urine test for pregnancy (that is why a
positive pregnancy test cannot be considered a positive
sign of pregnancy)
• Nausea and vomiting is usually marked
• Rapid increase in fundic height
b. Toxemia signs and symptoms appear before the 24th week of
gestation
c. No fetal heart tones
d. Vaginal bleeding seen as clear, fluid-filled grape-sized
vesicles
4. Management:
 a. D & C to evacuate the mole
b. Prophylactic course of Methotrexate, the drug of choice for
choriocarcinoma
c. Urine testing for one year to find out if new villi are
developing. Contraceptives (but not the pills) have to used
to as not to confuse the results.

D. INCOMPETENT CERVICAL OS – cervix dilates prematurely. It is

the chief cause of habitual abortion (=3 or more consecutive
abortions)
1. Causes:
a. Congenital developmental factors
b. Endocrine factors
c. Trauma to the cervix
2. Signs and symptoms:
a. Presence of show and uterine contractions
b. Rupture of membrane
c. Painless cervical dilatation
3. Management: McDonal/Shirodkar-Barter procedure – a
cerclage procedure wherein purse-string sutures are place
around the cervix on the 14th-18th week of gestation. These
are removed during vaginal delivery (if McDonald’s method,
since sutures are temporary), or the patient delivers by
Cesarean section (if Shirodkar method, since sutures are
permanent).

E. PLACENTA PREVIA – low implantation of the placenta so that it is in

the way of the presenting part.
1. Predisposing factors:
a. Increasing parity
b. Advanced maternal age
c. Rapid succession of pregnancies
2. Types:
a. Low lying
b. Partial
c. Complete
3. Diagnosis – made by means of symptoms and ultrasound –
also known as Ultrasonic Echo Sounding or Sonar, uses
intermittent waves of very high frequency (above audible
range) to “picture the fetus”. Sound waves are projected
towards the mother’s abdomen, are reflected back and
converted into electrical impulses and recorded on a
permanent graph paper.
a. Preparation:
• Explain the procedure to the patient, informing her that it
is painless and there are no known ill effects
 • Empty the bladder BUT ask the patient to take 6 glasses
of water afterwards in order to dilate the bladder. A full
bladder displaces the bowel and, therefore, permits better
visualization of the pelvis and its contents.
b. Clinical uses:
• Diagnose pregnancy as early as 5-6 weeks gestational
age
• Can establish that the fetus is increasing in size and,
therefore, can predict EDC
• Can determine gestational age by measuring the
biparietal diameter of the fetal skill (if it is more than 8.5
cm, it more or less weighs more than 2500 gms);
therefore, can diagnose intrauterine growth retardation,
hydrocephaly, microcephaly and anencephaly
• Can demonstrate size and growth rate of the amniotic
sac; therefore, can identify polyhydramnic,
oligohydramnios
• Can confirm presence, size and location of the placenta;
therefore, is valuable in diagnosing previa and H-mole
• Can diagnose multiple pregnancy
• Can visualize ascites, polycystic kidneys, ovarian cysts,
etc.
• Can determine baby’s sex (during third trimester and if in
cephalic presentation)
4. First and most constant symptom: painless bright red vaginal
bleeding due to tearing of placental attachment as a
consequence of the dilatation of the internal os
5. Management:
a. Complete bed rest
b. Monitor vital signs of the mother and the fetal heart rate
c. Prepare oxygen and blood
d. No attempt is made at doing internal exam. If ever it is to be
done, it is done in a double set-up (done in the operating
room wherein the patient has already signed the consent
form, preop medications have been given, abdominal prep
has been done, etc., so that if the placenta is accidentally
detached because of the IE, CS can be done immediately).
6. Complications:
a. Hemorrhage
b. Infection
c. Prematurity

F. ABRUPTIO PLACENTA – premature separation of the placenta.

1. Predisposing factors:
a. Maternal hypertension or toxemia
 b. Increasing parity and maternal age
c. Sudden release of amniotic fluid
d. Short umbilical cord
e. Hypofibrinoginemia
2. Signs and symptoms:
a. Severe, sharp, knife-like, stabbing pain high in the fundus
b. Hard, beardlike uterus; rigid abdomen
c. Signs of shock
d. Concealed bleeding, if extensive, causes the uterus to lose its
ability to contract. It becomes ecchymotic and copper-
colored, called Couvelaire uterus, causing severe bleeding.
Since the uterus no longer has the ability to contract,
hysterectomy will have to be done.

II. TOXEMIA/PREGNANCY-INDUCED HYPERTENSION (PIH) – a vascular

disease of unknown cause which occurs anytime after the 24th week of
gestation up to 2 weeks post-partum. It has the following triad of
symptoms: hypertension, edema and proteinuria (specifically albuminuria).
A. Predisposing factors:
1. Age – primis under 20 and over 30 years
2. Gravida – 5 or more pregnancies
3. Low socioeconomic status (SES)
4. Multiple pregnancy
5. With underlying medical conditions, e.g., heart disease,
hypertension or diabetes.
B. Pathogenesis:
C. Diagnosis: roll-over test – assess the probability of developing
toxemia when performed between the 28th and 32nd week
of pregnancy.
1. Procedure:
a. Patient lies in lateral recumbent position for 15 minutes until
BP has stabilized
b. Then rolls over to back position
c. BP is taken at 1 minute and 5 minutes after having rolled
over.
2. Interpretation: if diastolic increases 20 mm Hg, or more, patient
is prone to toxemia.

Table 10. Classification

I. Acute toxemia – symptoms appear after 24th week of gestation

A. Preeclampsia:
1. Mild
2. Severe
B. Eclampsia
II. Chronic Hypertension with pregnancy
 III. Unclassified

D. Details:
1. Preeclampsia
a. Underlying causes:
• Insufficient production of blood and platelets
• Generalized vasoconstriction and associated
microangiopathy (-disease of capillaries)
• Abnormal retention of sodium and water by body tissues
b. Medical complications:
• Cerebrovascular hemorrhage
• Acute pulmonary edema
• Acute renal failure
c. Types:
• Mild preeclampsia
• Signs and symptoms:
• Sudden, excessive weight gain of 1-5 lbs per week
(earliest sing of preeclampsia) due to edema which is
persistent and found in the upper half of the body (e.g.,
inability to wear the wedding ring)
• Systolic BP of 140, or an increase of 30 mmHg, or
more and a diastolic of 90, or a rise of 15 mmHg or
more, taken twice, 6 hours apart
• Proteinuria of 0.5 gm/liter or more
• Severe preeclampsia
• Signs and symptoms
• BP of 160/110 mmHg
• Proteinuria of 5 gm/liter or more in 24 hours
• Oliguria of 400 ml or less in 24 hours (normal urine
output in 24 hours = 1560 ml)
• Cerebral or visual disturbances
• Pulmonary edema and cyanosis
• Epigastric pain (considered an aura to the
development of convulsions)
• Anarsavea/pitting edema; dependent type
• Headache
• Blurred vision
• Oliguria
• Epigastric pain (Aura)
2. Eclampsia – the main difference between preeclampsia and
eclampsia is the presence of convulsions in eclampsia.
a. Signs and symptoms – as in preeclampsia plus:
• Increased BUN
 • Increased uric acid
• Decreased CO2 combining power

E. Management:
1. Complete bed rest – sodium tends to be excreted at a more
rapid rate if the patient is at rest. Energy conservation is
important in decreasing metabolic rate to minimize demands
for oxygen. Lowered oxygen tension in toxemia is the result
of vasoconstriction and decreased blood flow that diminishes
the amount of nutrients and oxygen in the cells. In any
condition wherein there is a possibility of convulsions, bed
rest should be in a darkened, non-stimulating environment
with minimal handling.
2. Diet:
a. For mile preeclampsia – high protein, high carbohydrate,
moderate salt restriction (no added table salt, (including
“bagoong”, “patis” and “toyo”), dired fish (e.g., “daing” and
“tuyo”), canned goods, bottled drinks, preserved foods and
cold cuts)
b. For severe preeclampsia – highprotein, high carbohydrate
and salt-poor (3 gms of salt per day)
3. Medications:
a. Diuretics – hourly urine output should be at least 20-30 ml
(normally 50-60 ml per hour). E.g.,
chlorothiazide/Diuril.
• Pharmacologic effect: decrease reabsorption of sodium
and chloride at the proximal tubules, thereby increasing
renal excretion of sodium, chloride and water, including
potassium.
• Side effects: fatigue and muscle weakness due to fluid
and electrolyte imbalance
• Nursing care: closely monitor intake and output
b. Digitalis – if with heart failure
• Pharmacologic action: Increase the force and contraction
of the heart, thereby decreasing heart rate. Should not be
given, therefore, if heart rate is below 60/minute.
(Implication: take the heart rate before giving the drug.)
c. Potassium supplements – any patient receiving diuretics are
prone to hypokalemia; if digitalis is given at the same time,
hypokalemia increases the sensitivity of the patient to the
effects of digitalis. Potassium supplements (e.g. banana)
must be given to prevent cardiac arrhythmias.
d. Barbiturates – sedation by means of CNS depression
e. Analgesics: antihypertensives; antibiotics; anticonvulsants
f. Magnesium sulfate – drug of choice
• Actions:
 • CNS depressant – lessens possibility of convulsions
• Vasodilator – decreases the BP
• Cathartic – it reduces edema by causing a shift of fluid
from the extracellular spaces into the intestines from
where the fluid can be excreted
• Dosage: 10 Gms initially, either by slow IV push over 5-10
minutes, or deep IM, 5 Gms/buttock; then IV drip of 1
Gm/hour (1 GM/100 ml D1 xxxxx) IF:
• Deep tendon reflexes are present
• Respiratory rate is at least 12 per minute
• Urine output is at least 100 ml
• Antidote for Magnesium sulfate toxicity: Calcium gluconate
10% IV to maintain cardiac and vascular tone
• Earliest sing of Magnesium sulfate toxicity: disappearance
of the knee jerk/patellar reflex
4. Methods of Delivery – preferably vaginal, but it not possible, CS
will have to be done
F. Prognosis: the danger of convulsions is present until 48 hours
postpartum.

III. DIABETES MELLITUS – chronic hereditary disease which is

characterized by hyperglycemia due to a relative insufficiency or lack
of insulin from the pancreas which, in turn, leads to abnormalities in the
metabolism of carbohydrates, proteins and fats.
A. Diabetogenic effects of pregnancy – many women who had no
evidence of diabetes in the past develop abnormalities in glucose
tolerance:
1. Decreased renal threshold for sugar that is why it is not unusual
to find sugar in the urine of pregnant women
2. Increased production of adrenocorticoids, anterior pituitary
hormones and thyroxins which affect carbohydrate and lipoid
metabolism, thus increasing carbohydrate concentration in the
blood (- hyperglycemia).
3. Rate of insulin secretion is increased BUT sensitivity of the
pregnant body to insulin is decreased, i.e., insulin does not
seem to be normally effective during pregnancy.
B. Attendant risks:
1. Toxemia
2. Infection
3. Hemorrhage
4. Polyhydramnios
5. Spontaneous abortion – because of vascular complication which
affect placental circulation
6. Acidosis – because of nausea and vomiting. Is the chief threat
to the fetus in utero.
 7. Dystocia – due to excessively large baby
C. Diagnosis – made on the basis of the Glucose Tolerance Test
1. Procedure:
a. NPO after midnight
b. 2 ml of 50% glucose/3 kg of pre-pregnant body weight is
given IV (oral tablet not advisable because of known
decreased gastric motility and delayed absorption of sugar
during pregnancy)
2. Interpretation of results:
a. If less than 100 mg – normal
b. If 100-120 mg% - possible gestational diabetes
c. If more than 120 mg% - overt gestational diabetes
D. Categories – to predict the outcome of pregnancy
1. Class A – GTT is only slightly abnormal; minimal dietary
restriction; insulin not needed; fetal survival is high
2. Class C to E – have 25 % prenatal mortality
3. Class F – therapeutic abortion (in other countries) may be
justified
E. Management:
1. Diet – highly individualized. Adequate glucose intake (1800-
2200 calories) is necessary to prevent intrauterine growth
retardation
2. Insulin requirements are likewise highly individualized, requiring
close observation throughout pregnancy. Since the effects of
the hormones are more pronounced during the second half of
pregnancy, the insulin requirements during the 2nd and 3rd
trimesters are, therefore, greater.
a. Insulin is regulated to keep urine +1 for sugar (minimal)
glycosuria is necessary to prevent acidosis, but negative for
acetone
b. Long-acting insulin (Ultralente) will have to be change to
regular insulin (Lente) during the last few weeks of
pregnancy.
3. Often delivered by CS because:
a. Baby is typically larger or maybe in distress because of
placental insufficiency
b. Severe metabolic imbalances in vaginal delivery can occur
because of depletion of glycogen reserved in the liver and
skeletal muscles by strenuous muscular exertion during
labor
4. Maximum difficulty in controlling diabetes is during the early
postpartum period because of the drastic changes in hormonal
levels.
F. Infant of the Diabetic Mother (IDM)
1. Is typically longer and weighs more because of:
a. Excessive supply of glucose from the mother
 b. Increased production of growth hormones from the maternal
pituitary
c. Increased secretion of insulin from the fetal pancreas
d. Increased action of adrenocortical hormones that favor
passage of glucose from mother to fetus
2. Congenital anomalies are more often seen
3. Cushingoid appearance (puffy, but limp and lethargic)
4. More often born premature, so respiratory distress syndrome is
common
5. Lose a greater proportion of weight than normal newborns
because of loss of extra fluid
6. Are prone to the following complications:
a. Hypoglycemia – blood sugar level less than 30 mgs. It is the
most common complication to watch for
• Cause: while inside the uterus, the fetus tends to be
hyperglycemic because of maternal hyperglycemia. The
fetal pancreas thus responds to the high glucose level of
insulin. Following delivery, the glucose level begins to fall
because the baby has been severed from the mother.
Since there has been previous production of high levels of
insulin, hypoglycemia develops.
• Clinical signs:
• Shrill, high-pitched cry
• Listlessness/jitterness/tremors
• Lethargy; poor suck
• Apnea; cyanosis
• Hypotonia; hypothermia
• Convulsions
• Consequence: hypoglycemia, if not treated, can lead to
brain damage and even death
• Management: feed with glucose water earlier than usual
or administer IV of glucose
b. Hypocalcemia – serum calcium level of less 7 mg%.
• Signs: same as hypelycemia
• Management: Calcium gluconate to prevent
hypocalcemic tetany

IV. HEART DISEASE

A. Classification:
1. Class I – no limitation of physical activity
2. Class II – slight limitation of physical activity; ordinary activity
causes fatigue, palpitation, dyspnea or angina
3. Class III – moderate to marked limitation of physical activity; less
than ordinary activity causes fatigue, etc.
 4. Class IV – unable to carry on any activity without experiencing
discomfort
B. Prognosis:
1. Class I and II – normal pregnancy and delivery
2. Class III and IV – poor candidates
C. Signs and symptoms:
1. Because of increased total cardiac volume during pregnancy,
heart murmurs are observed.
2. Cardiac output may become so decreased that vital organs are
not perfused adequately; oxygen and nutritional requirements
are not met.
3. Since the left side of the heart is not able to empty the
pulmonary vessels adequately, the latter become engorged,
causing pulmonary edema and hypertension. Moist cough in
gravidocardiacs, therefore, is a danger sign.
4. Liver and the other organs become congested because blood
returning to the heart may not be handled adequately, causing
the venous pressure to rise. Fluid then escapes through the
walls of engorged capillaries and cause edema or ascites.
5. Congestive heart failure is a high probability also because of the
increased cardiac output during pregnancy: dyspnea,
exhaustion, edema, pulse irregularities, chest pain on exertion
and cyanosis of nailbeds are obvious
D. Management:
1. Bed rest – especially after the 30th week of gestation to ensure
that pregnancy is carried to term or at least 36 weeks
2. Diet – should gain enough, but not to much as it would add to
the workload of the heart
3. Medications:
a. Digitalis
b. Iron preparations, e.g., Fer-in-sol or Feosol – anemia should
be prevented because the body compensates by increasing
cardiac output, thus further increasing cardiac workload.
4. Classes III and IV are not put on lithotomy position during
delivery to avoid increasing venous return. The semi-sitting
position is preferred to facilitate easy respirations.
5. Anesthetic of choice is caudal anesthesia for effortless, pushless
and painless delivery. Remember: Gravidocardiacs are not
allowed to push with contractions (to prevent Valsalva maneuver
which increase venous return to an already weak, damaged
heart). Low forceps, therefore, is the best method of delivery.
6. Ergotrate and other oxytocics, scopolamine, diethylstilbestrol
and oral contraceptives are contraindicated because they cause
fluid retention and promote thromboembolization.
7. Most critical period – the period immediately foll0owing delivery
because the 30%-50% increase in blood volume during
 pregnancy will be reabsorbed into the mother’s circulation in a
matter of 5-10 minutes and the weak heart must make rapid
adjustment to this change.

VI. MULTIPLE PREGNANCY (Twin Pregnancy)

A. Classification:
1. Monozygotic/Identical – twins begin with a single ovum and
sperm, but in the process of fusion or in one of the first cell
divisions, the zygote divides into two identical individuals.
a. Characteristics:
• Always of the same sex
• With 2 amnions, 2 chorion, 2 umbilical cords and 2
placentas fused as one
b. Incidence – a chance occurrence:
• More frequent among non-whites
• More frequent among young primis and old multis
2. Dizygotic/Fraternal – two separate ova are fertilized by 2
different sperms. They are actually siblings growing at the
same time in utero
a. Characteristics:
• May or may not be of the same sex
• With 2 amnions, 2 chorions, 2 placentas, and 2 umbilical
cords
b. Incidence – familial maternal patterns of inheritance

B. Suspect multiple pregnancy if:

1. Faster rate of increase uterine size
2. On quickening, there are several flurries of action in different
abdominal positions
3. On auscultation, 2 sets of fetal heart tones are heard
4. There is marked weight gain, not due to toxemia or obesity

C. Compications:
1. Toxemia
2. Polyhydramnios
3. Anemia
4. Abruptic placenta
5. Prematurity
6. Postpartum hemorrhage

VII. INSTRUMENTAL DELIVERIES

A. Forceps Delivery – use of metal instruments (e.g., Simpson, Elliot,
Piper for breech presentation) in order to extract the fetus
from the birth canal. Forceps are applied when the fetal
head is at the perineum (+3 or +4station) and the sagittal
 suture line is in an anteroposterior position in relation to the
outlet.
1. Purposes:
a. Shorten second stage of labor – primary purpose because of:
• Fetal distress
• Maternal exhaustion
• Maternal disease – cardiac, pulmonary complications,
hemorrhage
• Ineffective pushing due to anesthesia
b. Prevent excessive pounding of fetal head against the
perineum (e.g., low forceps for preemies)
c. Poor uterine contractions or rigid perineum
2. Prerequisites: prolonged and severe stretching
a. Pelvic xxxxxxxxxxxxxxxxxxxxxxxxxxx
b. xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
c. xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
d. Membranes have ruptured
e. Vertical presentation has been established
f. Rectum and bladder are empty
g. Anesthesia is given for sufficient perineal relaxation and to
prevent pain
3. Types:
a. Low
b. Mid
4. Complications:
a. Forceps marks –are normal and noticeable only for 24-48
hours
b. Bladder or rectal injury, facial paralysis, ptosis, seizures,
epilepsy, cerebral palsy are actually rare
B. Cesarean Section (CS)
1. Indications:
a. Cephalopelvic disproportion (CPD) – most common reason
b. Severe toxemia, placental accidents, fetal distress
c. Previous classic CS – selective CS – done prior to onset of
labor pains
2. Types:
a. Low segment – the method of choice. Incision is made in the
lower uterine segment which is the thinnest and most
passive part during active labor.
• Advantages:
• Minimal blood loss
• Incision is easier to repair
• Lower incidence of postpartum infection
• No possibility of uterine rupture
b. Classic – vertical incision. Recommended in:
 • Bladder or lower uterine segment adhesions resulting
from previous operations
• Anterior placenta previa
• Transverse lie
3. Preoperative care – patient for CS is both a surgical and an
obstetrical patient:
a. Check vital signs, uterine contractions and fetal heart rate
b. Physical examination; routine laboratory tests, blood typing
and cross-matching
c. Abdominal is shaved from the level of the xiphoid
process/below the nipple line, extending out to the flanks on
both sides up to the upper thirds of the thighs.
d. Retention catheter is inserted to constant drainage to keep
the bladder away from the operative site.
e. Preoperative medication is usually only Atropine sulfate. No
narcotics are given in order to prevent respiratory depression
in the newborn.
4. Postoperative care:
a. Deep breathing, coughing exercises; turning from side to side
b. Ambulate after 12 hours
c. Monitor vital signs
d. Watch for signs of hemorrhage – inspect lochia; feel fundus
(when boggy, massage with proper abdominal splinting and
give analgesics as ordered).
e. Breastfeeding, if desired, should be started 24 hours after
delivery (anestheti9c can be transmitted through breastmilk)
5. Most common complication: pelvic thrombosis

VIII. INDUCED LABOR – to bring out labor either by amniotomy or drugs

(oxytocin or prostaglandins) before the time when it would
have occurred spontaneously or because it does not occur
spontaneously.
A. Indications:
1. Maternal
a. Toxemia
b. Placental accidents
c. Premature rupture of the BOW
2. Fetal
a. Diabetes – terminated about 37 weeks GA if indicated
b. Blood incompatibility with rising titer
c. Excessive size
d. Postmaturity
B. Prerequisites:
1. No CPD
2. Fetus is viable – survival is decreased if below 32 weeks CA
3. Single fetus is longitudinal lie and is engaged
 4. Ripe cervix – fully or partially effaced; dilated at least 1 – 2 cm
C. Procedure
1. Oxytocin administration:
a. 10 IU of Pitocin in 1000 ml of D5W at a slow rate of 8
gtts/minute given initially. If no fetal distress is observed in
30 minutes, infusion rate is increased 16-20 drops per
minute.
b. Amniotomy will be done when cervical dilatation reaches 4
cm. Check FHR and quality of fluid after amniotomy.
c. Nursing care
• Primary concern: monitor intensity of uterine contractions.
Remember: if uterine contractions are unduly sustained
uterine rupture can occur.
• Monitor flow rate regularly
• Turn off IV drip if with abnormalities in FHR or uterine
contractions
• Watch out for:
• Hypertension – oxytocin is a vasoconstrictor
• Antidiuresis leading to water intoxication
• Headache and vomiting
• Convulsions, coma, even death
2. Prostaglandin administration:
a. Route: Either oral or IV, never IM, because it causes tissue
irritation
b. Effect: compared to oxytocin, the onset of contraction is
slower.

IX. INFECTIONS
A. Syphilis
1. Cause: Treponema pallidum – a spirochete which enters the
body during coitus or through cuts and other breaks in
the skin or mucous membrane.
2. Treatment: 2.4 – 4.8 million units of Penicillin (if allergic, 30 – 40
gms. of erythrocin) will usually prevent congenital syphilis in the
newborn because Penicillin readily crosses the placenta. If
untreated, syphilis can cause midtrimester abortion, CNS
lesions in the newborn or even death.
3. The newborn with congenital syphilis
a. Signs and symptoms:
• Jaundice at 2 weeks of life – first signs of the disease
• Anemia and hepatosplonomegaly
• “snuffles” (persistent rhinorrhea); coppery rashes on plams
and soles; mucous patches; condylomas; pseudoparalysis
due to bone inflammation
 • If untreated, can progress on to deformed bones, teeth,
nose, joints and CNS syphilis
b. Management: Penicillin IM for 10 days or one long-acting
Penicillin (Penadur LA)

B. Rubella/German Measles
1. Incidence:
a. Mother – the earlier the mother contacted the disease, the
greater the likelihood that the baby will be affected. The
rubella virus slows down division of infected cells during
organogenesis.
b. Newborn – can carry and transmit the virus for as long as 12-
24 months after birth
2. Signs and symptoms of Congenital Rubella Syndrome:
a. Low birth weight; jaundice; petechiae; anemia;
thrombocytopenia; hepatosplenomegaly
b. Classes sequelae;
• Eyes: choricretinitis, cataract, glaucoma
• Heart: Patent Ductus arteriosus, stenosis, coarctations
• Xxxx nerve deafness
• Dental and facial clefts

X. BLOOD INCOMPATIBILITY – excessive destruction of fetal red blood

cells which occurs when the:
A. Mother is Rh negative and the fetus is Rh positive (because the
father is either a homozygous or a heterozygous Rh positive)
B. Mother is Type O and the fetus is either Type A or Type B (because
the father is either Type A or B)

XI. MISCELLANEOUS RISK FACTORS

A. Age – maternal and infant mortality rates tend to be high in cases in
which the mother is younger than 15 or older than 40.
1. Adolescent pregnancy – is a high-risk pregnancy from both a
physical and a psychosocial standpoint. Physical, because of
rapid growth of both the pregnant adolescent and her fetus,
causing possible depletion of nutritional reserves.
Psychosocial, because adolescence is a crisis period by itself,
compounded by the situational crisis of pregnancy, plus the fact
that most pregnant adolescents are unwed adolescents.
a. Most common problems of pregnant adolescents:
• Toxemia
• Iron-deficiency anemia
2. Advanced age – is a precipitating factor in:
a. Placental accidents
b. Toxemia
c. Uterine atony or inertia
 d. Varicosities; hemorrhoids
e. Low birth weight babies
f. Chromosomal abnormalities, e.g., Down’s syndrome/Trisomy
21/Mongolism, commonly associated with menopause:
• Mechanism – a transitional phase, called the elimacterie,
heralds the onset of menopause. During this 1-2 year
period, the monthly menstrual flow occurs less frequently,
is irregular and diminished in amount. Ovulatory and an-
ovulatory periods, however, occur (that is why
contraceptive methods are advised until the menses have
been absent for at least six continuous months). After
there have been periods for one year, menopause is said
to have occurred.
• Classic signs:
• Vasomotor changes due to hormonal imbalances:
• Hot flushes (head, neck, upper thorax)
• Excessive sweating especially at night
• Emotional changes – insomnia, headache,
palpitations, nervousness, apprehension, depression
• Tendency to gain weight more rapidly
• Tendency to lose height because of osteoporosis
(“dowager hump”)
• Arthralgias and muscle pains
• Loss of skin elasticity and subcutaneous fat in labial
folds
• Artificial menopause/surgically-induced menopause –
results from:
• Ocphorectomy or irradiation of ovaries
• Panhysterectomy (more hysterectomy will not lead
to menopause since ovaries are still intact; only
menstruation will be absent)
B. Parity – first pregnancy is the period of highest risk. Risk increases
steadily from gravida 5 and above, especially when the mother is
over 40 years of age.
C. Birth interval – a subsequent pregnancy within 3 months of a
previous delivery is high risk, as much as a birth interval of more
than 5 years.
D. Weight
1. A pre-pregnant weight of less than 70 lbs or more than 180 lbs is
a risk factor
2. A weight gain during pregnancy of less than 10 lbs can lead to
low birth weight babies, prematurity, abortion, stillbirth and
toxemia. A weight gain of more than 30 lbs during pregnancy
maybe a sign of toxemia, diabetes, poly-hydramnios, H-mole or
multiple pregnancy.
 E. Height – a primi of short stature (less than 4 feet, 10 inches) could
mean a contracted pelvis or cephalopelvic disproportion.

THE NEONATES

DEFINITION: The first 28 days of life.

PRINCIPLES OF NEWBORN CARE

I. Establish and maintain patent airway.

A. Never stimulate a baby to cry unless secretions have been drained
out.
B. The position should be one that promotes drainage of secretions
(head lower than the rest of the body) EXCEPT when there are signs
of increased intracranial pressure (vomiting: bulging, tense
fontanelles; abnormally large head; increased BP, decreased PR and
RR and widening pulse pressure; shrill, high pitched cry), in which
case, the head should be higher than the rest of the body.
C. Suction the newborn properly:
1. Turn the baby’s head to one side
2. Suction gently and quickly – prolonged and deep suctioning of
the nasopharynx during the first 5-10 minutes of life will
stimulate the vagus nerve (located in the esophagus) and cause
bradycardia.
3. Suction the mouth first before the nose – when suctioning the
nose, the stimulation of the nasal mucosa will cause reflex
inhalation of pharyngeal material into the trachea and bronchi,
causing aspiration.
 4. To test for patency of the airway, occlude one nostril at a time
(REMEMBER: Newborns are nasal breathers). If the newborn
struggles when a nostril has been occluded, additional
suctioning is indicated.

II. Maintain appropriate body temperature. Chilling will increase the

body’s need for oxygen. The newborn suffers large losses of heat (cold
stress) because he is wet at birth, the delivery room is cold, he does not
have enough adipose tissues and does not know how to shiver. Effect of
cold stress:
• Metabolic acidosis – one of the ways by which heat is produced in the
newborn is by increasing metabolism. When this occurs, fatty acids
accumulate because of the breakdown of brown fat (seen only in
newborns).
• Hypoglycemia – due to the use of glucose stored as glycogen
A. Dry the newborn immediately
B. Wrap him warmly
C. Put him under a droplight

III. Immediate assessment of the newborn

A. Apgar score – standardized evaluation of the newborn’s condition.
Done at one minute after birth to determine the
general condition and then at 5 minutes to determine
how well the newborn is adjusting to extra uterine life.

Table 11. Apgar Score

SIGN 0 1 2

1. Hear rate * Absent 100 100

2. Respiratory effort Absent Weak cry Good, strong cry
3. Muscle tone ** Limp, flaccid Some flexion of extremities Well-flexed extremities
4. Reflex No response Grimace; weak cry Sneeze; good strong cry
5. Color Pale, blue Extremities blue, body pink Pink all over

* Most critical observation

** The general attitudes of the baby at birth is that of flexion

1. Interpretation of results:
a. 0 – 3 - the baby is in serious danger and needs immediate
resuscitation
b. 4 – 6 - condition is guarded and may need more extensive
clearing of the airway
c. 7 – 10 - baby is in the best possible health
 B. Assessment of gestational age
1. Methods of estimating gestational age:
a. Mother’s LMP (Naegele’s Rule)
b. Fundic height (McDonald’s method)
c. Bartholomew’s rule
d. Time quickening is first felt
e. Time fetal heart tones are first heard
f. Ultrasound
g. Assessment of newborn at birth

Table 12. Clinical Criteria for Gestational Age Assessment

SIGN Till 36 weeks 37 – 38 weeks 39 weeks

1. Sole creases Anterior transverse Occasional creases, Sole covered with creases
crease only anterior two-thirds
2. Breast nodule diameter 2 mm 4 mm 7 mm

3. Scalp hair Fine & fuzzy Fine & fuzzy Coarse & silky

4. Earlobe Pliable no cartilage Some cartilage Stiffened by thick cartilage

5. Testes and scrotum Testes in lower Intermediate Testes pendulum scrotum

scrotal sac with extensive rugae

C. Cephalometry – measurement of diameters of the skull:

subeccipitobregmatic, bipatrietal, occipitofrontal,
occipitomental, bitemporal

IV. Proper Identification – of the newborn must be done in the delivery room
before bringing to the Nursery.
Footprints are said to be the best way which identify newborns.

V. Nursery Care
A. Check identification band
B. Take anthropometric measurements:
1. Length – average: 50 cm (20 in.) = 19 - 21 ½ inches (47.5-
53.75 cm.)
2. Head circumference = 33 – 35 cm.
3. Chest circumference = 31 – 33 cm.
4. Abdominal circumference = 31 – 33 cm.
C. Take the temperature – at birth is 37.2oC or 99oF, but because of
evaporation from the moist skin and the cool delivery room, will
stabilize in 8 hours time and must be maintained at 35.5oC – 36.5oC
(97oF – 99oF) so as to prevent hypoglycemia and acidosis due to
hypothermia. Axillary and rectal temperatures are approximately the
 same immediately following birth but the rectal route is preferred in
order to check patency of the anus.
D. Specific nursing actions:
1. Give initial oil bath to cleanse the baby of blood, mucus and
vernix
2. Dress the umbilical cord. Inspect for the presence of 2 arteries
and 1 vein. Suspect a congenital anomaly if blood vessels are
not complete; a more thorough physical assessment is indicated
and closer observation in an ICU is done.
3. Crede’s prophylaxis – prophylactic treatment of the newborn’s
eyes against gonorrheal conjunctivitis (ophthalmic neonatorum)
which the baby acquires as he passes through the birth canal of
his mother who has untreated gonorrhea:
a. Wipe and face dry.
b. Shade the eyes from light and open one eye at a time by
exerting gentle pressure on the upper and lower lids.
c. 2 drops of 1% silver nitrate are instilled one at a time into the
lower conjunctival sac. (Be careful not to drop on the cheeks
because parents may worry about the stain)
d. Wash silver nitrate away with sterile NSS after 1 minute to
prevent chemical conjunctivitis (inflammation, edema,
purulent discharge)
e. Penicillin/chloromycetin/terramycin ophthalmic ointment may
be used since it does not irritate the eyes (although the baby
may develop sensitivity at an early age). Apply from the
inner to the outer canthus of the eye.
4. Vitamin K administration
a. Rationale: Vitamin K facilitates production of the clotting
factor, thus preventing bleeding. But Vitamin K is
synthesized in the presence of normal bacterial
flora in the intestines. Since the newborn’s
intestines are still relatively sterile, therefore, they
will not be able to synthesize Vitamin K; that is
why synthetic Vitamin K is given to prevent
hemorrhage.)
b. Method: 1 mg. Aquamephyton (generic name is
phytonadione) is injected IM into the lateral anterior
thigh (vastus lateralis). In children below 12 months
of age how have not yet learned how to walk, this is
the preferred site of injection because gluteal
muscles are not yet fully developed.
5. Weight-taking
a. Average birth weight = 6 ½ - 7.5 lbs = 3 – 3.4 kgs = 300 –
3400 gms.
b. Arbitrary lower limit – below which the newborn is said to be
of low birth weight: 5.5 lbs = 2.5 kgs = 2500 gms.
 c. Ideal procedure
• Weigh the clothes first
• Put on the baby’s clothes
• Weigh the baby with his clothes on
• Subtract the weight of the clothes from the total weight of
the baby and his clothes
d. Physiologic weight loss of 5 – 10% of birth weight (6-10 oz)
during the first 10 days of life because the newborn:
• Is no longer under the influence of maternal hormones
• Voids and passes out stools
• Has limited intake
• Has beginning difficulty establishing sucking
6. Feeding
a. Initial feeding – is a test feeding consisting of an ounce of
sterile water (glucose water has been found to irritating to
the lungs if aspirated) is given to find if the newborn can
swallow without aspirating.
b. Subsequent feedings – preferably given by demand

E. Physical Assessment
1. Pulse – normally irregular and 120-140 per minute. Apical pulse
(stethoscope below the left nipple) is recommended since
radial pulses are not ordinarily palpable (if prominent, in fact,
may b ea sign of congenital heart anomaly).
2. Respirations – are gentle, quiet, rapid but shallow; normally 30-
60 per minute. Largely diaphragmatic and abdominal (watch
for the rise and fall of the chest and abdomen).
3. Blood pressure – not routinely measured in newborns unless
coarctation of the aorta is suspected.
a. Normal values:
• At birth – 80/46 mm Hg
• After 15 days – 100/50 mm Hg
b. Size of cuff in children: Must not be more than 2/3 the size of
the extremity (will result in false low BP) nor less than ½ the
length of the extremity (will result in false high BP).
c. Procedure – flush method:
• Cuff is applied to an extremity
• Extremity is elevated and an elastic bandage is wrapped
around the distal portion of the extremity
• Slowly inflate the cuff up to 100 mm Hg, then remove the
bandage (extremity is expectedly pale)
• As soon as the extremity turns pink (flushes), read the
manometer.
 • Only one reading can be obtained, the average between
the diastolic and the systolic pressures, called flush
pressure (therefore, is normally 60).
4. Skin
a. Color – normally ruddy because of the increased
concentration of RBCs and the decreased amount of
subcutaneous fat
• Acrocynosis – body pink, extremities blue. Normal during
the first 24-48 hours of life.
• Generalized mottling is common due to an immature
circulatory system
• Pallor – due to anemia which results from excessive blood
loss when cord is cut, inadequate blood flow from cord to
infant at birth, inadequate iron stores because of poor
maternal nutrition. May also be due to blood
incompatibility.
• Gray color – indicated infection
• Jaundice – yellowish discoloration of the skin sclerae:
• Cause: Inability of the newborn to conjugate bilirubin.
• Normal Values
• Total bilirubin = 15 mg%
• Direct bilirubin = 1.7
• Indirect bilirubin = 13.3
• Most accurate method of assessing presence of
jaundice: Use natural light and blanch skin on the
chest or tip of the nose
• Physiologic jaundice – from the 2nd to the 7th day of life.
• Breastfed babies, however, have longer physiologic
jaundice because human milk has pregnanediol
which depresses the action of glucose
xxxxxxxxxxxxxxx (the enzyme responsible for
converting indirect bilirubin to direct bilirubin)
• Harlequin Sign – because of immaturity of circulation,
an infant who ahs been lying on his side will appear
red on the dependent side and pale on the upper side.
• Mongolian spots – slate-gray patches seen across the
sacrum/buttocks and consist of collections of pigment
cells (melanocytes). Disappear by school age. Seen
only among Southern European, Asian and African
children.
• Lanugo – fine, downy hair that covers the shoulders,
back and upper arms.
• Desquamation – drying of newborn’s skin
 • Cephalhematoma – due to increased intravascular
pressure during delivery
• Milia – unopened sebaceous glands found on the
nose, chin and cheeks; disappear spontaneously by 2-
4 weeks.
5. Head – largest part of the infant’s body (1/4 of his total length).
a. Forehead is large and prominent
b. Chin is receding and quivers when startled or crying
c. Fontanelles are neither sunken (a sign of dehydration) nor
bulging (a sign of increased intracranial pressure)
d. Suture lines should neither be separated nor fontanelles
prematurely closed (-craniosynostosis; leads to mental
retardation)
e. Craniotabes – localized softening of the cranial bones can be
indented by pressure of a finger. Corrects itself without
treatment after some months. More common among first-
borns because of early lightening.

Table 13. Comparison between Caput and Cephalhematoma

INDICATORS CAPUT SUCCEDANEUM CEPHALHEMATOMA

Definition Edema of the scalp Collection of blood

Location Presenting part of the head Between periosteum of skill

bone and the bone itself

Extent of Involvement Both hemispheres Confined to an individual

bone; does not cross suture
lines

Cause Pressure (as in prolonged labor) Rupture of capillaries due to

pressure

Period of absorption (most On or about the third day Takes several weeks
significant differences)

Treatment None None; support the anxious

parents

6. Eyes
a. Method of assessment: Put infant on upright position
b. Characteristics:
• Cry tearlessly during first 2 months because of immature
lacrimal ducts
• Cornea should be round and adult-sized
• Pupils should be round, not key-holed (- coloboma).
7. Ears – level of top part of external (should be in line with outer
canthus of the eye. If set lower, maybe a sign of kidney
malfunction or Down’s syndrome
8. Nose – may appear large for the face; there should be no septal
deviation
9. Mouth
a. Should open evenly when crying; if not, suspect cranial nerve
injury
b. Tongue appears large
c. Palate should be intact; no break on the lips
d. Epstein’s pearls – 1 or 2 small, round, glistening cysts seen
on the palate; due to extra load of calcium while in utero
e. A tooth may be seen; if loose, should be extracted to prevent
aspiration when feeding.
f. Oral thrush – white or gray patches on the tongue and side of
the cheeks due to Candida albicans acquired during
passage of the baby through the birth canal of the mother
with untreated Moniliasis; also known as oral moniliasis.
10. Neck
a. Thyroid gland is not palpable
b. Appears soft and chubby and creased with skin folds
c. Head should rotate freely on the neck and flex forward and
back
11. Chest – as large as, or smaller than, the head:
a. Should be symmetrical
b. Breasts maybe engorged, a result of the influence of maternal
hormones
c. Witch’s milk – thin, watery fluid also due to maternal
hormones
12. Abdomen:
a. Liver, spleen and kidneys are palpable at birth. Liver is about
1-2 cm below the right costal margin
b. Normally dome-shaped; if scaphoid, suspect Diaphragmatic
Hernia
13. Anogenital area
a. Take note of the time meconium is first passed (it should be
within the first 24 hours of life)
b. Female genitalia: may have swollen labia and drops of blood
due to maternal hormones
c. Male genitalia:
• Scrotum maybe edematous – also due to maternal
hormones
• Foreskin should be retracted to test for phimosis (-tight
foreskin)
 • Testes should be present; if not descended, the condition
is called crypto-orchidism (repair of undescended testes is
called orchidopexy).
• Circumcision – maybe done prior to discharge from the
nursery, preferably by the end of the first week.
• Procedure:
• Vitamin E injected IM
• Infant is restrained; penis is cleansed with soap and
water
• Yellen clamp is used
• Petrolatum gauze dressing is applied to prevent
adherence of circumcised site to the diaper while
applying pressure to prevent bleeding
• Nursing care:
• Check hourly for bleeding (most common
complication) during the first day. If small amount of
bright red blood is observed, apply gentle pressure
to the area with a sterile gauze pad
• Do not attempt to remove exudate which persists for
2-3 days. Just wash with warm water
• Diaper must be pinned loosely during first 2-3 days
when the base of the penis is tender
14. Back – on prone, appears flat (curves start to form only when
sitting or waling has been achieved).
15. Extremities
a. Arms and legs are short; hands are plump and clenched into
fists
b. Should move symmetrically
c. Abnormalities:
• Erb-Duchenne paralysis/Brachial plexus injury
• Causes:
• Lateral traction exerted on head and neck during
delivery of the shoulder in vertex presentation
• Excessive traction on the shoulders during breech
extraction, especially when the arms are extended
over the head
• Signs and symptoms:
• Inability to abduct arm from the shoulder, rotate arm
externally or supinate forearm
• Absent Moro reflex on affected arm
• Some sensory impairment in the outer aspect of
affected arm
• Management: Abduct the affected arm in external
rotation position with the elbow flexed
 • Congenital hip dislocation/dysplasia
• Signs and symptoms:
• Assist in replacing head of the femur into the
acetabulum of the hip bone by using 3 diapers
instead of one, or by putting a pillow between the
thighs to maintain abduction of the thighs and flexion
of the hip and knee joints
• Infant preferably carried astride mother’s hip
• Hip spica cast is applied at a later age, before the
infant starts to walk. Cast extends from the waistline
to below the knee of the affected leg and above the
knee of the unaffected leg. If treatment is delayed
(after the baby has already learned how to walk), the
child will become xxxxxxxxx walk with xxxxxxxxxxxxx
at a later age.

F. Systemic Evaluation
1. Cardiovascular System
a. Major Differences in fetal circulation:
• Exchange of oxygen and carbon dioxide takes place in the
placenta, not in the fetal lungs
• Because little blood goes to the fetal lungs, pressure in the
left side of the fetal heart is less than the pressure in the right
side of the fetal heart.
• Presence of fetal accessory structures:
• Foramen ovale – bypasses the pulmonary circulatory
system since it is the opening between the right and left
atria
• Ductus arteriosus – communication between the
pulmonary artery and the aorta
• Ductus venosus – communication which bypasses the
liver
• Umbilical vein – carries the most highly oxygenated blood
• Umbilical arteries – carry deoxygenated blood
b. Neonatal/adult circulation – as soon as breathing has been
initiated, oxygenation now takes place in the newborn’s lungs.
The change from fetal to neonatal circulation is, therefore,
associated with lung expansion, causing pressure in the left side
of the newborn’s heart to become higher compared to pressure
in the right side of the newborn’s heart.
• Increased pressure on the left side of the newborn’s heart
results in:
• Closure of the foramen ovale
 • Change of the ductus arteriosus into a mere ligament
(ligamentum arteriosum)
• The decreased pressure on the right side of the newborn’s
heart causes the ductus venosus to become a mere ligament
(ligamentum venosum)
• Since no more blood goes through the umbilical vein and
arteries, these blood vessels atrophy and degenerate.
c. Blood values – are all high in their newborn period as a response
to the pulmonary circulation:
• Red blood cells – 6 millon/ml3
• Hemoglobin – 17-18 Gms %
• Hematocrit – 52%
• White blood cells – 15,000 – 45,000 per ml3. A high WBC
count during the newborn period, therefore, is not a sign of
infection; with or without infection all newborns have high
WBC count.
2. Gastrointestinal tract – differences in stools:
a. Colostrum – xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx formed from
mucus, vernix, lanugo, hormones and
carbohydrates that accumulated while in utero
b. Transitional – on the 2nd to the 10th day of life in response to the
feeding pattern; are xxxx, green and loose,
resembling diarrhea to the untrained eye
c. Breastfed – golden yellow, xxxxx, more frequent (3-4 times/day)
and sweet-smelling because breast is high in lactic
acid which reduces the amount of putrefactive
organisms
d. Bottlefed – pale yellow, firm, less frequent (2-3 times/day) and
with a more noticeable odor
3. Urinary system – newborns should avoid within the first 24 hours of
life
a. Female newborn – form a strong stream when voiding
b. Male newborn – form a small produced arc when voiding. If not,
suspect a defect in the urethral meatus:
• Epispadia – urethral meatus located in the ventral (under)
surface of the penis
• Hypospadia – urethral opening located in the dorsal (above)
surface of the penis
• Management:
• Inspect for cryptoorchidism often found associated with
hypo-/epispadias
• Meatotomy is done to establish better urinary function
• When the child is older (12-18 months), adherent
chordae (-fibrous bands that cause the penis to curve
 downward) may be released surgically. If repair will be
extensive, surgery might be delayed until 3-4 years old.
• Child should not be circumcised because at the time of
repair, the surgeon may wish to use a portion of the
foreskin
• Surgical correction is done before school age so that the
child appears normal to his schoolmates
4. Autoimmune system
a. Type of immunity transferred from mother to newborn: passive
natural immunity
b. Newborns have antibodies from the mother against poliomyelitis,
diphtheria, tetanus, pertussis, rubella and measles (present in
the infant for one year). But little or no immunity against
chickenpox (that is why chickenpox is often fatal in the
newborn).
c. Newborns have difficulty forming antibodies until 2 months of age
(that is why immunizations are started at 2 months).
5. Neuromuscular system
a. Blink reflex – rapid eyelid closure when strong light is shone;
always present
b. Feeding reflexes:
• Rooting reflex – head will turn to the direction where cheek is
stroked near the corner of the mouth; will help infant find
food; disappears by 6 weeks of age when infant is already
capable of seeing things past the visual midline.
• Sucking reflex – anything placed between the lips will be
sucked; disappears by 6 months. IMPORTANT: Sucking
reflex disappears immediately if not stimulated regularly.
IMPLICATION: Any infant who will be put on NPO should be
given a pacifier not only for psychological reasons, but also
to prevent premature disappearance of the sucking reflex.
• Extrusion reflex – anything placed on the anterior portion of
the tongue will be spit out; disappears by 4 months of age
when infant is about ready for semi-solid foods.
• Swallowing reflex – anything place at the back of the tongue
will be swallowed and will never disappear.
c. Tonic neck reflex – (TNR)/Fencing reflex/boxer reflex – when on
his back, the infant’s arm and leg are extended on the side
where the head is turned, while the arm and the leg on the
opposite side are flexed; disappears by 2-3 months
d. Babinski reflex – when side of the sole is stroked with a “j” from
heel upward, the infant will fan out his toes; starts to disappear
by 3 months of age. (If the adult’s sole is stroked, the adult will
curve in his toes).
e. Landau reflex – when on prone, the newborn should
demonstrate some muscle tone; a test of spinal cord integrity
 f. Palmar or plantar grasp/step-in-place reflexes – accessory
reflexes.
g. Moro reflex – singular most important reflex indicative of
neurological status. If he bassinet is jarred or the infant’s head
is allowed to drop backward in supine position (change infant’s
equilibrium), the infant will abduct and then adduct his arms.
Disappears by 4-5 months.
6. Senses – all are functional at birth:
a. Sight – all newborns can see at birth, although they cannot see
objects past the visual midline (not until 6-8 weeks). The
visual field is 20-22 cm or 9 inches
b. Hearing – as soon as amniotic fluid has been absorbed, the
newborn can already hear
c. Taste – as soon as secretions have been suctioned, newborns
can already taste
d. Smell – as soon as the nose has been cleared of mucous and
fluid, newborns can smell
e. Touch – the most developed of all the senses

G. Discharge Instructions
1. Bathing – maybe given anytime convenient for the parents as long as
it is not within 30 minutes after a feeding because the increased
handling during bathing can cause regurgitation. Sponge baths are
done until the cord falls off (7th-14th day).
2. Cord care
a. Fold down diapers so that cord does not get wet during voiding
b. Dab rubbing alcohol (10%) once or twice a day
c. Small, pink granulating area may be clean on the day of the cord
falls off. If remains moist for a week, advise mother to bring
baby to the doctor’s clinic where cautery with silver nitrate stick
will be done to speed healing.
3. Nutrition
a. Recommended Daily Allowances
• Calories – 120 cal/kg body weight
(KBW) = 50-55 cal/lb body weight
= more or less 3000 cal/day
• Proteins = 96 Gms/KBW/day
• Fluids = 16-20 cc/KBW = 2.5 – 3 oz per lb body weight =
more or less 20 oz/day
• Vitamins – Vitamins A, C and D are recommended for both
bottlefed and breastfed babies during the entire first year of
life.

NUTRIENTS HUMAN MILK COW’S MILK

Protein 8% 20%
Fats 50% 50%
Carbohydrates 42% 30%
Sodium 7 mEq/liter 25 mEq/liter
Potassium 14 mEq/liter 36 mEq/liter
Calcium 12 mEq/liter 61 mEq/liter
Phosphorus 9 mEq/liter 53 mEq/liter
Chloride 12 mEq/liter 34 mEq/liter

Table 14. Comparison Between Human Milk and Cow’s Milk

c. Differences between human milk and cow’s milk

• Human milk contains less proteins.
Cow’s milk has more proteins but the newborn’s kidneys
become overwhelmed with the higher protein content of
cow’s milk that is why cow’s milk need to be diluted. The
main protein in human milk is lactalbumin; the main protein
in cow’s milk is casein. Since the curd tension in milk is
related to the amount of casein, the curd in cow’s milk is
therefore larger, tougher and more difficult to digest (that is
why bottlefed babies have frequent constipation). Heating
reduces the curd, that is why cow’s milk must be sterilized or
pasteurized so newborns can digest it.
• Human milk and cow’s milk have similar fat content; but, fatty
acid, which is necessary for growth and skin integrity, is three
times higher in human milk than in cow’s milk. Besides,
human milk has larger fat globules.
• Human milk contains more carbohydrates. Moreover, lactose
in human milk appears to be the most easily digestible of all
the sugars; it also improves calcium absorption and aids in
nitrogen retention.
• Cow’s milk has more minerals but, again, newborn’s kidneys
become overwhelmed with the high mineral content of cow’s
milk that is why it has to be diluted first.
d. Similarities between human milk and cow’s milk
• Both of them should be given by demand feeding
• Both bottlefed and breastfed babies should be burped at
least twice during a feeding – midway and after the feeding
• Both have the same energy value = xxxxxxxxxxxxxx
• Both are deficient in iron
4. Common health problems
a. Constipation – more common among bottlefed infants.
Management:
• Add more fluids or carbohydrates/sugar
• If due to an unusually tight anal sphincter, dilate twice or
thrice a day by means of a gloved little finger
 b. Loose stools – careful history should be taken; management
depends on cause
c. Colic – paroxysmal abdominal pain common in infants below 3
months of age
• Causes:
• Overfeeding
• Gas distention
• Too much carbohydrates
• Tense and unsure mother
• Management:
• Feed by self-demand. It is the best schedule because it
meets the individual needs of the newborn
• Tell mother to burp the infant at least twice during a
feeding
• Feed baby in upright position
• May need to change formula, as per doctor’s order
• Reduce energy content of formula
d. Spitting up – due to poorly developed cardiac sphincter; more
common among bottlefed infants. Will disappear when
coordination with swallowing is achieved and digestion
improves. Management:
• Feed in upright position because gravity will aid in gastric
emptying
• Position on right side after feeding
• Bubble/burp more frequently
e. Skin irritation – maybe due either to poor hygiene or irritation
from urine, feces and some laundry products.
Management:
• Expose to air – most important
• Careful washing and rinsing away of irritating soap from
the skin
• Starch bath, if a case of measles (ruboela)
f. Occasional “crossed eyes” – normal in many babies because the
eye muscles of coordination have not yet fully developed will
disappear spontaneously
g. Cradle cap – involves the sebaceous glands; due to poor
hygiene. Management: apply mineral oil or Vaseline on the
scalp at night before giving shampoo in the morning
5. Clothing the newborn – rule of thumb: if the mother feels warm, keep
the baby cool; if the mother feels cold, keep the baby warm.
6. Sleep patterns – babies sleep 16-20 hours a day.

RISK NEWBORNS
I. Premature Babies – born before the 38th week of gestation
A. Terminologies
1. Small-for-gestation age (SGA) – birth weight is less than expected for
the specific gestational age. E.g., a baby born on the 38th week of
gestation who weighs 5 lbs.
2. Appropriate-for-gestational age (AGA) – birth weight expected for the
specific gestational age. E.g., a baby born on the 34th week of
gestation who weighs 5 lbs.
3. Large-for-gestational age (LGA) – birth weight more than expected
for the specific gestational age. E.g., a baby born on the 36th week of
gestation who weighs 8 lbs.

B. Characteristics
1. Have underdeveloped subcutaneous tissues and less fat to act as
insulation. Are thin-skinned. This is the reason why rapid drying and
warming inside incubators are important. In incubator care:
a. Temperature = 92o – 94oF (33.3o – 34.4oC)
b. Humidity = 55 – 65%
c. Frequent positioning on the right side will favor closure of the
foramen ovale because of the increased pressure of the left
ventricle
2. Are poikilothermic (- easily take on the temperature of the
environment). Temperature stabilizes at a lower rate: 35o – 36oC.
Take the axillary, not the rectal temperature before crying will mean
increased energy expenditure. (Important: A special consideration in
the care of premature babies is conservation of energy for growth
and development.)
3. Physiologic weight loss is exaggerated.
4. General activity is more feeble and weak; they often assume frog-like
position; extremities have less muscle tone (scarf sign – elbow
passes the midline of the body; square window wrist – wrist at a 90 o
angle).
5. CNS centers for respiration are underdeveloped, which results in
irregular breathing with short periods of apnea. Oxygen administered
should never be more than 40% because it can lead to retrolental
fibroplasias (- an overgrowth of retinal blood vessels causing
blindness).
6. Nutritional requirements – are high in order to maintain rapid growth
appropriate for the developmental stage. Birth weight, kidney and
GIT functioning should be considered in determining nutritional
requirements of the preemies.
a. Method of feeding – basically by NGT.
• Rationale
• Prematures often have ineffective sucking which is not
coordinated with swallowing and, therefore, may aspirate.
 • Minimal handling is necessary in order to conserve
energy.
• Procedure
• Determine the distance to which the NGT is to be inserted
by measuring from the ear lobe to the nose to the distal
end of the sternum
• Mummify (restrain) the baby as the NGT is being inserted
• Check location after NGT has been inserted:
• Submerge tip of the NGT in a glass of water; if bubbles
appear, it is inside the lungs
• Inject 5 cc. of air, then auscultate. If no sound is heard
as air is injected, it means that the NGT is not in the
stomach but in the lungs
• Aspirate contents; if acids are aspirated, the NGT is in
the stomach
• Determine amount of residual milk or undigested milk and
subtract the same amount from the next feeding because
this means that the baby is not able to digest all the milk
that is given to him. Be sure to put back the residual milk
since it contains acids and the baby can develop
metabolic alkalosis if not give back to the baby.
• Keep the NGT always closed to avoid abdominal
distention
• Fill syringe with formula before opening NGT; let formula
flow by gravity
• Feed with sterile water after the formula in order to
prevent clogging the NGT.

C. Special Problems
1. Hyperbilirubiremia – because of immaturity of the liver, kernicterus
(-staining of brain cells with bilirubin, causing brain damage or even
death) appears to occur at a lower bilirubin level. Management:
phototherapy – photooxidation by the use of artificial blue light in
order to convert bilirubin into an excretable form. Nursing
responsibilities in phototherapy care:
a. Expose all areas of the body to light by turning the infant every 2
hours
b. Cover eyes and genitalia
c. Give plenty of fluids to prevent dehydration
d. Check for loose stools and increased body temperature

• Hypoxia increases capillary permeability, causing effusion

from the pulmonary capillaries into the alveoli and terminal
bronchioles
 • Hyalin-like membrane forms around the alveoli and
bronchioles, causing further hypoxia
• Atelectasis, the chief lesion of RDS, thus occurs.
b. Signs and symptoms:
• Expiratory grunting – major symptom
• Increased respiratory rate
• Flaring alae nasi
• Cyanosis; retractions; rales
• Respiratory acidosis
• Blood values:
• Low pH level (normal = 7.35 – 7.45)
• Low pO2 level (normal = 40 – 60 mm Hg)
• High pCO2 level (normal = 35 - 45)
c. Management:
• Monitor vital signs, arterial blood gases, skin color, muscle
tone
• Proper positioning; NPG; IV; NGT care
• Oxygen; high humidity; warmth; CPAP
• Suction PRN
• Prevent complications
• Sodium bicarbonate – for acidosis

II. Postterm/Postmature Babies – born after the 42nd week of gestation

A. Classic signs – “old man faces”; evidence intrauterine weight loss,

dehydration and chronic hypoxia.
1. Long and thin
2. Cracked skin which is loose, wrinkled and stained greenish-yellow,
with no vernix nor lanugo
3. Long nails; firm skull
4. Wide-eyed alertness of a one month old baby
B. Management:
1. Monitor vital signs
2. IV, as ordered
C. Outlook: reasonable

III. Tracheoesophageal Fistula

A. Definitions
1. Esophageal atresia – failure of the esophagus to form a continuous
passage from the pharynx to the stomach
2. Tracheoesophageal fistula – abnormal sinus connection between the
esophagus and the trachea.
B. Type
 1. Type I/A – upper and lower segments of the esophagus are blind; no
connection to the trachea
2. II/B – upper end of esophagus opens in the trachea; blind lower
segment
3. III/C – upper end is blind, lower end connect into the trachea. Most
common type (85%)
4. IV/D – both upper and lower ends of the esophagus open into the
trachea by a fistula
5. Type V/E – “H” type; no esophageal atresia but with fistula; rare type
6. Type VI/F – stenosis occurs 2/3 of the way down the esophagus.
Obstruction may be partial or complete.
C. Clinical manifestations
1. Excessive amount of secretions – outstanding symptom which occurs
soon after birth:
a. Constant drooling
b. Large amounts of secretions from the nose
2. Intermittent cyanosis – due to aspiration from the blind upper pouch
3. Abdominal distention – air from trachea passes through the fistula
into the stomach
4. When fed, infant responds violently after first or second swallow:
a. Coughs and chokes
b. Fluid returns through nose and mouth
c. Infant struggles
5. Inability to pass catheter through the nose or mouth into the stomach
D. Diagnostic evaluation
1. Maternal history of polyhydramnios – helpful clue
2. Flat plate X-ray of abdomen and chest reveals presence of gas in the
stomach and chest
3. X-ray with radiopaque catheter; radiopaque contrast medium never
used because of aspiration
E. Preoperative nursing care
1. Position newborn with the head and chest elevated 20 o-30o to prevent
reflux of gastric juices into the tracheobronchial tree
2. Regular suctioning
3. Put in incubator with high humidity to aid in liquefying secretions and
thick mucus
4. Administer oxygen PRN
5. Assist in bougie treatment (elongation of proximal pouch using a
mercury weighted dilator or firm catheters inserted briefly each day)
6. Give antibiotics as ordered to prevent or treat associated pneumonitis
7. Monitor IV or hyperalimentation
8. Observe closely for:
a. Vital signs; respiratory behavior
b. Amount of secretions
c. Abdominal distention
d. Skin color
 F. Surgery
1. Primary repair – esophageal anastomosis and division of fistula
2. Gastrostomy and cervical esophagestomy, temporarily until infant
gains weight. Staging (-repeated operations separated by periods of
time, waiting for growth) is the accepted philosophy of treatment.
G. Postoperative care
1. Observe for signs of stricture at the anastomosis site; refusal to feed;
pronounced coughing; dysphagia; atelectasis; pneumonia
2. Maintain patent airway:
a. Suction PRN – mark catheter to determine how far it can be
inserted without disturbing anastomosis site
b. Change position frequently and stimulate baby to cry but avoid
hyperextension of the neck to prevent tension on the suture line
c. Continued use of incubator
3. Maintain adequate nutrition – oral feeding started 6-14 days postop
a. Low residue diet to keep stools soft
b. Feed slowly in upright position to allow time for swallowing
4. Oral hygiene to prevent bacterial growth
5. Allow infant to suck on a pacifier to meet psychological and
physiologic needs
6. Encourage parental participation to promote strong parental-infant
bonding

IV. Chalasia
A. Pathophysiology: On the 3rd to the 10th day of life, the cardiac sphincter
muscles fail to function, causing it to be relaxed and constantly patent.
B. Characteristics: Unknown cause; self-limiting – disappears
spontaneously within 3 months
C. Signs and symptoms
1. Prolonged, repeated non-projectile vomiting which is more
pronounced when patient is lying flat on his back
2. Often hungry after each vomiting episode
3. Aspiration may occur
4. Pressure on abdomen causes reflux of stomach contents into the
esophagus
D. Management:
1. Thickened feedings (formula + cereals) – because they are less
easily vomited
2. Put on upright position for 30 minutes after every feeding

V. Imperforate Anus
A. Unknown etiology – arrest in embryologic development at 8 weeks of
intrauterine life
B. Types
C. Signs and symptoms
1. Normal opening
 2. No meconium
3. Green-tinged urine – due to fistula
4. Inability to insert rectal thermometer
5. Abdominal distention
D. Diagnosis: xxxxxxxxxxx xxxxx method – infant is held upside down
while abdomen is filmed to determine distance from rectum to anal
dimple
E. Management:
1. NPO; IV xxxxx gastric xxxxxxxxxxx
2. Temporary colostomy – if poor surgical risk (very young baby,
malnourished; high agenetic or stretic type
3. Surgery:
a. Anoplasty
b. Abdominoperineal pull-through
4. Postoperative care:
a. Expose perineum to air by putting infant on supine with legs
suspended straight up or on prone position
b. Check bowel sounds frequently
c. NGT for gastric decompression
d. Change position from side to side to decrease tension on suture
line
e. Oral feedings resumed 1-2 days postop, when peristalsis has
resumed (fluids are retained; stools/flatus passed)

VI. Spina Bidifa – congenital problem in which there is a defective closure of

the spinal column.
A. Classification
1. Occulta – posterior laminae are usually affected, with no protrusion of
spinal contents. Skin over the defect may reveal a dimple, a small
fatty mass or a tuft of hair.
2. xxxxxxx
a. Meningocele
b. Myelomeningocele – congenital failure of the arches of one or
more vertebrae to unite at the center of the back; so that the
bony wall normally surrounding the spinal canal at that place is
missing. There is external protrusion, through a transparent
sac, containing spinal fluid meninges, spinal cord and/or nerve
roots. It is the most severe of the spinal deformities.
c. Encephalocele- a cranial meningocele or meningomyelocele
occurring at occipital area of the skull but may occur as a nasal
or nasopharyngeal defect.

B. Associated clinical problems – depend on the location; all body parts

below the session are affected
1. Motor function:
a. Feet maybe deformed
 b. Joints of ankles, knees or hips may be immobile
c. Variable degrees of weakness in the lower extremities
d. Spontaneous and induced movements are decreased or absent
2. Sensory function:
a. Sensations usually absent below the level of the defect
b. Ulcerations of the skin are common
3. Impaired functioning of the autonomic nervous system:
a. Skin is dry and cool
b. Sweating ability is impaired
4. Urinary and bowel problem:
a. Inefficient bladder causes constant urinary dribbling
b. Stasis of urine causes UTI
c. Possible renal destruction
d. Fecal incontinence or retention due to poor innervation of the
anal sphincter and bowel musculature
5. Hydrocephalus – occurs in 65% of children; usually develops within
the first 6 weeks of life.

C. Preoperative management/conservative treatment:

1. Careful handling to avoid rupture, pressure, irritation or leakage from
the protruding mass by putting child on prone position, with the hips
abducted
2. Meticulous hygiene to prevent irritation-sterile donut ring over the
lesion
3. Watch for signs of increased intracranial pressure:
a. Anterior fontanelle for tenseness, fullness and bulging
b. Shrill, high-pitched cry
c. Measure head circumference daily for any significant increase
d. Vomiting, irritability
e. Increasing BP, decreasing PR and RR and widening pulse
pressure
4. Passive range of motion (ROM) exercises to impaired lower
extremities

D. Surgical correction
1. Early excision of the sac if it is small and then primary closure is done
2. If base of the defect is too large for primary closure, conservative
treatment is carried out first while waiting for epithelization to take
place and then closure is done at a later time.

E. Postoperative care
1. Keep on prone position
2. Monitor urine output – bladder injury is a high possibility in
operations involving the spinal column
3. Measure head circumference daily
4. Monitor movement of lower extremities
F. Complications
1. Meningitis
2. Severe neurologic deficits
3. Hydrocephalus
a. Types:
• Noncommunicating – blockage within the ventricles which
prevents CSF from entering the subarachnoid space
• Communication – obstruction in the subarachnoid cistern at
the base of the brain and/or within the subarachnoid space

b. Management
• 1.5 – 2 Gms. Mannitol 20%/KBW over 10 -15 minutes – since
Mannitol is a diuretic, an indwelling, catheter should be
inserted for accurate recording of intake and output
• Ventriculo-peritoneal/ventriculo-atrial shunt – to bring the CSF
to an area from where it can be excreted from the body. After
the procedure, the child should be positioned on the side
where the shunt is to prevent sudden decrease in intracranial
pressure.