CHAPTER 1 - MOTHER AND CHILD HEALTH & ANTEPARTUM/ PREGNANCY

This chapter adds information about how to educate women and their partners about sexuality and pregnancy to better prepare
them for childbearing and childrearing.

MAJOR TOPIC/S SUBTOPIC/S

1. Concept of Mother and Child Health Concept of Procreation
Process of Human Reproduction
Risk Factors related to Development of Genetic Disorders
Common Tests for Determination of Genetic Abnormalities
Utilization of Nursing Process in the Prevention of Genetic Disorders
2. Antepartum / Pregnancy Anatomy and Physiology of the Reproductive System
Menstrual Cycle
Process of Conception
Fetal Circulation
Milestones of Fetal Development
Common Teratogens and their Side Effects
Assessment of Health History
Normal Changes in Pregnancy
Danger Signs of Pregnancy
Normal Laboratory Findings during Pregnancy
Prenatal Exercises
Childbirth Preparation

Specific Activities:
1. Labeling diagrams
2. Matching Type
3. Critical Thinking Exercises
4. Multiple Choice Questions with Rationalization of answers

MOTHER AND CHILD HEALTH

1.1 CONCEPT OF PROCREATION

Terminologies:

 Sexuality: includes feelings, attitudes and actions; encompasses and gives direction to a person’s physical,
emotional, social and intellectual responses
 Biologic Gender: used to denote a person’s chromosomal sex
 Gender Identity/ Sexual Identity: inner sense a person has of being male or female
 Gender Role: male or female behavior a person exhibits

1.2. PROCESS OF HUMAN REPRODUCTION

HUMAN SEXUAL RESPONSE (EPOR)

1. EXCITEMENT PHASE:

Duration: a few minutes to a few hours

Stimulation: sensory stimuli such as touch, sight, sound, smell or active imagination
Purpose: to prepare both sexes physically and emotionally for the act.
Characteristics:
 Female: vaginal lubrication in female; nipples become erect, breast size increases.
 Male: there is penile erection due to vasocongestion. HR, RR, BP increases.
2. PLATEAU PHASE: starts upon insertion of penis into the vagina and active intercourse starts

Characteristics: generalized muscle tension, hyperventilation, increase BP, HR, respiration, flushing may spread
to abdomen, thighs, and back.

 In women, formation of orgasmic platform- retraction of clitoris beneath the prepuce, opening of vagina
narrows
 In men, full distention of the penis , testes become enlarges and elevated toward the body

3. ORGASMIC PHASE:
 Duration: the shortest stage (few seconds) in the sexual response cycle in which the body suddenly discharges
accumulated sexual tension; accompanied by an intense pleasure affecting the whole body.
 It is the climax or orgasm of sexual excitement involving the release of sexual tension
Characteristics:
 In male: strong rhythmic muscular contraction of the epididymis, prostate, vas deferens, seminal vesicle,
ejaculatory ducts and penis resulting to the ejaculation of semen
 In women – strong rhythmic contractions of the orgasmic platform, uterus and anal sphincter muscles
releasing mucoid fluid from the vagina.

4. RESOLUTION PHASE: follows the orgasm in both male and female

Characteristics:
 In male – penis returns to non-erect state, testes lower and return to normal size
 In female – vagina and labia return to normal, lowering of the cervix, clitoris and size of breast
 Both: general muscle relaxation occurs; flushing disappears, heart rate & BP return to normal, external and
internal genital organs return to an unaroused state, with a desire to sleep. Takes approx. 30 minutes for
both men and women.

5. REFRACTORY PHASE – only in male; period during which no amount of stimulation can cause another
erection. Not manifested in women because females ARE MULTI-ORGASMIC. This phase lengthens with age.

1.2 RISK FACTORS RELATED TO GENETIC DISORDERS

GENES
 basic units of heredity that determine both the physical and cognitive characteristics of people. It consist of
strands DNA that are woven in the nucleus to produce chromosomes.
 A person with normal genome has either 46XY (Male) or 46XX (Female). Chromosomal aberration exists if
there is a missing or extra chromosome.

1.3. ASSESSMENT AND DIAGNOSTIC EXAM FOR GENETIC ABNORMALITIES

 History Taking
 assess history of genetic disorders
 ethnic background
 ask for history of miscarriage
 Physical Assessment
 Diagnostic Testing

TABLE 1. SCREENING PROCEDURES FOR GENETIC ABNORMALITIES

DIAGNOSTIC EXAM DESCRIPTION/ FINDINGS

Karyotyping Specimen: peripheral venous blood or scraped cells (buccal
area)
 cells are allowed to grow until it reach metaphase
 cells will be stained and examined under the
microscope
Maternal Serum screening -assesses alpha-fetoprotein (AFP)

(AFP : produced by the fetal liver; peaks in maternal serum bet.

13th -32nd wk AOG)

↓ : Down Syndrome (Trisomy 21)

↑: Spina Bifida

Done @: 15th week AOG

Chorionic Villi Sampling Specimen: chorionic villi (placenta) for DNA analysis

Done as early as 5 weeks AOG

Common: 8th - 10th week AOG

WOF: vaginal bleeding, chills and signs of infection

 Rh negative: give RhoGam to prevent isoimmunization
amniocentesis -withdrawal of amniotic fluid through the abdominal wall for
analysis

Done @ 14th -16th week AOG (when amniotic fluid is already at

200 ml)

Needle is guided thru utz

Percutaneous Umbilical Cord Blood Sampling “cordocentecis”
 removal of blood from the fetal umbilical cord at about
17 weeks AOG using amniocentesis technique
Fetal Imaging Magnetic Resonance Imaging (MRI) and ultrasound are used
to assess for general size and structural disorders of the internal
organs, spine or limbs
Fetoscopy  insertion of a fiberoptic fetoscope through a small
incision in the mother’s abdomen into the uterus and
membranes to visually inspect the fetus for gross
abnormalities

OTHER TESTS

1. UTZ
2. NON-STRESS TEST
 Done to assess FHT vs. fetal activity
 Heart beat of the fetus should accelerate by 15 beats for 15 seconds, twice in a 20 minute period(reactive).
 if the result is Non-reactive, the doctor orders for CST/OCT.

3. CONTRACTION STRESS TEST/OXYTOCIN CHALLENGE TEST

 it evaluates the reaction of the fetal heart rate induced by oxytocin induction or nipple stimulation
 POSITIVE- there is persisent late deceleration
 NEGATIVE-there is no pesistent late deceleration
 SUSPICIOUS- inconstant late deceleration pattern.

Variable deceleration = Cord Compression

Early deceleration = Head Compression
Late Deceleration = Uteroplacental Insufficiency

4. FETAL MOVEMENT
 Quickening: 16th for multipara and 20th week for primipara

fetus moves at least 10 times in a day

 Sandovsky Method
 in a left recumbent position, mother counts fetal movement after a meal; RESULT: moves TWICE q 10
mins (10-12x per hour)
 CARDIFF METHOD
 “Count-to-ten”
 woman records the time interval it takes for her to feel the movements
 INTRAPARTUM (PROCESS OF LABOR AND DELIVERY)
Before you proceed…
 Set your learning goals. At the end of this chapter, you are expected to attain the following Intended Learning
Outcomes:
1. Identify factors affecting labor and delivery
2. Distinguish the significance of the following factors: the passenger, passageway and powers of labor
and delivery
3. Discuss psychological changes in mothers during the different phases and stages of labor and delivery
4. differentiate the nature of the condition of clients during labor and delivery
5. Identify signs and symptoms of a complicated labor
6. Identify coping mechanisms of the mother, partner and family in relation to labor and delivery
 Prepare your books and notebooks. Highlight concepts that need to be reinforced. Jot down supplemental
information as needed.
 Be sure to read the entire lecture notes. DO NOT SKIP. An electronic copy of this chapter is also provided
along with other resources to facilitate better understanding of the topics.

Key Terms
 Intrapartum  Person
 Stages of Labor  True Labor
 Mechanism of labor  False Labor
 Power  Contractions
 Passenger  Dilatation
 Passageway  Effacement
 Psyche

Let’s Begin!
THEORIES OF LABOR ONSET

A. Uterine Stretch Theory

 any hallow body organ when stretched to capacity will necessarily contract and empty.
B. Oxytocin theory
 labor, being considered a stressful event, stimulates 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 occur.
D. Prostaglandin theory
 Initiation of labor is said to result from the release of arachidonic 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 decrease in blood supply, the uterus contracts.

ESSENTIAL FACTORS OF LABOR (5Ps)

1. Passages
2. Power
3. Passenger
4. Person
5. Position
PASSAGES

FUNCTIONS (Sit Sit)

 Serves as birthcanal
 It proves attachment to muscles, fascia and ligaments
 Supports uterus during pregnancy
 It provides protection to the organs found within the pelvic

TYPES (GAPA)

 Gynecoid
 normal female type of pelvis
 most ideal for childbirth
 round shape, found in 50% of women

 Android
 male pelvis
presents the most difficulty during childbirth
 found in 20% of women

 Platypelloid
 flat pelvis, rarest, occurs to 5% of women

 Anthropoid
 apelike pelvis, deepest type of pelvis found in 25% of women

DIVISION OF PELVIS
1. False Pelvis – “provide and direct”
2. True Pelvis – “the tunnel” IPO

 Inlet or Pelvic Brim – entrance to true pelvis

ANTEROPOSTERIOR DIAMETER DOT

1. Diagonal Conjugate – midpoint of sacral promontory to the lower margin of symphysis pubis (12.5
cm)
2. Obstetric Conjugate – midpoint of sacral promontory to the midline of symphysis pubis (11 cm)
3. True Conjugate – midpoint of sacral promontory to the upper margin of symphysis pubis (11.5 cm)
 Pelvic Canal
 situated between inlet and outlet
 designed to control the speed of descent of the fetal head

 Outlet
 most important diameter of the outlet.

POWERS (3 I’s)
 Involuntary – not within the control of the parturient
 Intermittent – alternating contraction and relaxation
 Involves discomfort (compression, stretching and hypoxia)

PHASES OF UTERINE CONTRACTIONS

1. Increment/Crescendo – “ready, get set”
2. Acme/Apex – “go”
3. Decrement/Decrescendo – “stop”

 INTENSITY - strength of uterine contraction

 Mild – slightly tensed fundus
 Moderate – firm fundus
 Strong – rigid, board like fundus

 FREQUENCY
 rate of uterine contraction
 measured from the beginning of a contraction to the beginning of the next contraction

 DURATION
 length of uterine contraction
 measured from the beginning of a contraction to the end of the same contraction

 INTERVAL
 measured from the end of contraction to the beginning of the next contraction

ASPECTS OF CONTRACTION
A. 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 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)

B. Fetal heart rate (FHR)

 should not be mistaken for uterine soufflé (synchronizes with maternal pulse rate)

 Normally 120 to 160 per minute

 should not be taken 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, causes bradycardia
 Should be taken every hour during the latent phase of labor, every half hour during the active phase
and every 15 minutes during the transition period
 For any abnormality in FHR, the initial nursing action is to change the mother’s position

Signs of fetal distress

 Bradycardia (FHR less than 100/minute) or tachycardia (FHR more than 180/minute)
 Meconium – stained amniotic fluid in non – breech presentation
 Fetal thrashing – hyperactivity of the fetus as it struggles for more oxygen

PASSENGER

HEAD (BOTu)
 Biggest part of the fetal body
 Olways the presenting part
 Turn to present smallest diameter

CRANIAL BONES 1 FOSE, 2 PaTe

1 frontal bone 2 parietal bone
1 occipital bone 2 temporal bone
1 sphenoid bone
1 ethmoid bone

SUTURE LINES – allow skull bones to overlap (molding) and for further brain development (SFC La)
  Sagittal Suture – between 2 parietal bones
 Frontal Suture – between 2 frontal bones
 Coronal Suture – between frontal and parietal
 Lamdiodal Suture – between parietal and occipital

FONTANELS
 intersection of suture lines

Anterior Fontanel or Bregma

 intersection of SFC
 diamond shaped, closes b/n 12 – 18 months
 3 x 4 cm

Posterior Fontanel or Lambda

 triangular shaped, closes b/n 2 – 3 months

DIAMETERS OF THE FETAL HEAD

 AP > T (fetal head)

1.Tranverse Diameters “BBB”

 Biparietal
 most important TD
 greatest diameter presented to the pelvic inlet’s AP and at the outlet’s TD
 average measurement is 9.5 cm
 Bitemporal – average measurement is 8 cm
 Bimastoid – average measurement is 7 cm

2. Anteroposterior Diameters “SOO”

 Suboccipitobregmatic
 smallest APD
 fully flexed (presenting part)
 measured from the inferior aspect of occiput to the anterior fontanel
 average measurement is 9.5 cm
 Occipitofrontal
 head partially extended and presenting part is the anterior fontanel
 average size is 12. 5 cm
 Occipitomental
 head is extended and the presenting part is the face
 measured from the chin to the posterior fontanel
 average size is 13.5 cm

FETAL LIE
 relationship of the long axis of the fetus to the long axis of the mother

 Longitudinal Lie – “parallel”

 Transverse Lie – “right angle/lying crosswise”
 Oblique Lie – “slanting”

Attitude or Habitus – degree of flexion or relationship of the fetal parts to each other.
 PRESENTATION AND PRESENTING PART

LIE PRESENTATION ATTITUDE

A. Longitudinal Lie Vertex – most ideal Complete flexion

1. Cephalic (head) - suboccipitobregmatic is presented (9.5 cm)

Brow – occipitomental is presented (13.5 cm)

Moderate flexion

Sinciput – occipitofrontal is presented (12.5 cm)

Partial flexion (military

position)

Extension

Face presentation
2. Breech (butt)
Hyperextended

Chin presentation

Good flexion

Complete breech - feet & legs flexed on the thighs

and the thighs are flexed on the abdomen
Moderate flexion

Frank breech - hips flexed and legs extended (MOST

COMMON)

Very poor flexion

Footling Breech – one or both feet are the presenting

parts
Flexion

B. Transverse Lie Shoulder Presentation – fetus is lying

perpendicular to the long axis of the mother
Causes:
- vaginal delivery is NOT POSSIBLE
 1. relaxed
abdominal wall
*Compound Presentation – when there is prolapsed
2. placenta previa of the fetal hand alongside the vertex, breech or
shoulder.

POSITION
 relationship of the fetal presenting part to a specific quadrant in the mother’s pelvis

The pelvis is divided into four quadrants

 Right anterior
 Left anterior
 Right posterior
 Left posterior
 Posterior positions result in more backaches because of pressure of the fetal presenting part on the
maternal sacrum

Points of direction in the fetus

 Occiput – in vertex presentations
 Chin (mentum) – in face presentations
 Sacrum – in breech presentations
 Scapula (acromio) – in horizontal presentations

Possible fetal positions

Vertex
 LOA – left occipitoanterior (most common and favorable position at birth)
 LOP – left occipitoposterior
 LOT – left occipitotransverse
 ROA – right occipitoanterior
 ROP – right occipitoposterior
 ROT – right occipitotransverse

Breech
 LSA – left sacroanterior
 LSP – left sacroposterior
 LST – left sacrotransverse
 RSA – right sacroanterior
 RSP – right sacroposterior
 RST – right sacrotransverse

Face
 LMA – left mentoanterior
 LMP – left mentoposterior
 LMT – left mentotransverse
 RMA – right mentoanterior
 RMP – right mentoposterior
 RMT – right mentotransverse

Shoulder
 LADA – left acromiodorsoanterior
 LADP – left acromiodorsoposterior
 RADA – right acromiodorsoanterior
 RADP – right acromiodorsoposterior

STATION
 relationship of the presenting part of the fetus to the ischial spine of the mother.

 Minus (-) station – presenting part is above the ischial spine

 Zero (0) station – presenting part is at the level of the ischial spine
  Positive (+) station – presenting part is below the level of the ischial spine

FLOATING
 head is movable above the pelvic inlet

 +1 station – fetus is engaged

 +2 station – fetus is in midpelvis
 +4 station – perineum is bulging

THE PERSON

FACTORS affecting labor

 Perception & meaning of childbirth
 Readiness & preparation for childbirth
 Coping skills
 Past experiences
 Cultural & social background
 Presence of significant others and support system

SIGNS OF LABOR (WRISLIR)

 Weight Loss
 2-3 pounds (progesterone)

 Ripening of the Cervix

 “soft”

 Increased Braxton Hicks

 “irregular, painless”

 Show
 “ruptured capillaries + operculum = pinkish color”

 Lightening
 “the baby dropped”; settling of presenting part into the pelvic brim
 2 weeks (primi) and before or during (multi)

 Relief of respiratory discomfort

 Increased frequency of urination
 Leg pains
 Muscle spasms
 Increased vaginal discharge
 Decreased fundal height

 Increased Level of Activity – large amount of epinephrine (AG)

 Rupture of Membranes – gush or steady trickle of clear fluid

FALSE LABOR “CANDAC”

 Contraction disappear with ambulation
 Absence of cervical dilation
 No ↑ DIF (duration, intensity, frequency)
 Discomfort @ abdomen
 Absence of show
 Contraction stops when sedated

TRUE LABOR “CUPPAD”

 Contraction persists when sedated
 Uterine contraction ↑ DIF (duration, intensity, frequency)
 Progressive cervical dilation
 Presence of show
 Ambulation increase contractions
 Discomfort radiates to lumbosacral area
 Table 2.2 LENGTH OF LABOR

STAGE OF LABOR PRIMI MULTI

1ST STAGE 10 – 12 HOURS 6 – 8 HOURS

30 MINS – 2 HOURS 20 – 90 MINS

2ND STAGE
Ave: 50 mins Ave: 20 mins

3RD STAGE 5 – 20 MINS 5 – 20 MINS

4TH STAGE 2 – 4 HOURS 2 – 4 HOURS

POST PARTUM

CHAPTER 4

This chapter adds information about proper care for the mother during the post-partum period.

Duration: 24 Hours

MAJOR TOPICS SUBTOPICS

POSTPARTUM 1. Definition

2. Specific Body Changes on the Mother

3. Psychological Changes on the Mother

4. Phases of Puerperium

� “Taking In”

� “Taking Hold”

� “Letting Go”

5. Monitoring of Vital signs, uterine involution,

amount & pattern of lochia, emotional responses,
responses to drug therapy, episiotomy healing

6. Possible complications during post partum :

bleeding & infection

7. Appropriate Nursing Diagnoses

8. Nursing care of mothers during post partum

a. Safety measures: limitations in movement,

protection from falls, provision of adequate clothing,
wound care

e.g. episiotomy

b. Comfort measures: exercises, initiation of lactation,

relief of discomforts like breast engorgement and
nipple sores, hygienic measures, maintaining
adequate nutrition

c. Measures to prevent complication: ensuring

adequate uterine contraction to prevent bleeding,
adequate monitoring, early ambulation, prompt
referral for

complications

d. Support for the psychosocial adjustment of the

mother
 e. Health teaching needs of mother, newborn, family

f. Accurate documentation and reporting as needed

9. Health beliefs & practices of different cultures in

pregnancy, labor delivery, puerperium

Activities:

1. Critical thinking exercises

Before you proceed…

ü Set your learning goals. At the end of this chapter, you are expected to attain the
following Intended Learning Outcomes:

1. Define postpartum.

2. Determine the basic physiologic changes that occur in the postpartal period as a woman’s
body returns to its prepregnant state.

3. Recognize the psychologic adjustments that normally occur during the postpartal period.

4. Delineate the phases of puerperium that a post partum mother undergoes.

5. Distinguish the nursing responsibilities/ actions that must be undertaken in the care of
mothers during the post partum period (safety measures, comfort measures, measures to prevent
complications)

6. Identify the physiologic and psychosocial components of a normal postpartal assessment.

7. Cite possible nursing diagnoses during the post partum period needs.

8. Discuss health teachings needs of mother, newborn and family.

9. Identify significant data needed to be recorded and reported.

10. Integrate the health beliefs and practices (during pregnancy, labor and deliver, puerperium) of
different cultures to the nursing practice.

ü Prepare your books and notebooks. Highlight concepts that need to be reinforced. Jot down
supplemental information as needed.

Key Terms

l Postpartum

l Taking In

l Taking Hold

l Letting Go
l Lochia

l Post-partum hemorrhage

Let’s Begin!

POST-PARTUM PERIOD

ü PRINCIPLES UNDERLYING PUERPERIUM

A. Promoting and return to normal (involution) of different parts of the body

1. Vascular changes

1.1 The 30% - 50% increase in total cardiac volume during pregnancy will be reabsorbed into the
general circulation with 5 – 10 minutes after placental delivery. Implication: the first 5 – 10 minutes
after placental delivery is crucial to gravidocardiacs because the weak heart may not be able to
handle such workload.

1.2 While blood cell (WBC) count increases to 20,000 – 30,000/mm3. implication: the WBC count,
therefore, cannot be used as a indication or sign of postpartum infection

1.3 There is extensive activation of the clothing factors, which encourages thromboembolization.
This is the reason why:

1.3.1 Ambulation is done early – 4 – 8 hours after normal vaginal delivery. When ambulating the
newly – delivered patient for the first time, the nurse should hold on to the patient’s arm.

1.3.2 Recommended exercises

2.1 Kegel and abdominal breathing on postpartum day one (PPD1).

2.2 Chin – to – chest – on PPD2 to tighten and firm up abdominal muscles

2.3 Knee – to – abdomen – when perineum has healed, to strengthen abdominal and gluteal
muscles.

1.3.3 Massage is contraindicated

1.4 All blood values are back to prenatal levels by the 3 rd or 4th week postpartum

2. Genital Changes

2.1 Uterine involution is assessed by measuring the fundus by fingerbreadth (=1 cm.). on
PPD1, fundus is 1 finger breadth below the umbilicus; on PPD2, 2 fingerbreaths below and so forth
until on PPD10, it can no longer be palpated because it is already behind the symphysis
pubis. Subinvoluted uterus is aa uterus larger than normal and vaginal bleeding with clots since
blood clots are good media for bacteria, it is , therefore, a sign of puerperal sepsis.

2.2 To encourage the return of the uterus to its usual anteflexed position, prone and knee chest
positions are advised.
2.3 Afterpains/afterbirth pains – strong uterine contractions felt more particularly by multis, those
who delivered large babies or twins and those who breastfeed. It is normal and rarely lasts for
more than 3 days.

Management:

2.3.1 Never apply heat on the abdomen

2.3.2 Give analgesics as ordered

2.4 Lochia – uterine discharge consisting of blood, deciduas, WBC, mucus and some bacteria.

2.4.1 Pattern

Ø Rubra – first 3 days postpartum; red and moderate in amount

Ø Serosa – net 4 – 9 days; pink or brownish and decreased in amount

Ø Alba – from 10th day up to 3 – 6 weeks postpartum; colorless and minimal in amount

2.4.2 Characteristics

Ø Pattern should not reverse

Ø It should approximate menstrual flow. However, it increases with activity and decreases with
breastfeeding.

Ø It should not have any offensive odor. It has the same fleshy odor as menstrual blood. If fol
smelling, may mean either poor hygiene or infection

Ø It should not contain large clots.

Ø It should never be absent, regardless of method of delivery. Lochia has the same pattern and
amount, whether CS or normal vaginal delivery

2.5 Pain in perineal region may be relieved by:

2.5.1 Sim’s Position – minimizes strain on the suture line

2.5.2 Perineal heat lamp or warm Sitz baths twice a day – vasodilatation increases blood supply
and, therefore, promotes healing

2.5.3 Application of topical analgesics or administration of mild oral analgesics as ordered

2.6 Sexual activity – maybe resumed by the 3rd or 4th week postpartum if bleeding has stopped
and episiorrhapy has healed. Decreased physiologic reactions to sexual stimulation are expected
for the first 3 months postpartum because of hormonal changes and emotional factors.

2.7 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 the absence of
menstruation may her body’s way of conserving fluids for lactation. Implication: she should be
protected against a subsequent pregnancy by observing a method of contraception, except the
pill).

2.8 Postpartum check – up – should be done after the 6th week postpartum to assess involution

3. Urinary Changes

3.1 There is marked diuresis within 12 hours postpartum to eliminate excess tissue fluid
accumulation during pregnancy.

3.2 Some newly delivered mothers may complain of frequent urination in small amounts; explain
that this is due to urinary retention with overflow. Other, on the other hand, may have difficulty
voiding because of decreased abdominal pressure or trauma to the bladder. Voiding may be
initiated by:

3.2.1 Pouring warm and cold water alternately over the vulva

3.2.2 Encouraging the client to go the comfort room

3.2.3 Let her listen to the sound of running water

3.2.4 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:

4.1 Decreased muscle tone

4.2 Lack of food + enema during labor

4.3 Dehydration

4.4 Fear of pain from perineal tenderness due to episiotomy, lacerations or hemorrhoids

5. Vital Signs

5.1 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.

5.2 Bradycardia (heart rate of 50 – 70 per minute) is common for 6 – 8 days

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 feeling of inadequacy in taking care of a new baby. Management:
explain that it is normal; crying is therapeutic, in fact.
3. Letting-go phase - interdependent; refining new roles

C. Prevent postpartum complications

1. Hemorrhage

- Bleeding of >500 cc (NSD 500 cc normal, CS 600-800 cc)

A. Early postpartum hemorrhage - bleeding within 1st 24 hours;

- boggy or relaxed uterus, profuse bleeding (UTERINE ATONY)

Management: massage uterus until contracted

- cold compress

- modified Trendelenburg position

- IV drip: OXYTOCIN

2. Infection

1. Sources

1.1 Endogenous (primary) sources – bacteria in the normal flora become virulent when tissues are
traumatized and general resistance is lowered.

1.2 Exogenous sources – pathogens introduced from external sources. (Most common is
anaerobic streptococci). Common exogenous sources:

1.2.1 Hospital personnel

1.2.2 Excessive obstetric manipulations

1.2.3 Breaks in aseptic techniques – faulty handwashing, unsterile equipment and supplies

1.2.4 Coitus in late pregnancy

1.2.5 Premature rupture of the membranes

2. General symptoms: malaise anorexia, fever, chills and headache

3. General management

3.1 Complete bed rest (CBR)

3.2 Proper nutrition

3.3 Increased fluid intake

3.4 Analgesics

3.5 Antipyretics and antibiotics, as ordered

4. Types of infection

4.1 Infection of the perineum

4.1.1 Specific symptoms

Ø Pain, heat and feeling of pressure in the perineum

Ø Inflammation of the suture line, with 1 or 2 stitches sloughed off

Ø With or without elevated temperature

4.1.2 Specific management

Ø Doctor removes sutures to drain area and resutures

Ø Hot sitz bath or warm compress

4.2 Endometritis

4.2.1 Specific symptoms

Ø Abdominal tenderness

Ø Uterus not contracted and painful to touch

Ø Dark brown, foul-smelling lochia

4.2.2 Specific management

Ø Oxytocin administration

Ø Fowler’s position to drain out lochia and prevent pooling of infected discharge

4.3 Thrombophlebitis – infection of the lining of a blood vessel with formation of clots; usually an
extension of endometritis

4.3.1 Specific symptoms

Ø Pain, stiffness and redness in the affected part of the leg

Ø Leg begins to swell below the lesion because venous circulation has been blocked

Ø Skin is stretched to a point of shiny whiteness, called milk leg or phlegmasia alba dolens

Ø Positive Homan’s sign – pain in the calf when the foot is dorsiflexed

4.3.2 Specific management

Ø Bed rest with affected leg elevated

Ø Anticoagulants, e.g., Dicumarol or Heparin, to prevent further clot formation or extension of a

thrombus
o Analgesics are given but never Aspirin because it inhibits prothrombin formation therefore
causes hemorrhage

D. Establish successful lactation

PHYSIOLOGY OF BREASTMILK PRODUCTION

Low Estrogen and high progesterone level after placental delivery

Stimulation of the anterior pituitary gland to produce PROLACTIN

(Remember: Prolactin = Production of Milk)

Acts on the acinar cells to produce foremilk stored in collecting tubules

During feeding, the posterior pituitary gland is stimulated to produce OXYTOCIN

Causes contraction of smooth muscles of collecting tubules, thus milk is being ejected

(remember: Oxytocin = “oozing of milk” or Milk Let-down reflex)

Video Links: https://youtu.be/DAI_6ksFh0U , https://youtu.be/w0iDfcAYZWc

FAMILY PLANNING
CHAPTER 4

Family Planning Methods

-spacing of pregnancy/ birth control

l Philippine Family Planning Program

-improvement of family welfare

-FOCUS: women’s health, safe motherhood and child survival

ü Role of Nurse: EDUCATOR and FACILITATOR

ü Ideal spacing: 3 years (WHO)

METHODS OF FAMILY PLANNING

A. NATURAL METHODS

- Based on abstinence at the time of ovulation to prevent conception.

Advantages:

1. Safe and has no side effects

2. Inexpensive

3. Acceptable to religious affiliations that do not accept artificial methods of contraception

4. Helpful for planning pregnancy and avoiding pregnancy

5. Promotes communication about family planning and contraception between couples

Disadvantages:

1. Involves long preparation and intensive recording before it can be used

2. There is a need to abstain on certain days which may be incovenient for the couple

3. Not ideal to women with irregular cycles

4. Not very reliable because of menstrual cycle variations that may occur anytime

1. Behavioral

1.1 Abstinence

1.2 Coitus Interruptus/ Withdrawal: not always effective d/t premature ejaculation

2. Calendar Method

Checkpoint question: The ovum is viable for _______ hrs while the sperm is viable for ______

2.1. Rhythm or Calendar Method

2.1.1 Ogino Kaus Method (Regular Cycle)

- The couple abstain on days when the woman is fertile

- subtract 14 from the number of days of the menstrual cycle to determine day of ovulation

- abstain 5 days before and 3 days after ovulation

Example:

Checkpoint question:

If I had my LMP on July 6, 2020 and my regular cycle is 30 days, when will I abstain from sexual activity?

Date of ovulation: ________________

Date/s to abstain: _________________
Scenario: LMP is March 15; add 14 to determine
ovulation Day; subtract 5 then add 3
15 16 17 18 19 20 21
22 23 24 25 26 27 28
29 30 1 2 3 4 5

2.1.2 Irregular (Remember these two #s: 18 and 11)

I have 18 short shorts and 11 long pants

-subtract 18 from the shortest cycle
-subtract 11 from the longest cycle

Checkpoint question:

If I had my LMP on July 6, 2020 , my shortest cycle is 25 days cycle and the longest is 30 days, when will I
abstain from sexual activity?

Date of ovulation: ________________

Date/s to abstain: _________________

Scenario: LMP is March 6; shortest cycle: 26
Longest cycle:30

26-18 = 8th day; 30-11 = 19th day

Count the 8th and 19th day from LMP

6 7 8 9 10 11 12
13 14 15 16 17 18 19
20 21 22 23 24 25 26
2.2 Billing’s Method: check the cervical mucus

Checkpoint question:

List down the characteristics of cervical mucus during ovulation:

-also called as Wet Dry wet method

-based on the changes in cervical mucus during the mesntrual cycle

-before ovulation, the normal vaginal discharge is either absent or it is thick and scant.

- just before ovulation, mucus discharge become clear, abundant, slippery and stretchable due to
high estrogen level.

l CHARACTERISTICS OF MUCUS DURING OVULATION

- clear, watery mucus

-SPINNBARKEIT - mucus is stretchable

-positive ferning’s test; when mucus is examined under the microscope, it resembles a fern-like
appearance
2.3. Basal Body Temperature

-pre-ovulatory temperature is ↓ d/t high estrogen and low progesterone

-ovulation - ↑ temp d/t progesterone

-take BT at same time each day after at least 4-6 hours of sleep for 3 months before using this
method

-sustained increase in temp by 0.5-1 degree during ovulation for 3 days

2.4. Sympthothermal Method (Billing’s + BBT): combination of Billing’s Method and Basal Body
Temperature

-couple needs to record cycke days, coitus, mucus changes, increase libido, abdominal bloating,
mittelschmerz

2.5. Lactational Amenorrhea Method (LAM) - continuous and exclusive breastfeeding; good for
6 months

- used only temporarily based on exclusive breastfeeding

- can be used when woman is: breastfeeds often during day and night

- menstruation has not yet returned

3. Barrier Method

3.1. Chemical (jellies, creams, foams, tablets)

3.1.1 Spermicides: makes vagina more acidic

S/e: vaginitis, works for 2 hours only

3.2 Mechanical

3.2.1 Condom (Male and Female): inserted when penis is erect; placed prior to contact

: spermatozoa are deposited at the tip of the condom

: interrupts sex; reduces sensation

: Contraindication: LATEX ALLERGY (Severe redness, itching, swelling)

: Side effect: perineal irritation

: prevents STIs

3.2.2 Diaphragm (inserted into the anterior vagina and cervix)

Ø Specific action: A circular rubber disc that fits over the cervix and forms a barrier against the
entrance of sperms
Ø Is initially inserted by the doctor who determines the depth of the vagina

Ø May be coated with spermicide jelly or cream for double protection

Ø Maybe washed with soap and water after use; us reusable

Ø Sperms remain viable in 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

Ø needs fitting (consult physician if you have gained 10 lbs)

3.2.3 Cervical Cap

- risk for infection

- use spermicide

-inserted 2 hrs prior to intercourse and removed 6 hrs after intercourse (risk for cervicitis)

3.2.4 IUD (98% effective)

- a flexible appliance is inserted into the uterine cavity

- made of copper (*assess allergies)

- Copper-coated: 5 years ; progesterone-coated: 1 year)

- Specific action: Prevent implantation by setting up a non-specific cell inflammatory reaction to

the device

- Inserted during 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 IUD in place, it need not be removed since it stays outside the
membranes and, therefore, will not in any harm the fetus.

DANGER SIGNS:

Period is late or missed

Abdominal pain is severe

Increased temperature (chills and fever)

Noticeable vaginal discharge, foul smelling

Spotting, bleeding, clots, heavy period

When to insert: after delivery or during menstruation

When to check: once a week for the first month ,Then once every month

Common complication:

Ø Pelvic Inflammatory Disease (PID)

Period is either late or skipped

Abdominal pain

Increase temperature/ chills

Noticeable vaginal discharge; foul smelling

Spotting, bleeding

Mngt: treat with antimicrobial

Wof: Wilson’s disease (d/t copper toxicity)

4. Surgeries

1.1. Female

4.1.1 Bilateral Tubal Ligation (BTL)

- best time to perform: AFTER DELIVERY

Requirements: 30 and above

- number of desired children

- man will give consent

4.1.2 Hysterectomy

4.2. Male

Sterilization: a surgical procedure intended to discontinue the capacity of a person to have

children. Passages of the ovum and sperm cells are occluded to render the person infertile

Reasons for sterilization

ü Genetic abnormalities

ü Medical reasons - hypertensive, renal or cardiovascular disease

ü The couple have reached their desired number of children

4.2.1. Vasectomy: reversible thru microsurgery

- does not provide immediate sterility

- need to ejaculate for up to 20 times to remove all sperm

5. Hormonal (99% efficient): inhibits OVULATION!

5.1. Pills

5.1.1 Mini-pill (Progestin only pill): alters cervical mucus; prevents IMPLANTATION

5.1.2 Morning after pill: taken after unprotected intercourse at midcycle; ESTROGEN only

5.1.3 Combined: available in 21 or 28 day preparations (with FeSO4 placebo pills (7 tabs)

*taken during the first day of menstruation

*set schedule for drinking pills

*IF YOU MISSED A PILL: take the pill as soon as you remember it along with the pill scheduled on
that day.

*IF YOU MISSED 2 PILLS: take two pills as soon as you remember and two pills again the
following day (S/E: breakthrough bleeding); use another method of contraception

*IF YOU MISSED 3 or MORE PILLS: throw out the rest of the pack and start a new one

S/E: N/V, breast tenderness, weight gain, breakthrough bleeding

C/I: History of DVT and heavy smokers; advanced age (>35 y/o), breastfeeding (if pills contain
estrogen), liver disease (hepatotoxic)

Diagram 2.2. OCP Danger Signs

OCP DANGER SIGNS

Hypertensive effects

Abdominal pain (severe)

Chest pain

Headache

Eye problems (blurred vision, loss of vision)

Severe leg pain

REFER IMMEDIATELY!

5.2INJECTABLES

DEPO PROVERA (Depo Medroxyprogesterone; X ESTROGEN)

: good for 3 months (dosage: 150 mg progesterone)

: DO NOT MASSAGE THE SITE

: DO NOT SHAKE WHEN PREPARING

: interferes with INSULIN (not for DIABETICS)

5.3IMPLANTS

Norplant : 6 capsules of progestin are inserted SC in the upper arm

: can lasts for up to 5 years

: made up of synthetic progesterone-levonorgestrel.

:it slowly releases hormones to suppress ovulation

: makes cervical mucus thicker and rapidly transports ovum through the oviducts and prevents
thickening of the endometrium to prevent implantation.

: implanted using anethesia during menses or within 7 days of menses, 6 weeks after delivery or
immediately after abortion

Advantages: long term reversible contraception

: does not interfere with coitus

: has no estrogen related side effects

: can be used during breastfeeding

: can be used by adoloescents

: rapid return of fertility - 3 months after removal

Disadvantages: expensive, scarring at insertion site

Side effects: weight gain

: irregular menstrual cycle, spotting, breakthrough bleeding, amenorrhea, prolonged periods

: hair loss

: depression

: infection at insertion site

: local reaction of itching and pain at insertion site usually resolves within one month

Contraindications: Pregnancy, desire to get pregnant within the next 2 years, undiagnosed
vaginal bleeding

Video Link: https://youtu.be/ONzym0s82r8

CARE OF THE NEWBORN

ESSENTIAL CARE OF THE NEWBORN

IMMEDIATE CARE OF NEWBORN

1st days of life:
1. Initiation and maintenance of respiration
2. Establishment of extra uterine circulation
3. Control of body temp
4. Establishment of waste elimination
5. Intake of adequate nourishment
6. Prevention of infection
7. Establishment of an infant-parent relationship
8. Dev’t care that balances rest & stimulation or mental dev’t

Video Link: https://youtu.be/AjcoR2tozyQ, https://youtu.be/QUueKJ5rGFo

Implementation of “UNANG YAKAP” by DOH

Legal basis: A.0 2009-0025
Signed on December 1, 2009
Goal: To reduce neonatal mortality

ESSENTIAL AND IMMEDIATE PROCEDURES UNDER UNANG YAKAP

 Immediate and thorough drying within the first 30 seconds after delivery
 Rationale: Secretions can cause heat loss which may result to HYPOTHERMIA or
COLD STRESS
 Initiate early skin-to-skin contact
 Properly timed cord clamping and cutting
 : clamp the cord 3 cms away from the navel and placed kelly clamp 5 cms away from
the base. Cut in between when the pulsation has stopped. DO NOT MILK THE
CORD.
 Initiate early breastfeeding within 90 minutes

NON-IMMEDIATE PROCEDURES
 Bathing of the newborn - done after 6 hours
 Vitamin K administration to prevent bleeding
 Crede’s prophylaxis/Eye prophylaxis to prevent infection

Initiation and Maintenance of Respiration

2nd stage of labor- initial airway

initiation of airway is a crucial adjustment

most neonatal deaths w/n 24 h caused by inability to initiate airway
lung function begins after birth only
RR in the first minute of life may be as high as 80 bpm.
as respiratory activity is established and maintained, this rate settles to an average of 30-60
bpm
Rate, depth and rhythm are IRREGULAR and with short periods of APNEA (lasting for less
than 15 seconds -- periodic respirations)
assess the RR by observing the rise and fall of the abdomen because primarily it involves the
use of the diaphragm and abdominal muscles
Coughing and sneezing reflexes will help clear the airway
How to initiate airway:
a. Remove secretions using bulb syringe
b. Catheter Suctioning
1) Place head to side to facilitate drainage of secretions
2) Suction mouth 1st before nose
o neonates are nasal breathers
o they show signs of distress when nostrils are occluded
o Signs and symptoms of distress: short periods of crying, increased depth of
respirations
3) Period of time
 5-10 sec suctioning, gentle and quick
o Prolonged & deep suctioning can lead to: Hypoxia, Laryngospasm,
Bradycardia d/t stimulation of vagal nerve located near esophagus & anus
c. If not effective, requires effective laryngoscopy to open airway. After deep suctioning, an
endotracheal tube can be inserted and oxygen can be administered by positive pressure bag
and mask with 100% oxygen at 40-60 breaths per minute

Nursing considerations when administering oxygen:

1. No smoking to prevent combustion
2. Always humidify to prevent drying of mucosa
3. Over dosage of oxygen can lead to scarring of retina leading which may lead
to BLINDNESS (Retro Lentalfibrolasia or Retinopathy of Prematurity) ROP -
prone to: SGA, LBW, Preterm
4. In cases of meconium staining, never administer oxygen with pressure
 (O2 pressure will push mecomium inside) ------Atelectasis (lung collapse)

Control of Body Temperature

 GOAL: maintain temperature of not less than 97.7% F (36.5 C)
 Maintenance of temperature is crucial in preterm and SGA (small for gestational age) - more
prone to stress and hypothermia

Factors Leading to Development of HYPOTHERMIA

1. Preterms are born Poikilothermic- cold blooded
o Babies easily adapt to temp of environment due to immaturity of thermo
regulating system of body (Hypothalamus)
2. Inadequate subcutaneous tissue fats
3. Baby is not capable of shivering *Earliest sign of hypothermia- increase in RR
4. Babies are born wet

PROCESS OF HEAT LOSS

1. Evaporation - loss of heat through conversion of a liquid to vapor.
2. Conduction - transfer of heat to a cooler solid object in contact with the baby
3. Convection - flow of heat from the newborn’s body surface through air currents
4. Radiation - transfer of body heat to a cooler solid object without direct contact

Effects of Hypothermia (Cold stress)

1.) Hypoglycemia- 45-55 mg/dl normal (40- borderline) due to utilization of glucose
2.) Metabolic acidosis- catabolism of brown fats (best insulator of newborns body) will form
ketones (found in chest/back)
3.) High risk for kernicterus- bilirubin in brain leading to cerebral palsy
4.) Additional stress to cardiovascular system
 Prevention of Hypothermia:
1. Dry and wrap baby. Put the baby in a basinette covered with warm blanket
2. Use radiant warmer if necessary
3. Initiate skin-to-skin contact- kangaroo care (skin to skin contact)

BREASTFEEDING

1. Implications of Physiology of Breastmilk production

1.1 Regardless of the mother’s physical condition, method of delivery, or breast
size/condition, milk will be produced.
1.2 Lactation does not occur during pregnancy because estrogen and progesterone are
present and therefore inhibit prolactin production.
1.3 Lactation – suppressing agents are to be given immediately after placental delivery to be
effective.
1.4 Oral contraceptives are contraindicated in lactating mother because they contain estrogen
and progesterone, thereby decreasing milk supply.
1.5 Afterpains are felt more by breastfeeding women because of oxytocin production; they
also have less lochia and experience more rapid involution.
1.6 In an emergency delivery;
1.6.1 Determine the EDC, whether the woman in labor is a primi or a multi, and the
stage of labor.
1.6.2 If no sterile equipment is available to cut the cord, wrap the baby and placenta
together; never cut the cord unless sterile equipment is are available.
1.6.3 If the uterus fails to contract after delivery, put the infant to the breast; the
sucking of the infant produces oxytocin which causes uterine contraction

Advantages of Breastfeeding
 Store milk- plastic storage container
1. Economical: >good for 6 mon. from freezer/ at room. temp. don’t heat
2. Always available
3. Promotes Bonding
4. Breastfed babies have higher IQ than bottle fed babies.
5. It facilitates rapid involution
6. Decrease incidence of breast cancer.
7. Contents of BREAST MILK:
a. Antibodies- IgA
b. Lactobacillius bifidus- interferes w/ attack of pathogenic bacteria in GIT
c. Macrophages
d. Lactoferrin - iron bindig protein
e. Lyzozymes - breastmilk enzyme that destroys bacteria by lyzing or disolving cell
membrane
f. Interferons - it inhibits viral growth
g. Immunoglobulin

Health Teachings
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.
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
away from the infant’s nose.
 Stimulate the baby to open his mouth to grasp the nipples by means of the rooting reflex
a) Rooting reflex- by touching the side of lips/cheeks then baby will turn to stimulus.
b) Sucking – when you touch middle of lips then baby will suck
 Disappears by 6 months
 When not stimulated sucking will stop.
c) Swallowing- when food touches posterior of tongue then it will be automatically
swallowed NEVER DISAPPEAR
d) Extrusion/ Protrusion reflex
 when food touches anterior portion of tongue then it will be automatically
extruded or protruded.
Purpose: to prevent from poisoning
Disappear by 4 months & baby can already spit out by 4 months.
 Infant should grasp not only the nipple but also the areola for effective sucking
motion. Effectiveness is ensured when the: (PROPER LATCHING)
o baby’s mouth covers the areola
o Lower lip is turned outward
o mother feels after pains as the baby sucks
o other nipple flows with milk while baby is feeding on other breast
 To prevent nipples from becoming sore and cracked, infant should be introduced to the breast
gradually. The baby should be fed for only 5 minutes at each breast during each feeding on the
first day, increasing the time at each breast by 1 minute per day until the infant is nursing for
10 minutes at each breast, 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; if only half-
emptied will also half-refill and after some time, will become insufficient.
 To break away from the closed suction at the breast after feeding, insert a clean little 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 gamma globulin (antibodies), the only
group of substances that can never be replicated by any artificial formula.
 Advise the mother to learn how to relax during feedings because tension prevents good let-
down.

ASSOCIATED PROBLEMS
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 will also prevent contamination of the nipples
and areolae.
 Cold compress is applied if the mother does not intend to breastfeed; warm compress is
applied if she will breastfeed.
 Breast pump should not be used and breast massage should not done if the mother is
not going to breastfeed, since either will stimulate milk production.

Sore nipples – not contraindications to breastfeeding.

 Management:
 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 breasts
 Milk becomes scantly

Management
 Antibiotics as ordered
 Ice compress
 Proper breast support
 Discontinue breastfeeding in affected breast

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.

Contraindications
 Drugs – oral contraceptives, atropine, anticoagulants, antimetabolites, cathartics,
tetracyclines. (Insulin, epinephrine, most antibiotics, antidiarrheals and histamines are
generally not contraindicated. Therefore, diabetics and those with asthma can
breastfeed.)
 Certain disease conditions, specifically tuberculosis, because of the close contact
between mother and baby during feeding. (However, mothers may use masks to prevent
droplet spread) TB germs, however, are not transmitted thru breast milk.

a. Maternal Conditions:
 HIV
 CMV
 Coumadin
 use of warfarin
b. Newborn Condition:
 Inborn errors of metabolism
 Erythroblastosis Fetalis – Rh incompatibility
 Hydrops fetalis
 Phenylketonuria, Galactosemia
 Video Link:
https://youtu.be/v8ug9_0kjyo
https://youtu.be/xWPbykBKEMA
https://youtu.be/DQj-Mn0c370

Establish Waste Elimination

A. Types of Stools

1. Meconium - physiologic stool

Characteristics - blackish green, sticky, tar like, odorless (Sterile intestine) (no bacteria) will pass w/in 24 – 48
hrs

**Failure to pass mecomium after 24 hours- GIT obstruction

Suspect presence of: Hirschsprungs disease

Imperforate anus

Meconium ileus – due to Cystic Fibrosis

2. Transitional Stool - (4-14 days)

- green loose & shiny, like diarrhea to the untrained eye (primipara mother)

- by 4th day of life, breastfed babies pass three or four light yellow stools per day

- described as sweet-smelling due to lactic acid, which reduces the amount of putrefactive organisms in the
stool.

Note: A newborn placed under phototherapy lights as a treatment for jaundice has bright green stools
because of increased bilirubin excretion.

Newborns with bile duct obstruction have clay-colored (gray) stools, because bile pigments are not entering
the intestinal tract

Blood-flecked stools usually indicate an anal fissure

4. Bottlefed Stool - pale yellow, formed hard with typical offensive odor, seldom passed, 2–3 x/day

5. Supplementary - with food added -brown & odorous

Indication of Stool Changes: Jaundice baby – light stool

Under phototherapy – bright yellow

Mucus mixed with stool - milk allergy

Clay colored stool – obstruction to bile duct

Chalk clay stool – after barium enema

Black stool – GIT bleeding (melena)

Blood flecked stool - anal fissure.

*Currant jelly stool – intussusception

*Ribbon like stool – Hirschsprung disease

*Steatorrhea stool – fatty, bulky foul smelling odor stool

- malabsorption syndrome (Example: Celiac disease or Cystic fibrosis)

ASSESSMENT OF WELL-BEING

Video Link: https://youtu.be/cQKaTCMFjwc

A. APGAR SCORE – Dr. Virginia Apgar

 Special Considerations: 1st 1 min – determine general condition of baby

 Next 5 min- determine baby’s capabilities to adjust extra uterinely (most
important)
 Next 15 min – (optional) dependent on the 5 min

A- appearance- color – slightly cyanotic after 1st cry baby becomes pink.
P- pulse rate – apical pulse – left lower nipple
G- grimace – reflex irritability- (1) tangential foot slap, (2) catheter insertion
A – activity – degree of flexion or muscle tone
R – respiration - assessment of lungs
 Baby cries – within 30 secs
 Failure to cry after 30 secs – asphyxia neonatorum

Respiratory depression – due to Demerol (given to the mother).

 Administer Naloxone

Table 4.4. APGAR Scoring Chart

0 1 2
HR (most important) Absent <100 >100
Respiratory Effort Absent Slow, irregular, weak Good strong cry
Muscle Tone Flaccid extremities Some flexion Well flexed
Reflex Irritability No Response Grimace Cough, sneeze
Acrocyanosis Pinkish
Color Blue/pale (body- pink
extremities-blue)

APGAR Result
0 – 3 = severely depressed, need CPR, admission NICU
4 – 6 = moderately depressed, needs add’l suctioning & O2 administration
7 - 10 =good/ healthy

Management: CPR – cardio-pulmonary resuscitation

 New: Cardio pulmonary cerebral resuscitation (CPCR)

Method:
 5 minutes deficient in oxygen – irreversible brain damage
 1. Stimulate baby by tapping the shoulders. If there is no response, CALL FOR HELP!
2. Position flat on back, use cardiac board
3. Perform head tilt chin lift maneuver except if you suspect a spinal cord injury
 Breathing (ventilating the lungs)
 check for breathlessness
 if breathless, give 2 breaths- ambu bag
o 1 yr old- mouth to mouth, pinch nose to create a seal
o < 1 yr – mouth to nose
o infant – puff
 Circulation:
 Check for pulselessness:
 carotid- adult
 Brachial – infants
 CPR – breathless/pulseless
 Compression – for infant: 1 fingerbreath below the nipple line

CPR: Ventilation: Compression ratio

o Infant 1:5
o Adults 2:30

Respiration Evaluation
Table 4.5. Respiratory Assessment
Criteria 0 1 2
Chest movement synchronized Lag on respiration See - saw
Intercostal retraction No retraction Just visible Marked
Xiphoid retraction None Just visible Marked
Nares dilatation None Minimal Marked
Expiratory grunt None Heard on stet only Heard on naked ear

1. Assessment tool that determines respiration of baby: Silvermann Anderson Scale

 Lowest score – best
 Interpretation result:
0 -3 – normal, no RDS
4 – 6 – moderate RDS
7 – 10 – severe RDS

Assessment of Gestational Age

1. Clinical Criteria:
Table: Ballards & Dobowitz

Findings Less 36 weeks 37 - 38 39 and up

(Preterm)
Sole creases Anterior transverse crease Occasional creases 2/3 Covered with creases
only in
Breast nodules 2mm 4mm or 3.5 mm > 5 or 7mm
Scalp hair Fine & fuzzy Fine & fuzzy Coarse & silky
Ear lobe Pliable Some cartilage Thick cartilage
Testes and testes in lower canal Some intermediate Testes pendulus
Scrotum Scrotum – small few rugae Scrotum fully covered w/ rugae

2. Signs of Preterm Babies

  Born after 20 weeks & before 37 weeks
 Frog leg or lax position
 Hypotonic muscle tone- prone to respiratory problem
 Scarf sign – elbow passes midline pos.
 Square window wrist – 90 degree angle of wrist
 Heel to ear sign
o Complications: RDS, Hypothermia
 Abundant lanugo

Type of Feeding Pre-Term:

 Gavage Feeding –a nasogastric tube is inserted
o Rationale: To prevent aspiration due to absence of gag & swallowing reflex

3. Signs of Post term babies:

> 42 weeks

>Classic sign – old man’s face

>Desquamation – peeling of skin

*Long brittle finger nails

>Wide & alert eyes

Neonates in Nursery

1. Special & Immediate Interventions:

a. Nursing responsibility upon receiving baby- proper identification
b. Take anthropometric measurement
 normal length- 19.5 – 21 inch or 47.5 – 53.75cm, average 50 cm
 head circumference 33- 35 cm or 13 – 14 “
 Hydrocephalus - >14”
 Chest 31 – 33 cm or 12 – 13” (Average 32 cm)
 Abdomen 31 – 33 cm or 12 – 13”

c. Bathing (Sponge Bath)

SUPPLIES NEEDED
 padding for hard surfaces such as blanket or towels
 bowl of warm water
 washcloth
 mild baby soap
 clean diaper
 baby towel

1. Choose a warm room, around 75 F (23.8 C) for the bath, remove your baby’s clothes and
diaper, and wrap them in a towel.
2. Lay your baby on a flat surface, such as the floor, table, counter next to a sink, or your bed. If
your baby is off the ground, use a safety strap or keep one hand on them at all times to make
sure they don’t fall.
3. Unwrap the towel one part at a time to expose only the area of the body you’re washing
 4. Start at your baby’s face and top of their head: First dip the clean cloth in the warm water. Use
only warm water without soap for this step to avoid getting soap in your baby’s eyes or mouth.
Wipe the top of the head and around the outer ears, chin, neck folds and eyes.
5. Add a drop or two of soap into the warm water. Dip the washcloth in the soapy water and
wring it out.
6. Use the soapy water to clean around the rest of the body and diaper area. You’ll want to clean
under the arms and around the genital area. If your baby was circumcised, avoid cleaning the
penis to keep the wound dry unless otherwise directed by the physician
7. Dry your baby off, including drying between skin folds. Put on a clean diaper. You can use a
towel with a built-in hood to keep their head warm while they dry off too.

d. Dressing the Umbilical Cord

 Check AVA, then draw 3 vessel cord
o if 2 vessel cord—suspect absence of kidneys
o leave about 1 inch” of cord
o if BT or IV infusion – leave 8” of cord
Best site of blood nerve access: umbilical cord

 Check cord every 15 minutes for the 1st 6 hrs: Monitor for bleeding
o If bleeding is more than 30 cc of blood, suspect for hemorrhage
o Excessive bleeding of cord – Omphalagia – suspect hemophilia or blood dyscrasia
o Cord turns black on 3rd day & fall 7 – 10 days
o Failure to fall after 2 weeks- Umbilical granulation (w/o foul smelling odor, pinkish)

MANAGEMENT: silver nitrate or cautery

 clean with normal saline solution not alcohol
 don’t use bigkis – air
 persistent moisture-urine, suspect patent uracus – fistula bet bladder & normal umbilicus

e. Crede’s Prophylaxis
 Purpose: prevent opthalmia neonatorum or gonorrheal conjunctivitis
 Mode of Transmission: NSD of mother with gonorrhea or chlamydia
 Drug:
o erythromycin ophthalmic ointment- apply from inner to outer canthus
o Silver nitrate (used before) – 2 drops of drug in the lower conjunctiva
 Side effects: staining of skin, chemical conjunctivitis

f. Administer Vitamin K
 newborns are at risk for bleeding disorders during the first week of life because their
gastrointestinal tract is sterile at birth and unable to produce Vitamin K, which is necessary
for coagulation
 to prevent hemorrhage related to physiologic hypoprothrombinemia:
o Aquamephyton, phytomenadione or konakion
o Dosage: 0.5 – 1.5 mg IM, vastus lateralis; 5 mg preterm baby

Nursing Considerations:
 Anticipate the need for injection immediately after birth
 Administer IM injection into large muscle (anterolateral aspect of thigh)
 Assess for signs of bleeding, such as black, tarry stools, hematuria, decreased hematocrit
and bleeding from any open wounds or base of the cord

g. Checking for weight

 Normal weight: 3,000 – 3400 gms/ 3 – 3.4 kg / 6.5 - 7.5 lbs

> Arbitrary lower limit 2500 grams

> Low birth weight baby delivered: below 2500 grams

> Small for gestational age (SGA): < 10th % rank or born small

> Large for gestational age (LGA): > 90th % rank or macrosomia (>4000 grams)

> Appropriate for GA: within 2 standard deviation of mean (AGA)

> Physiologic weight loss: 5 – 10% wt loss few days after birth

· Small GA < (less) 10

· Large GA > (more) 90

Newborn Screening
Definition:
NBS is an essential public health strategy that enables the early detection and management of
several congenital disorders, which if left untreated, may lead to mental retardation and/or
death. Early diagnosis and initiation of treatment, along with appropriate long-term care help
ensure normal growth and development of the affected individual. It has been an integral part
of routine newborn care in most developed countries.

Program objective:
By 2030, Filipino newborns are screened; Strengthen quality of service and intensify monitoring
and evaluation of NBS implementation; Sustainable financial scheme; Strengthen patient
management

Policies and Laws:

RA 9288 or the Newborn Screening act of 2004 and DOH AO no. 2014-0045 or the Guidelines
on the Implementation of the Expanded Newborn Screening Program

Importance of NBS:
Most babies with metabolic disorders look normal at birth. One will never know that the baby
has the disorder until the onset of signs and symptoms and more often ill effects are already
irreversible.

When is Newborn Screening done?

Newborn screening is ideally done on the 48th hour or at least 24 hours from birth. Some
disorders are not detected if the test is done earlier than 24 hours. The baby must be screened
again after 2 weeks for more accurate results.

How is Newborn Screening done?

Newborn screening is a simple procedure. Using the hell prick method, a few drops are taken
from the baby's heel and blotted on a special absorbent filter card. The blood is dried for 4
hours and sent to the Newborn Screening Laboratory. (NBS Lab)

Who will collect the sample for Newborn Screening?

A physician, a nurse, a midwife or medical technologist can do the newborn screening.

Where is Newborn Screening Available?

 Newborn screening is available in practicing health institutions (hospitals, lying-ins, Rural Health
Units and Health Centers). If babies are delivered at home, babies may be brought to the
nearest institution offering newborn screening

When is the Newborn Screening results available?

Newborn screening results are available within three weeks after the NBS Lab receives and
tests the samples sent by the institutions. Results are released by NBS Lab to the institutions
and are released to your attending birth attendants or physicians. Parents may seek the results
from the institutions where samples are collected.

A negative screen mean that the result of the test is normal and the baby is not suffering from
any of the disorders being screened. In case of a positive screen, the NBS nurse coordinator
will immediately inform the coordinator of the institution where the sample was collected for
recall of patients for confirmatory testing

What should be done when a baby has a positive newborn screening result?
Babies with positive results should be referred at once to the nearest hospital or specialist for
confirmatory test and further management. Should there be no specialist in the area, the NBS
secretariat office will assist its attending physician.

Disorder Effect Effect if SCREENED and

Screened SCREENED treated
CH (Congenital Hypothyroidism) Severe Mental Retardation Normal
CAH (Congenital Adrenal Hyperplasia) Death Alive and Normal
GAL (Galactosemia) Death or Cataracts Alive and Normal
PKU (Phenylketonuria) Severe Mental Retardation Normal
G6PD Deficiency Severe Anemia, Kernicterus Normal

1. Congenital Hypothyroidism (CH)

 CH results from lack or absence of thyroid hormone, which is essential to growth of the brain
and the body. If the disorder is not detected and hormone replacement is not initiated within
(4) weeks, the baby's physical growth will be stunted and she/he may suffer from mental
retardation.

2. Congenital Adrenal Hyperplasia (CAH)

 CAH is an endocrine disorder that causes severe salt lose, dehydration and abnormally high
levels of male sex hormones in both boys and girls. If not detected and treated early, babies
may die within 7-14 days.

3. Galactosemia (GAL)
 GAL is a condition in which the body is unable to process galactose, the sugar present in milk.
Accumulation of excessive galactose in the body can cause many problems, including liver
damage, brain damage and cataracts

4. Phenylketonuria (PKU)
 PKU is a metabolic disorder in which the body cannot properly use one of the building blocks
of protein called phenylalanine. Excessive accumulation of phenylalanine in the body causes
brain damage

5. Glucose-6-Phosphate Dehydrogenase Deficiency (G6PD Deficiency)

  G6PD deficiency is a condition where the body lacks the enzyme called G6PD. Babies with this
deficiency may have hemolytic anemia resulting from exposure to certain drugs, foods and
chemicals.

6. Maple Syrup Urine Disease

 Is an autosomal recessive metabolic disorder affecting branched-chain amino acids. It is one
type of organic academia. The condition gets its name from the distinctive sweet odor of
affected infant’s urine, particularly prior to diagnosis and during times of acute illness

GROWTH AND DEVELOPMENT

GROWTH

· Increase in physical size of a structure or whole

· Quantitative

· 2 parameters

o Weight

Weight gain:

2x = 5 – 6 mos. 3x = 1 year

4x = 2 – 2½ years

Most sensitive measurement for growth

o Height

ü ESTROGEN: responsible for increase in height in female

ü TESTOSTERONE: responsible for the increase in height in male

- 1”/ mo – 1 – 6 mos

- 1.5”/ mo – 7 – 12 mos

- 50 % - 1st Year

Stoppage of height coincide with the eruption of the wisdom teeth

HEIGHT COMPARISON

9 y/o à male = female

12 y/o à Male < Female

13 y/o à Male > Female

DEVELOPMENT

ü Increase in the skills or capacity to function

ü Qualitatively

ü How to measure development:

o By observing the child doing simple task

o By noting parent’s description of the child’s progress

o Measure by DENVER DEVELOPMENTAL SCREENING TEST (DDST)

· MMDST

o Metro Manila Developmental Screening Test

o Philippine Based exam

· Main Rated Categories

o LANGUAGE  ability to communicate

o PERSONAL/ SOCIAL  ability to interact

o FINE MOTOR ADAPTIVE  ability to use hand movements

o GROSS MOTOR SKILLS  ability to use large body movements

MATURATION

· Synonymous with development

· Readiness/ learning is effortless

COGNITIVE DEVELOPMENT

· Ability to learn and understand from experiences, to acquire and retain knowledge, to respond to a
new situation and to solve problems

LEARNING: change of behavior

IQ= [Mental Age/ Chronological Age] x 100 Normal IQ = 90 - 110

GIFTED CHILD  > 130 IQ level

BASIC DIVISIONS OF LIFE

· Prenatal

o Conception to birth

· Infancy

o Neonatal  first 28 days

o Formal Infancy  29th – 1 year

· Early Childhood

o Toddler  1 – 3 y/o

o Preschool  4 – 6 y/o

· Middle Childhood

o School Age  7 – 12 y/o

· Late Childhood

o Pre – adolescent  11 – 13 y/o

o Adolescent – 12 – 13 y/o to 21

PRINCIPLES OF GROWTH AND DEVELOPMENT

· Growth and development is a continuous process (WOMB TO TOMB PRINCIPLE)

ü begins from conception and ends with death

ü Not all parts of the body grows at the same time or at the same rate (ASYCHRONOUS
GROWTH)

ü Each child is unique

ü Growth and development occurs in a regular direction reflecting definite and predictable patterns
or trends

Directional Terms

· Cephalocaudal/ Head to Tail: It occurs along bodies long axis in which control over head,
mouth and eye movemens and precedes control over upper body torso and legs

· Proximo – Distal/ Centro – Distal: Progressing from center of the body to the extremities

· Symmetrical/ Each side of the Body: Develop at the same direction at the same time and at
the same rate

· Mass – Specific: Differentiation – SIMPLE TO COMPLEX; BROAD TO REFINE

· Sequential Trend: Involves a predictable sequence of growth and development to which the
child normally passes

Example: Locomotion - Creeps  Stands  Walks  Run

Language and Social Skills - Cry  coo

· Secular Trend: Refers to the worldwide tend of maturing earlier and growing larger as
compared to succeeding generation

· BEHAVIOR: most comprehensive indicator of developmental stages

· PLAY: universal language

· A great deal of skills is learned by practice

· There is optimum time for initiation of experience or learning

· Neonatal reflexes must be lost first before development can proceed

· persistent primitive infantile reflexes is a possible case of cerebral palsy

PATTERNS OF GROWTH AND DEVELOPMENT

· Renal  digestive  circulatory  musculoskeletal

o childhood

· Brain  CNS  Neurologic Tissue  rapidly grows with in 1 – 2 years

o Brain achieves its adult proportion @ 5 years

o Rapid growth and development of brain from1 – 2 years

o Malnutrition may result to Mild Mental Retardation

· Lymphatic System (Lymph Nodes)

o Grows rapidly during infancy and childhood

o Provide protection against infection

o TONSIL reach its adult proportion @ 5 years

· Reproductive

o Grows rapidly during puberty

RATES OF GROWTH AND DEVELOPMENT

· Fetal and Infancy

o Period of most rapid growth and development

o Prone to develop anemia

· Toddler

o Period of slow growth and development

· Toddler and preschool

o Period of alternating rapid and slow growth and development

· School Aged
o Slower growth and development

o Least to develop anemia

· Adolescent

o Period of rapid growth

o Secondary prone to anemia

Two Primary Factors Affecting Growth and Development

· Heredity

o Race

o Sex

o Intelligence

o Nationality

· Environment

o Quality of Nutrition

o Socio Economic Status

o Health

o Ordinal Position in the family

o Parent – Child Relationship

*Universal Principle: F are born < wt. than M by 1 oz.; F are born < lt. than M by 1 in.

THEORIES OF DEVELOPMENT

Developmental Task

· A skill or growth responsibility arising at a particular time in the individual’s life.

· The successful achievement of which will provide a foundation for the accomplishments of the
future tasks

SIGMUND FREUD’S PSYCHOSEXUAL THEORY

· 1856 – 1939

· An Austrian Neurologist

· Founder of Psychoanalysis

· 1st to introduce Personality Development

 Phase Age Site of Activities Task

Gratificati
on
Oral Phase 0 – 18 Mouth · Biting · Provide oral stimulation even if
baby is place NPO (use
mos. · Crying pacifier)CBQ

· Sucking · Never discourage thumb sucking

(enjoyment and
release

of tension)
Anal 19 mos. – Anus · Elimination · Help the child achieve bowel
Phase (stage and bladder control even if the child is
where OC 3 yrs. · Retention/ hospitalized
are develop Defecation of
ed) Feces · Principle of holding on and
letting go

· Mother wins or child wins

· Child Wins

o Holding on

o Child turns to be hardheaded,

antisocial, stubborn, unreliable,
irresponsible

· Mother Wins

o Letting go

o Child turns to be kind, obedient,

perfectionist

o Meticulous, OCs, reliable,

responsible
Phallic 4 – 6 yrs. Genital · May show · Accept the child fondling his
Phase exhibitionis m own genetalia as normal area of
exploration
· Have or
increase · Divert attention from
knowledge of 2 masturbation
sexes
· Answer the child’s question

directly

· Human sexuality
 Latent 7 – 12 yrs. School aged · Period of · Help the child achieve (+)
Phase suppression experiences so that he’ll be ready to
face the conflicts of adolescents
· No obvious

development,
slower growth

· Child’s
energy or Libido
is diverted into
more concrete

type of thinking
Genital 12 – 18 yrs Genitalia · Achieve · Give opportunity to relate to
Phase sexual maturity opposite sex
and learn to
establish
satisfactory
relationship with
the opposite

sex

ERIK ERICKSON’S STAGES OF PSYCHOSOCIAL THEORY

· Former student of Freud

· Stresses the importance of culture and society to the development of one’s personality

· “environment”

1. Trust vs. Mistrust

· 0 – 18 months

· TRUST is the foundation of all psychosocial tasks

· Theme: Give and Receive

· Trust is developed via

o Satisfying needs of infants on time

o Care must be consistent and adequate

o Give experiences that will add security

o Hugs, kisses, touch, eye to eye contact, soft music

2. Autonomy vs. Shame & Doubt

· 18 mos. to 3 years
· Theme: independence and self – government

· Give opportunity for decision making, offer choices

· Encourage the child to make decision rather than judge

· Parents has a moral obligations to set limits

3. Initiative vs. Guilt

· 4 – 6 years old

· Learns how to do BASIC things

· Give opportunity exploring new places and events

· Right time for amusement park and zoos

· Activity recommended: molding clay and finger painting

· Enhances creativity and imagination and facilitates fine motor development

4. Industry vs. Inferiority

· 7 – 12 years old

· Learns how to do things well

· Give appropriate short assignments and projects

· Unfinished project will develop inferiority

5. Identity vs. Role Confusion

· 12 – 18 or 20 years old

· Learns who he is or what kind of person he will become by adjusting to new body image and
seeking EMANCIPATION/ freedom from parents

6. Intimacy vs. Isolation

· 18 – 25 or 30 years old

· Career focus

· Looking for a lifetime partner

7. Generativity vs. Stagnation

· 30 – 45 years old

8. Ego Integrity vs. Despair

· 45 years old and above

JEAN PIAGET’S STAGES OF COGNITIVE DEVELOPMENT

· Reasoning powers

· Swiss Psychologist

· Genetic Epistemologist

1. Sensorimotor

· 0 – 2 years old

· Also called Practical Intelligence

o words and symbols are not yet available

o communication through senses

1. Schema 1: Neonatal Reflex

o 1 month

o Early reflexes

2. Schema 2: Primary Circular Reaction

o 1 – 4 months

o Activities related to body; repetition of behavior

 Example: thumbsucking

3. Schema 3: Secondary Circular Behavior

o 4 – 8 months

o Activities not related to the body

o Discover person and object’s permanence

o Memory traces are present and anticipate familiar events

4. Schema 4: Coordination of Secondary Reaction

o 8 – 12 months

o Exhibit goal directed behavior

o  sense of permanence and separateness

o Play activities: Throw and retrieve

5. Schema 5: Tertiary Circular Reaction

o 12 – 18 months

o use trial and error to discover characteristic of places and events

o “Invention” of new means

o capable of space and time perception

6. Schema 6: Invention of New Means thru Mental Coordination

o 18 – 24 months

o Symbolic representation

o Transitional phase to the pre-operational thought period

2. Pre-operational Thought

1. Pre – conceptual Thought

o 2 – 4 years old

o Concrete, literal, static thinking

o CBQ EGOCENTRIC – unable to view anothers viewpoint

o CBQ (-) REVERSIBILITY – in every action there is opposite reaction; cause and effect

o Concept of time is only now and concept of distance is only as far as they can see

o CBQ ANIMISM – consider inanimate object as alive

2. Intuitive Thought

o Beginning of causation

3. Concrete Operational

o 7 – 12 years old

o SYSTEMATIC REASONING as solution to problems

o Concept of (+) reversibility

o Concept of Conservation – constancy despite of transformation

o Activity recommended: Collecting and Classifying

4. Formal Operational

o 12 years old and above

o Period when cognition achieve its final form

o Can solve hypothetical problem with SCIENTIFIC REASONING

o Can deal with past, present and future

o Capable of ABSTRACT, mature thought and formal reasoning

o Activity recommended: talk time; focus on opinions and current events

KOHLBERG’S THEORY OF MORAL DEVELOPMENT

· Recognized the theory of moral development as considered to closely approximate cognitive

stages of development

· Stages of Moral Development

o Infancy

o Premoral

o Amoral

o Pre-religious

Age Stage Description

PRECONVENTIONAL (Level I)
0 – 3 yrs 1 · PUNISHMENT/ OBEDIENCE/ ORIENTATION

o Heteronomous morality

o Child does right because PARENT tells him to and to avoid

punishment
4 – 7 yrs. 2 · INDIVIDUALISM

o Instrumental purpose and exchange

o Carries out action to satisfy own needs rather than society

o Will do something for another if that person does something

for the child

CONVENTIONAL (Level II)
4 – 10 yrs. 3 · ORIENTATION TO INTERPERSONAL RELATIONS OF
MUTUALITY

o Child follows rules because of need to be a “good person” in

own eyes and eyes of others

10 – 12 4 · MAINTAINANCE OF SOCIAL ORDER, FIXED RULES AND
AUTHORITY
yrs.
o Child finds following rules satisfying

o Following rules of authority figures as well as parents in an

effort to keep the “system” working

POST – CONVENTIONAL (Level III)
Older than 5 · SOCIAL CONTRACT, UTILITARIAN LAW – MAKING
12 PERSPECTIVE

o Follows standards of society for the good of the people

6 · UNIVERSAL ETHICAL PRINCIPLE ORIENTATION

o Follows internalized standards of conduct

o Only few people achieved this level

o Only saints and holy

DEVELOPMENTAL MILESTONES

· Major marker of growth and development

· Determines developmental delays

TEETH QUESTIONS

6 mos. Eruption of first temporary teeth 2 LOWER CENTRAL INCISORS

30 mos. Temporary teeth complete 20 decidous teeth

POSTERIOR MOLAR --> last to appear Time to go to Dentist

Begins to brush teeth

3 years Tooth brushing with minimal supervision
6 years Tooth brushing alone Temporary teeth begins to fail

1st permanent teeth  1st MOLAR

Last to appear  WISDOM TOOTH

BOWEL/ BLADDER CONTROL

Bowel Control  18 months / 1 ½ years Day Time Bladder Control  2 years

Night Time Bladder Control  3 years

MILESTONES

Infancy

· Solitary play

o Consider when choosing a play

Ø Safety

Ø Age appropriateness

Ø Hygiene
· Fear: Stranger Anxiety

o Begins: 6 – 7 months

o Peaks: 8 months

o Diminishes: 9 months

Neonate

· Complete head lag

· Largely reflex visual fixation for human face

· Hands fisted with thumbs in

· Cries without tears because lacrimal glands are not fully developed

1 month

· Dance reflex disappear

· Looks at mobile; follows midline

· Alert to sound, regards face

2 months

· Holds head up when in prone

· Social smile, cries with tears, cooing sound

· Closure of posterior fontanel (2-3 months)

· Head lag when pulled to sitting position

· No longer clinches fist tightly

· Follows object past midline

· Recognizes parents

3 months

· Holds head and chest up when in prone

· Holds hands open at rest

· Hand regard, follows object past midline

· Grasp and tonic neck reflexes are fading

· Reaches for familiar people or object

· Anticipates feeding

4 months

· Head control complete

· Turns front to back; needs space to turn

· Laughs aloud; Babbling sound

· Babinski Reflex disappears

5 months

· Turn both ways (roll over)

· Teething rings, handles rattle well

· Moro reflex disappears (5 – 6 months)

· Enjoys looking around environment

6 months

· Reaches out in the anticipation of being picked- up

· Sits with support

· Puts feet in mouth in supine position

· Eruption of first temporary teeth ( Lower 2 central incisors)

· Vowel sounds “ah, eh”

· Uses palmar grasp; handless bottle well

· Recognizes strangers

7 months

· Transfer objects from hand to hand (6 – 7 months)

· Likes objects that are good sized for transferring

8 months

· Sits without support

· Peak of stranger anxiety

· Plantar reflex disappear (6-8 months)

9 months
· Creeps or crawls; need space for creeping

· Neat pincer grasp reflex, probes with forefinger

· Finger feeds, combine 2 syllables “mama & dada”

10 months

· Pulls self to stand

· Understand the word no

· Respond to name

· Peek – a – boo, pat a cake, since they can clap

11 months

· Cruising, stand with assistance

· Walking while holding to his crib’s handle

· One word other than mama and dada

12 months

· Stands alone

· Walk with assistance

· Drink from cup, cooperates in dressing

· Says two words other than mama and dada

· Pots & pans, pull toys and nursery rhymes

· Imitates actions, comes when called

· Follows one – step command and gesture

· Uses mature pincer graps, throws objects

Toddler (12 months to 3 years)

A. Physical tasks: this is a period of slow growth

1. Weight: gain of approximately 11 lb (5 kg) during this time; birth weight quadrupled by 2 1/2 years

2. Height: grows 20.3 cm (8 inches);

3. Head circumference: 19½ - 20 inches (49 - 50 cm) by 2 years; anterior fontanel closes by 18 months

4. Pulse 110; respirations 26; blood pressure 99/64

5. Primary dentition (20 teeth) completed by 2 1/2 years

6. Develops sphincter control necessary for bowel and bladder control

B. Psychosocial tasks

1. Increases independence; better able to tolerate separation from primary caregiver.

2. Less likely to fear strangers.

3. Able to help with dressing/undressing at 18 months; dresses self at 24 months.

4. Has sustained attention span.

5. May have temper tantrums during this period; should decrease by 2 1/2 years.

6. Vocabulary increases from about 10 - 20 words to over 900 words by 3 years.

7. Has beginning awareness of ownership (my, mine) at 18 months; shows proper use of pronouns (I,
me, you) by 3 years.

8. Moves from hoarding and possessiveness at 18 months to sharing with peers by 3 years.

9. Toilet training usually completed by 3 years.

a. 18 months: bowel control

b. 2 - 3 years: daytime bladder control

c. 3 - 4 years: nighttime bladder control

C. Cognitive tasks

1. Follows simple directions by 2 years.

2. Begins to use short sentences at 18 months to 2 years.

3. Can remember and repeat 3 numbers by 3 years.

4. Knows own name by 12 months; refers to self, gives first name by 24 months; gives full name by 3
years.

5. Able to identify geometric forms by 18 months.

6. Achieves object permanence; is aware that objects exist even if not in view.

7. Uses “magical” thinking; believes own feelings affect events (e.g., anger causes rain).

8. Uses ritualistic behavior; repeats skills to master them and to decrease anxiety.

9. May develop dependency on “transitional object” such as blanket or stuffed animal.

D. Nutrition
1. Caloric requirement is approximately 100 calories/kg/day.

2. Increased need for calcium, iron, and phosphorus.

3. Needs 16 - 24 oz milk/day.

4. Appetite decreases.

5. Able to feed self.

6. Negativism may interfere with eating.

7. Initial dental examination at 3 years.

E. Play

1. Predominantly- “parallel play” period.

2. Provide toys appropriate for increased locomotive skills: push toys, rocking horse, riding toys or
tricycles; swings and slide.

3. Give toys to provide outlet for aggressive feelings: work bench, toy hammer and nails, drums, pots,
pans.

4. Provide toys to help develop fine motor skills, problem-solving abilities: puzzles, blocks; finger
paints, crayons.

G. Fears: separation anxiety

1. Learning to tolerate and master brief periods of separation is important developmental task.

2. Increasing understanding of object permanence helps toddler overcome this fear.

3. Potential patterns of response to separation

a. Protest: screams and cries when mother leaves; attempts to call her back.

b. Despair: whimpers, clutches transitional object, curls up in bed, decreased activity, rocking.

c. Denial: resumes normal activity but does not form psychosocial relationships; when mother returns,
child ignores her

Preschooler (3 to 5 years)

A. Physical tasks

1. Slower growth rate continues

a. Weight: increases 4 - 6 lb (1.8 - 2.7 kg) a year

b. Height: increases 2 1/2 inches (5-6.25 cm) a year

c. Birth length doubled by 4 years

2. Vital signs decrease slightly

a. Pulse: 90-100

b. Respirations: 24-25/minute

c. Blood pressure: systolic 85-100 mm Hg

diastolic 60-90 mm Hg

3. Permanent teeth may appear late in preschool period; first permanent teeth are molars, behind last
temporary teeth.

4. Gross motor development

a. Walks up stairs using alternate feet by 3 years.

b. Walks down stairs using alternate feet by 4 years.

c. Rides tricycle by 3 years.

d. Stands on 1 foot by 3 years.

4. Gross motor development

e. Hops on 1 foot by 4 years.

f. Skips and hops on alternate feet by 5 years.

g. Balances on 1 foot with eyes closed by 5 years.

h. Throws and catches ball by 5 years.

i. Jumps off 1 step by 3 years.

j. Jumps rope by 5 years.

5. Fine motor development

a. Hand dominance is established by 5 years.

b. Builds a tower of blocks by 3 years.

c. Ties shoes by 5 years.

d. Ability to draw changes over this time

1) copies circles, may add facial features by 3 years.

2) copies a square, traces a diamond by 4 years

B. Psychosocial tasks

1. Becomes independent
a. Feeds self completely.

b. Dresses self.

c. Takes increased responsibility for actions.

2. Aggressiveness and impatience peak at 4 years then abate.

3. Gender-specific behavior is evident by 5 years.

4. Egocentricity changes to awareness of others; rules become important; understands sharing

C. Cognitive development

1. Focuses on one idea at a time; cannot look at entire perspective.

2. Awareness of racial and sexual differences begins.

a. Prejudice may develop based on values of parents.

b. Manifests sexual curiosity.

c. Sexual education begins.

d. Beginning body awareness.

3. Has beginning concept of causality.

4. Understanding of time develops during this period.

a. Learns sequence of daily events.

b. Is able to understand meaning of some time-oriented words (day of week, month, etc.) by 5 years.

5. Has 2000-word vocabulary by 5 years.

6. Can name 4 or more colors by 5 years.

7. Is very inquisitive (why? why? why?)

D. Nutrition

1. Caloric requirement is approximately 90 calories/kg/day.

2. May demonstrate strong taste preferences.

3. More likely to taste new foods if child can assist in the preparation.

F. Play

1. Predominantly associative play

2. Enjoys imitative and dramatic play.

a. Imitates same-sex role functions in play.

b. Enjoys dressing up, dollhouses, trucks, cars, telephones, doctor and nurse kits.

3. Provide toys to help develop gross motor skills: tricycles, wagons, outdoor gym; sandbox, wading
pool.

4. Provide toys to encourage fine motor skills, self-expression, and cognitive development:
construction sets, blocks, carpentry tools; flash cards, illustrated books, puzzles; paints, crayons, clay,
simple sewing sets.

5. Television, when supervised, can provide a quiet activity; some programs have educational content.

G. Fears

1. Greatest number of imagined and real fears of childhood during this period.

2. Fears concerning body integrity are common.

a. Magical and animistic thinking allows children to develop many illogical fears (fear of
inanimate objects, the dark, ghosts).

School-age (6 to 12 years)

A. Physical tasks

1. Slow growth continues.

a. Height: 2 inches (5 cm) per year

b. Weight: doubles over this period

c. At age 9, both sexes same size; age 12, girls bigger than boys

2. Dentition

a. Loses first primary teeth at about 6 years.

b. By 12 years, has all permanent teeth except final molars.

3. Bone growth faster than muscle and ligament development; very limber but susceptible to bone
fractures during this time.

4. Vision is completely mature; hand-eye coordination develops completely.

5. Gross motor skills: predominantly involving large muscles; children are very energetic, develop
greater strength, coordination, and stamina.

6. Develops smoothness and speed in fine motor control.

B. Psychosocial tasks

1. School occupies half of waking hours; has cognitive and social impact.
a. Readiness includes emotional (attention span), physical (hearing and vision), and intellectual
components.

b. Teacher may be parent substitute, causing parents to lose some authority.

2. Morality develops

a. Before age 9 moral realism predominates: strict superego, rule dominance; things are black or
white, right or wrong.

b. After age 9 autonomous morality develops: recognizes differing points of view, sees “gray” areas.

3. Peer relationships

a. Child makes first real friends during this period.

b. Is able to understand concepts of cooperation and compromise (assist in acquiring attitudes and
values); learns fair play vs competition.

c. Help child develop self-concept.

d. Provide feeling of belonging.

4. Enjoys family activities.

5. Has some ability to evaluate own strengths and weaknesses.

6. Has increased self-direction.

7. Is aware of own body; compares self to others; modesty develops.

C. Cognitive development

1. Period of industry

a. Is interested in exploration and adventure.

b. Likes to accomplish or produce.

c. Develops confidence.

2. Concept of time and space develops.

a. Understands causality.

b. Masters concept of conservation: permanence of mass and volume; concept of reversibility.

c. Develops classification skills: understands relational terms; may collect things.

d. Masters arithmetic and reading.

D. Nutrition

1. Caloric needs diminish in relation to body size: 85 kcal/kg.

2. “Junk” food may become a problem; excess sugar, starches, fat.

3. Obesity is a risk in this age group.

4. Nutrition education should be integrated into school program.

E. Play

1. Rules and ritual dominate play; individuality not tolerated by peers; knowing rules provide sense of
belonging; “cooperative play.”

2. Team play: games or sports

a. Help learn value of individual skills and team accomplishments.

b. Help learn nature of competition.

3. Quiet games and activities: board games, collections, books, television, painting

4. Athletic activities: swimming, hiking, bicycling, skating

G. Fears:

more realistic fears than younger children; include death, disease or bodily injury, punishment; school
phobia may develop, resulting in psychosomatic illness.

Adolescent (12 to 19 years)

A. Physical tasks

1) boys become leaner with broader chest.

2) girls have fat deposited in thighs, hips, and breasts; pelvis broadens.

a. Girls: height increases approximately 3 inches/year; slows at menarche; stops around age 16.

b. Boys: growth spurt starts around age 13; height increases 4 inches/year; slows in late teens.

c. Boys double weight between 12 and 18, related to increased muscle mass.

d. Body shape changes

e. Apocrine glands cause increased body odor.

f. Increased production of sebum and plugging of sebaceous ducts causes acne.

4. Sexual development: girls

a. Development of secondary sex characteristics and sexual functioning under hormonal control

b. Breast development is first sign of puberty.

1) bud stage: areola around nipple is protuberant.

2) breast development is complete around the time of first menses.

5. Sexual development: boys

a. Development of secondary sex characteristics, sex organs and function under hormonal control.

b. Enlargement of testes is first sign of sexual maturation; occurs at approximately age 13, about 1
year before growth spurt.

c. Scrotum and penis increase in size until age 18.

d. Reaches reproductive maturity about age 17, with viable sperm.

e. Nocturnal emission: a physiologic reflex to ejaculate buildup of semen; natural and normal; occurs
during sleep (child should not be made to feel guilty; needs to understand that this is not enuresis).

f. Masturbation increases (also a normal way to release semen).

g. Pubic hair continues to grow and spread until mid 20s.

h. Facial hair; appears first on upper lip.

i. Voice changes due to growth of laryngeal, cartilage.

j. Gynecomastia: slight hypertrophy of breasts due to estrogen production; will pass within months
but causes embarrassment.

B. Psychosocial tasks

1. Early adolescence: ages 12-14 years

a. Starts with puberty.

b. Physical body changes result in an altered self-concept.

c. Tends to compare own body to others.

d. Early and late developers have anxiety regarding fear of rejection.

e. Fantasy life, daydreams, crushes are all normal, help in role play of varying social situations.

f. Is prone to mood swings.

g. Needs limits and consistent discipline.

2. Middle adolescence: ages 15-16 years

a. Is separate from parents (except financially).

b. Can identify own values.

c. Can define self (self-concept, strengths and weaknesses).

d. Partakes in peer group; conforms to values/fads.

e. Has increased heterosexual interest; communicates with opposite sex; may form “love” relationship.

3. Late adolescence: ages, 17-19 years

a. Achieves greater independence.

b. Chooses a vocation.

c. Participates in society.

d. Finds an identity.

e. Finds a mate.

f. Develops own morality.

g. Completes physical and emotional maturity.

C. Cognitive development

1. Develops abstract thinking abilities.

2. Is often unrealistic.

3. Is capable of scientific reasoning and formal logic.

4. Enjoys intellectual abilities.

5. Is able to view problems comprehensively.

D. Nutrition

1. Nutritional requirements peak during years of maximum growth: age 10-12 in girls, 2 years later in
boys

2. Appetite increases.

3. Inadequate diet can retard growth and delay sexual maturation.

4. Food intake needs to be balanced with energy expenditure.

5. Increased needs include calcium for skeletal growth; iron for increased muscle mass and blood cell
development; zinc for development of skeletal and muscle tissue and sexual maturation.

F. Activities:

group activities predominate (sports are important); activities involving opposite sex by middle
adolescence.

G. Fears
1. Threats to body image: acne, obesity

2. Injury or death

3. The unknown

Child’s Response to Death

1. Toddlers - may insist on seeing a significant other long after that person’s death.

2. Preschoolers - See death as temporary; a type of sleep or separation.

3. School-age – See death as a period of immobility.

- Feel death is punishment.

4. Adolescents - Have an accurate understanding of death.

Teacher’s Insight:

Caring for patients in different walks of life can really be challenging. It is always essential for nurses
to equip themselves with the proper knowledge, skills and attitude in dealing with these patients. The
behaviors of children differ from one stage to another. Therefore, proper assessment of their needs is
our top priority. One must know the psychosocial, physiologic and cognitive adjustments of each
group in order to provide individualize care.

Nurses have an important role as educators and due to their profession, they have great potential to
support lifestyle and behavior changes. In our setting, there are many misconceptions and people
tend to have deficient knowledge regarding family planning. Therefore, nurses must be equipped
with essential information about contraceptive methods in order to provide clients with evidence
based and individualized patient education, along with emotional and psychological support to
improve their quality of life.