MIDWIFERY/OBSTETRICS

AND GYNECOLOGY
(OBG) NURSING - I
Sixth Semester [Link]. Nursing Notes According to Inc Syllabus

Spidy Bright Publication Bright Medico [Link]. Nursing

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Table Of Contents…

Unit no. Chapters Complete/pending

01 Introduction to midwifery

Anatomy and physiology of human reproductive

02 system and conception (Maternal, Fetal & Newborn
physiology)

03 Assessment and management of normal pregnancy

(ante-natal):

04 Physiology, management and care during labour

05 Postpartum care/Ongoing care of women

Assessment and ongoing care of normal neonates

06

07 Family welfare services

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Unit- 01
Introduction to midwifery

Introduction to Midwifery and History of Midwifery in India

1. Definition of Midwifery
• Midwifery is the art and science of caring for women during pregnancy,
childbirth, and postpartum period, including care of the newborn.
• Midwifery focuses on normal reproductive processes and provides
women-centered care.
• A midwife is a trained health professional who supports women to give
birth naturally and safely.
2. Objectives of Midwifery
• Promote safe motherhood
• Ensure healthy childbirth
• Prevent maternal and neonatal complications
• Educate and support mothers during antenatal, intranatal, and
postnatal periods
• Provide family planning and reproductive health services
3. Scope of Midwifery
• Care during normal pregnancy and delivery
• Postnatal care of mother and newborn
• Management of minor disorders in pregnancy
• Identification of high-risk cases and timely referral
• Health education and counseling
• Contraceptive services and reproductive health
• Participation in safe abortion care (as per law)
4. Philosophy of Midwifery Practice
• Childbirth is a natural physiological process

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• Every woman has the right to respectful, informed, and safe care
• Care should be evidence-based and culturally appropriate
• Midwifery promotes minimal intervention, unless necessary
5. Role of Midwife
• Conduct normal deliveries
• Provide antenatal and postnatal care
• Monitor fetal well-being
• Identify complications and refer promptly
• Educate mother and family on nutrition, breastfeeding, hygiene
• Maintain records and reports
• Support in family welfare and immunization programs
6. History of Midwifery in India
• In ancient India, childbirth was handled by traditional birth attendants
called “Dais”.
• These women learned through experience, not formal training.
• Formal midwifery training began during British rule.
• Midwifery education was integrated into general nursing courses in
early 20th century.
• In 1908, the first midwifery training school was opened in Chennai.
• The Trained Nurses Association of India (TNAI) was established in
1908 to regulate training.
• The Indian Nursing Council (INC) was established in 1947 and sets
midwifery education standards.
• Auxiliary Nurse Midwives (ANMs) were introduced post-independence
to reduce maternal and infant mortality.
• Over the years, India shifted focus from home births to institutional
deliveries to improve outcomes.
• Introduction of Reproductive and Child Health Programs (RCH) and
Janani Suraksha Yojana (JSY) emphasized the midwife’s role.
7. Current Status of Midwifery in India
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• Midwifery is included in General Nursing & BSc Nursing curricula

• Specialized courses for Nurse Practitioners in Midwifery (NPM) have
been launched
• Government initiatives support skilled birth attendants (SBA) in rural
areas
• New midwifery-led care models aim to reduce maternal mortality
Possible Exam Questions
Two Marks
1. Define midwifery.
2. Name the organization that regulates midwifery education in India.
Five Marks
1. Write any five roles of a midwife.
2. Explain the philosophy of midwifery practice.
Ten Marks
1. Describe the history and development of midwifery in India.
2. Explain the scope and responsibilities of a midwife in the Indian
healthcare system.
Current Scenario of Midwifery in India
1. Introduction
• Midwifery is regaining attention in India due to the urgent need to
improve maternal and newborn health outcomes.
• The Government of India is promoting midwifery-led care to strengthen
reproductive health services, especially in underserved areas.
• Focus is on Skilled Birth Attendance (SBA), Nurse Practitioner in
Midwifery (NPM), and institutional deliveries.
2. Key Goals of Current Midwifery Development
• Reduce Maternal Mortality Rate (MMR) and Infant Mortality Rate
(IMR)
• Promote respectful maternity care (RMC)
• Enhance access to quality obstetric services
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• Create a midwifery cadre for independent practice in normal deliveries

3. Nurse Practitioner in Midwifery (NPM) Program – 2018 Onward
• Launched by the Ministry of Health and Family Welfare (MoHFW)
with technical support from WHO
• Training of Registered Nurse Midwives (RNMs) to become Nurse
Practitioners
• Focus: Autonomous care during normal pregnancies and deliveries
• Training Centers: National Midwifery Training Institutes (NMTIs) and
State Midwifery Training Institutes (SMTIs)
4. Midwifery-Led Care Units (MLCUs)
• MLCUs are standalone units within hospitals, led by trained midwives
• Offer woman-centered, low-intervention childbirth services
• Reduce unnecessary cesarean sections
• Promote natural birthing practices
5. Integration with National Health Programs
• Midwives play a key role in implementing:
o Reproductive, Maternal, Newborn, Child and Adolescent
Health (RMNCH+A)
o Janani Shishu Suraksha Karyakram (JSSK)
o Janani Suraksha Yojana (JSY)
o LaQshya Program for improving labor room quality
o Mission Indradhanush for immunization
6. Policy and Regulatory Support
• Indian Nursing Council (INC) is preparing curriculum for Midwifery
programs
• Nursing and Midwifery Bill 2020 aims to strengthen midwifery and
regulate practice
• Promotion of Continuing Midwifery Education (CME) and skill labs
for training
7. Challenges in the Current Scenario
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• Shortage of trained midwives

• Inadequate infrastructure and training centers
• Limited public awareness and acceptance of midwifery-led care
• Need for policy implementation and legal recognition of autonomous
midwife role
8. Opportunities and Future Direction
• Midwifery has the potential to revolutionize maternal health care in
India
• Expanding NPM training and employment
• Strengthening midwifery associations and leadership roles
• Fostering public-private partnerships in maternal care
Possible Exam Questions
Two Marks
1. What is the full form of NPM?
2. Name one government program that supports institutional deliveries.
Five Marks
1. Write five roles of midwives in the current healthcare system.
2. What are Midwifery-Led Care Units (MLCUs)?
Ten Marks
1. Discuss the current scenario of midwifery in India.
2. Describe the Nurse Practitioner in Midwifery program and its objectives.
Trends in Maternity Care in India
1. Introduction
• Maternity care in India has evolved significantly over the past few
decades.
• Focus has shifted from institutional delivery alone to respectful, quality,
women-centered, and safe maternity care.
• National and global efforts have influenced maternal health practices,
access, and outcomes.

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2. Maternity Care in India

A. Rise in Institutional Deliveries
• Due to schemes like Janani Suraksha Yojana (JSY) and Janani Shishu
Suraksha Karyakram (JSSK).
• National Family Health Survey (NFHS-5) reports >88% institutional
births.
• Increased access to skilled birth attendants.
B. Midwifery-Led Care Units (MLCUs)
• Promoted under LaQshya Program for quality intrapartum care.
• Emphasis on natural birthing, reduced unnecessary interventions.
• Introduction of nurse practitioners in midwifery with advanced
training.
C. Respectful Maternity Care (RMC)
• Focus on non-discriminatory, dignified care.
• Reduction in verbal and physical abuse during childbirth.
• Incorporation of birth companions, privacy, and informed consent.
D. Digitization of Maternal Health Records
• Use of Reproductive and Child Health (RCH) Portal, Mother and
Child Tracking System (MCTS).
• Digital tools for ANC tracking, follow-up, and referral.
E. Continuum of Care
• Antenatal → Intranatal → Postnatal services integrated.
• Home-based newborn and postnatal care by ASHAs and ANMs.
• Fixed day services for antenatal check-ups (e.g., Pradhan Mantri
Surakshit Matritva Abhiyan - PMSMA).
F. Reduction in Maternal Mortality Ratio (MMR)
Year MMR (per 1,00,000 live births)

2014–16 130

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Year MMR (per 1,00,000 live births)

2016–18 113

2019–21 97
• Due to improved access to EmOC (Emergency Obstetric Care) and
trained personnel.
G. Increased Role of Community Health Workers
• ASHAs act as birth companions, referral agents, educators.
• Support in transport, facility navigation, and follow-up.
H. Focus on High-Risk Pregnancy Management
• Early identification and referral.
• e-Raktkosh for managing blood availability.
• High-risk pregnancies tracked using Mamta Card or ANC high-risk
tags.
I. Promotion of Birth Preparedness and Complication Readiness (BPCR)
• Women and families educated about:
o Danger signs
o Emergency transport
o Blood donors
o Financial preparedness
J. Introduction of Birth Companions
• Encouraged under LaQshya and RMC guidelines.
• Birth companion can be a spouse, mother, sister, or ASHA worker.
• Provides emotional support and reduces anxiety.
K. Integration of Traditional and Complementary Therapies
• Yoga, breathing exercises, Ayurveda-based nutritional counseling
integrated into ANC.
3. Government Programs Influencing Maternity Care

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Program Objective

Janani Suraksha Yojana Promote institutional deliveries with financial

(JSY) aid

JSSK Free delivery, transport, diet, and postnatal care

Improve quality of care during labor and

LaQshya
delivery

PMSMA Free ANC check-up on the 9th of every month

Poshan Abhiyaan Nutritional support during pregnancy

4. Diagram Suggestions
• Line graph showing reduction in MMR over the years
• Flowchart: Maternity care continuum
• Pie chart: Institutional vs home deliveries in NFHS-5
5. Role of Nurse/Midwife in Changing Trends
• Deliver evidence-based, respectful maternity care
• Educate women on birth preparedness and postnatal care
• Participate in community outreach and home visits
• Use digital health tools for tracking and referrals
• Provide emotional and psychological support to expectant mothers
6. Possible Outcome Questions
Two Marks
1. Mention any two government programs for improving maternity care in
India.
2. What is the current trend in place of childbirth in India?
Five Marks
1. Write a short note on the role of ASHAs in maternity care.
2. Describe the features of the LaQshya program.
Ten Marks
1. Discuss recent trends in maternity care in India.
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2. Explain how government programs have improved maternal and neonatal

outcomes in India.
Midwifery in India – Transformative Education for Relationship-Based and
Transformative Midwifery Practice
1. Introduction
• Transformative midwifery education aims to develop skilled,
autonomous, respectful, and compassionate midwives.
• Relationship-based care emphasizes woman-centered, respectful
maternity care (RMC).
• India is moving toward a global standard midwifery model, focusing on
competency-based education and practice.
2. Need for Transformative Midwifery in India
• India has a large burden of maternal and neonatal deaths, mostly from
preventable causes.
• Traditional nurse-midwife training was integrated, lacking depth in
midwifery skills.
• WHO recommends separate professional midwifery education to
ensure global standards.
• Rising demand for non-interventionist, respectful childbirth practices
in urban and rural settings.
3. Characteristics of Transformative Midwifery Education
• Competency-based curriculum (as per ICM & WHO standards)
• Focus on hands-on skill acquisition and clinical confidence
• Woman-centered approach, fostering trust and emotional support
• Promotes critical thinking, evidence-based practice, and ethical values
• Emphasis on leadership, autonomy, and inter-professional
collaboration
4. Components of Relationship-Based Midwifery Practice
• Builds trust, empathy, and respectful communication with women and
families

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• Acknowledges and supports emotional, physical, social, and cultural

needs
• Encourages informed decision-making and shared responsibility
• Supports continuity of care, especially in antenatal, intrapartum, and
postnatal periods
5. India’s Initiatives in Transformative Midwifery
A. Launch of Nurse Practitioner in Midwifery (NPM) Program (2018)
• Led by Ministry of Health and Family Welfare (MoHFW) with WHO
support
• 18-month post-basic midwifery course for Registered Nurses
• Establishment of National Midwifery Training Institutes (NMTIs) and
State Midwifery Training Institutes (SMTIs)
• Goal: Create Midwifery-Led Care Units (MLCUs) in hospitals
B. Curriculum Development
• Developed in collaboration with WHO, ICM, and international midwifery
experts
• Based on International Confederation of Midwives (ICM) core
competencies
• Integrates gender sensitivity, communication, ethics, and emergency
skills
C. Training and Assessment Approach
• Simulation-based learning and clinical mentoring
• Regular assessments based on competencies, not just theory
• Final skill checklists and exams before certification
D. Midwifery-Led Care Units (MLCUs)
• Provide low-intervention, respectful, woman-led care
• Improve maternal outcomes and patient satisfaction
• Ensure continuity of care from pregnancy to postnatal phase
6. Benefits of Transformative and Relationship-Based Midwifery
• Reduces unnecessary cesarean sections and interventions
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• Increases maternal satisfaction and birth confidence

• Reduces maternal and neonatal morbidity and mortality
• Promotes respectful, dignified childbirth experiences
7. Challenges in Implementation
• Resistance to change in medical-dominant hospital systems
• Lack of public awareness about role of midwives
• Limited number of qualified educators and trainers
• Need for legal recognition and autonomy for midwives
8. Future Directions
• Expansion of NPM programs across all states
• Establishment of midwifery regulatory frameworks
• Career progression pathways and academic roles for midwives
• Community-based midwifery integration in rural areas
• Public campaigns to build trust and awareness in midwifery care
Possible Exam Questions
Two Marks
1. What is the full form of NPM?
2. Define relationship-based midwifery care.
Five Marks
1. List five features of transformative midwifery education.
2. Write a short note on midwifery-led care units.
Ten Marks
1. Explain the role of transformative education in strengthening midwifery
practice in India.
2. Describe the components and importance of relationship-based midwifery
care.
Vital Health Indicators – Maternal Mortality Ratio (MMR), Infant Mortality
Rate (IMR)

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1. Definition of Vital Health Indicators

• Vital health indicators are statistical measures that help assess the health
status of a population, especially related to reproductive, maternal,
newborn, and child health (RMNCH).
• They are used to monitor progress, evaluate health programs, and
guide policy decisions.
2. Maternal Mortality Ratio (MMR)
• Definition: The number of maternal deaths per 100,000 live births during
a given time period.
• Maternal death: Death of a woman while pregnant or within 42 days of
termination of pregnancy, from any cause related to or aggravated by the
pregnancy or its management.
• Formula:
MMR = (Number of maternal deaths / Number of live births) × 100,000
• India's MMR (2020 SRS data): 97 per 100,000 live births
• Sustainable Development Goal (SDG) Target: Reduce MMR to less
than 70 by 2030
Causes of Maternal Mortality
• Hemorrhage
• Hypertensive disorders
• Sepsis
• Unsafe abortion
• Obstructed labor
• Anemia and poor nutrition
Prevention Strategies
• Skilled birth attendance
• Antenatal and postnatal care
• Emergency obstetric care
• Health education and awareness
• Institutional deliveries

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3. Infant Mortality Rate (IMR)

• Definition: The number of deaths of infants under 1 year of age per 1,000
live births in a given year.
• Formula:
IMR = (Number of infant deaths / Number of live births) × 1,000
• India’s IMR (NFHS-5, 2019–21): 28 per 1,000 live births
• Target (National Health Policy 2017): Reduce IMR to 23 by 2025
Causes of Infant Mortality
• Prematurity
• Birth asphyxia
• Neonatal infections
• Congenital anomalies
• Poor maternal health
• Inadequate newborn care
Prevention Strategies
• Early initiation of breastfeeding
• Immunization
• Essential newborn care (warmth, hygiene, feeding)
• Institutional delivery
• Timely referral and treatment
4. Other Related Vital Indicators (for reference)
• Neonatal Mortality Rate (NMR): Deaths of infants under 28 days of
age per 1,000 live births
• Perinatal Mortality Rate: Stillbirths + deaths within 7 days per 1,000
total births
• Under-Five Mortality Rate (U5MR): Deaths of children under 5 years
per 1,000 live births
• Stillbirth Rate: Fetal deaths (after 28 weeks of gestation) per 1,000 total
births

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Comparison Table
India’s
Indicator Definition Target
Value

Maternal Mortality Maternal deaths per 100,000 <70 (SDG

97
Ratio (MMR) live births 2030)

Infant Mortality Rate Infant deaths (<1 year) per 23 (NHP

28
(IMR) 1,000 live births 2025)

Neonatal Mortality Rate Deaths <28 days per 1,000 <16 (by
20
(NMR) live births 2030)

Under-Five Mortality Deaths under 5 years per <25 (SDG

32
Rate (U5MR) 1,000 live births 2030)
Possible Exam Questions
Two Marks
1. Define Maternal Mortality Ratio.
2. What is the current Infant Mortality Rate in India?
Five Marks
1. Write five causes of maternal mortality.
2. Explain the strategies to reduce infant mortality.
Ten Marks
1. Define and compare MMR and IMR. Discuss causes and prevention
strategies for each.
2. Describe the importance of vital health indicators in improving maternal
and child health in India.
Neonatal Mortality Rate (NMR), Perinatal Mortality Rate (PMR), Fertility
Rates
1. Neonatal Mortality Rate (NMR)
Definition:
• The number of deaths of live-born infants within the first 28 days of life
per 1,000 live births in a given year.
Formula:
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• NMR = (Number of neonatal deaths / Number of live births) × 1,000

India’s NMR (SRS 2020):
• 20 deaths per 1,000 live births
Causes of Neonatal Mortality:
• Premature birth and low birth weight
• Birth asphyxia
• Neonatal infections (sepsis, pneumonia, meningitis)
• Congenital anomalies
• Hypothermia
• Tetanus (in non-immunized mothers)
Prevention Strategies:
• Early and exclusive breastfeeding
• Clean and safe delivery practices
• Skilled birth attendance
• Essential newborn care (warmth, feeding, hygiene)
• Timely immunization (e.g., BCG, OPV, Hep-B)
• Kangaroo Mother Care (KMC) for preterm/low birth weight babies
2. Perinatal Mortality Rate (PMR)
Definition:
• The number of late fetal deaths (stillbirths) plus early neonatal deaths
(within 7 days of birth) per 1,000 total births (live births + stillbirths).
Formula:
• PMR = (Late fetal deaths + Early neonatal deaths) / Total births ×
1,000
India’s PMR (SRS 2020):
• 26 per 1,000 total births
Causes of Perinatal Mortality:
• Complications during pregnancy (e.g., preeclampsia, eclampsia)

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• Obstructed or prolonged labor

• Birth injuries
• Intrauterine infections
• Poor maternal nutrition
• Lack of antenatal care
Prevention Strategies:
• Regular antenatal check-ups
• Institutional deliveries with skilled birth attendants
• Early detection and management of high-risk pregnancies
• Emergency obstetric and neonatal care
• Timely referral system
3. Fertility Rates
A. Total Fertility Rate (TFR):
Definition:
• The average number of children a woman would have if she were to live
through her reproductive years and bear children according to the current
age-specific fertility rates.
India’s TFR (NFHS-5, 2019–21):
• 2.0 children per woman (Below replacement level fertility, which is 2.1)
B. Crude Birth Rate (CBR):
Definition:
• The number of live births per 1,000 population in a given year.
India’s CBR (SRS 2020):
• 20.2 births per 1,000 population
C. General Fertility Rate (GFR):
Definition:
• The number of live births per 1,000 women aged 15–49 years in a year.
India’s GFR (SRS 2020):
• 82.5 per 1,000 women of reproductive age

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Factors Affecting Fertility Rates:

• Age at marriage and childbirth
• Education level of women
• Availability and use of contraceptives
• Socio-economic status
• Cultural and religious beliefs
• Urban vs. rural residence
Measures to Control Fertility Rates:
• Family planning services
• Awareness programs
• Incentives for small families
• Female education and empowerment
• Accessible and affordable contraceptive methods
Comparison Table of Indicators
India’s
Indicator Definition
Value

Neonatal Mortality Deaths within first 28 days per 1,000 live

20
Rate births

Perinatal Mortality Late fetal + early neonatal deaths per 1,000

26
Rate total births

Total Fertility Rate Avg. number of children per woman 2.0

Crude Birth Rate Live births per 1,000 population 20.2

General Fertility
Live births per 1,000 women aged 15–49 82.5
Rate

Possible Exam Questions

Two Marks
1. Define neonatal mortality rate.

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2. What is the current TFR of India?

Five Marks
1. Mention causes and prevention of neonatal deaths.
2. Write a short note on Total Fertility Rate.
Ten Marks
1. Compare NMR, PMR, and TFR. Explain causes and preventive strategies
of each.
2. Discuss trends in fertility rates in India and measures to control
population growth.
Maternal Death Audit
1. Definition of Maternal Death Audit
• Maternal Death Audit is a qualitative, in-depth, systematic review of
maternal deaths to identify causes and contributing factors and propose
actions for preventing future deaths.
• It focuses on what went wrong and why, not on blaming individuals.
2. Objectives of Maternal Death Audit
• Identify direct and indirect causes of maternal deaths
• Understand avoidable factors at community, facility, and system levels
• Improve quality of obstetric care
• Guide policy, planning, and resource allocation
• Ensure accountability in maternal healthcare
3. Types of Maternal Death Audits
1. Facility-Based Maternal Death Review (FB-MDR)
o Conducted at health facilities where the death occurred
o Uses patient records, staff interviews, and care timelines
2. Community-Based Maternal Death Review (CB-MDR)
o For deaths that occurred at home or in transit
o Involves ASHAs, ANMs, family members, and community
informants

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3. Verbal Autopsy
o Interview with family members to understand events leading to
death
o Used where no medical records or hospital death certificate exists
4. Confidential Enquiry into Maternal Deaths (CEMD)
o Anonymous, detailed, national-level investigation of a sample of
maternal deaths
5. Near-Miss Review
o Studies cases where women nearly died but survived obstetric
complications
o Offers insight into what saved the mother and what risks were
present
4. Steps in Conducting a Maternal Death Audit
1. Identification and Notification of Maternal Death
o Mandatory notification within 24–48 hours
o Use of formats like the Maternal Death Review (MDR) Form
2. Data Collection
o Medical records, partograph, ANC cards
o Verbal autopsy, interviews with family/staff
3. Analysis and Case Summary Preparation
o Timeline of events
o Identification of delays (Delay Model - see below)
4. Review Meeting
o Multidisciplinary committee analyzes findings
o Identify gaps in care, logistics, communication
5. Recommendations and Action Plan
o Improve protocols, staffing, training, referrals, supplies
6. Implementation and Monitoring
o Ensure follow-up actions are taken
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o Evaluate impact on maternal care

5. Three Delays Model (Used in Audits)
Helps identify where the breakdown happened in maternal care:
Delay
Description
Type

Delay in recognizing danger signs and deciding to seek care

1st Delay
(family/community level)

2nd
Delay in reaching a health facility (transport, cost, distance)
Delay

3rd Delay in receiving appropriate care at the facility (staff, supplies,

Delay management issues)
6. Tools Used in India
• Maternal Death Review (MDR) formats
• Maternal Death Surveillance and Response (MDSR) System
(launched by MoHFW)
• MCTS/RCH Portal for real-time data reporting
7. Benefits of Maternal Death Audits
• Enhances transparency and accountability
• Drives evidence-based improvements in care
• Reduces preventable maternal deaths
• Promotes teamwork, learning culture, and system strengthening
• Aids policy makers in resource allocation
8. Challenges in Implementation
• Underreporting or delayed reporting
• Poor documentation
• Fear of blame among staff
• Lack of trained personnel for conducting reviews
• Non-functional review committees in some states

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9. WHO Recommendations for Effective Audit

• No blame, no punishment environment
• Confidentiality must be maintained
• Multidisciplinary review teams
• Regular review meetings and follow-up actions
Possible Exam Questions
Two Marks
1. Define maternal death audit.
2. Mention one objective of a maternal death audit.
Five Marks
1. Write the steps involved in conducting a maternal death audit.
2. What is the Three Delays Model?
Ten Marks
1. Discuss types of maternal death audits and their significance in improving
maternal healthcare.
2. Describe the process, benefits, and challenges of conducting maternal
death audits in India.
National Health Programs Related to RMNCH+A (Reproductive, Maternal,
Newborn, Child and Adolescent Health)
1. Introduction to RMNCH+A Strategy
• RMNCH+A is a comprehensive approach launched by the Ministry of
Health and Family Welfare (MoHFW), Government of India in 2013.
• It integrates Reproductive, Maternal, Newborn, Child and Adolescent
health services across the life cycle.
• The ‘+’ (plus) signifies the inclusion of Adolescent health, linking all
age groups and service delivery platforms for a continuum of care.
2. Objectives of RMNCH+A
• Reduce maternal and child mortality and morbidity
• Improve nutritional status of women and children

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• Provide universal access to reproductive health services

• Promote adolescent health and development
• Ensure quality and equity in healthcar
3. Key Components of RMNCH+A
Component Focus Area

Reproductive Family planning, prevention and treatment of STIs/RTIs,

Health safe abortion services

Antenatal, intranatal, postnatal care; institutional

Maternal Health
deliveries; EmOC

Early initiation of breastfeeding, essential newborn care,

Newborn Health
home-based care

Immunization, nutrition, management of childhood

Child Health
illnesses (IMNCI)

Menstrual hygiene, anemia control, sexual health

Adolescent Health
education, peer counseling
4. Major National Health Programs under RMNCH+A
A. Reproductive and Maternal Health
1. Janani Suraksha Yojana (JSY)
o Conditional cash transfer scheme to promote institutional
deliveries
o Target group: Pregnant women (especially BPL and SC/ST)
o Free delivery and cash benefit to mother and ASHA
2. Janani Shishu Suraksha Karyakram (JSSK)
o Free delivery, cesarean, treatment, drugs, diagnostics, transport for
mother and newborn
o No out-of-pocket expense
3. Pradhan Mantri Surakshit Matritva Abhiyan (PMSMA)
o Free antenatal checkup on the 9th of every month by specialists
o Detect high-risk pregnancies early

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4. Family Planning Services

o Basket of choices: condoms, oral pills, IUCD, sterilization
o Mission Parivar Vikas in high-fertility districts
5. Surakshit Matritva Aashwasan (SUMAN)
o Assures quality, respectful maternal and newborn care without
expense
o Accountability mechanism for grievance redressal
B. Newborn and Child Health
6. India Newborn Action Plan (INAP)
o Targets single-digit NMR and stillbirth rate by 2030
o Strategies: essential newborn care, resuscitation, Kangaroo Mother
Care (KMC), NICUs
7. Integrated Management of Neonatal and Childhood Illness (IMNCI)
o Combines care for sick newborns and under-5 children
o Addresses pneumonia, diarrhea, malaria, malnutrition
8. Universal Immunization Program (UIP)
o Vaccines for 12 VPDs including measles, polio, TB, hepatitis,
rotavirus
o Mission Indradhanush to improve immunization coverage
9. Rashtriya Bal Swasthya Karyakram (RBSK)
o Early identification and intervention for 4Ds: Defects at birth,
Diseases, Deficiencies, Developmental delays
C. Adolescent Health
[Link] Kishor Swasthya Karyakram (RKSK)
o Covers 10–19-year-olds
o Focus: nutrition, sexual & reproductive health, mental health,
substance abuse, injuries
o Provides Adolescent Friendly Health Clinics (AFHCs) and Peer
Educator Program

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[Link] Iron and Folic Acid Supplementation (WIFS)

o For adolescent girls and boys to prevent anemia
o Weekly IFA tablets + deworming every 6 months
[Link] Hygiene Scheme (MHS)
o Distribution of sanitary napkins to adolescent girls in rural areas
o Promotes safe and hygienic menstrual practices
5. Service Delivery Platforms Under RMNCH+A
• ASHAs and ANMs: Frontline service providers
• Village Health and Nutrition Days (VHNDs): Monthly sessions for
immunization, ANC, nutrition
• Health and Wellness Centres (HWCs): Expanded PHCs under
Ayushman Bharat
• Facility-based newborn and maternal care units: SNCU, NBSU,
FRUs, PHCs
• Adolescent Friendly Health Clinics (AFHCs
6. Continuum of Care Approach
Stage Services

Adolescence Peer education, anemia control, SRH education

Pregnancy Antenatal care, nutrition, counseling

Childbirth Skilled attendance, EmOC, institutional delivery

Newborn Essential newborn care, breastfeeding

Infancy & Childhood Immunization, nutrition, illness management

Possible Exam Questions
Two Marks
1. Expand RMNCH+A.
2. Mention any two adolescent health programs under RMNCH+A.
Five Marks
1. Write a short note on Janani Suraksha Yojana.
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2. Explain the objectives of RMNCH+A strategy.

Ten Marks
1. Describe national health programs under RMNCH+A and their benefits to
maternal and child health.
2. Explain the continuum of care model in the RMNCH+A strategy.
Current Trends in Midwifery and OBG Nursing
1. Introduction
• Midwifery and OBG Nursing are rapidly evolving to meet the changing
healthcare needs of women throughout the reproductive cycle.
• Trends are influenced by advancements in medical science,
government policies, global recommendations, and women's rights
movements.
2. Current Trends in Midwifery and OBG Nursing
1. Woman-Centered Care
• Emphasizes respectful maternity care (RMC), emotional support,
dignity, and shared decision-making.
• Recognizes individual rights and promotes personalized birth plans.
2. Midwifery-Led Care Units (MLCUs)
• Introduction of Midwifery-Led Care Units in government hospitals as
per WHO guidelines.
• Trained Nurse Practitioners in Midwifery (NPM) lead labor and delivery
care, especially for low-risk pregnancies.
• Promotes natural, low-intervention birth processes.
3. Competency-Based Midwifery Education
• Adoption of ICM and WHO-recommended competency frameworks.
• Emphasis on clinical skills, simulations, critical thinking, and
communication.
• 18-month post-basic midwifery programs under NPM initiative.
4. Respectful Maternity Care (RMC)

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• Ensures the dignity, privacy, consent, and freedom from abuse during
childbirth.
• Adopted as a key component in government programs like SUMAN
(Surakshit Matritva Aashwasan).
5. Integration of Technology
• Use of Electronic Medical Records (EMR) for maternal tracking and
documentation.
• Tele-obstetrics and tele-midwifery for remote monitoring in rural areas.
• Mobile apps for pregnancy tracking, reminders, and health education.
6. High-Dependency Units (HDUs) and Maternal ICUs
• Setup in tertiary hospitals to manage high-risk pregnancies and critical
obstetric complications.
• Improves maternal outcomes in conditions like eclampsia, sepsis,
hemorrhage.
7. Evidence-Based Practice
• Emphasis on use of latest clinical guidelines, Cochrane reviews, and
WHO recommendations.
• Reduces unnecessary interventions like routine episiotomies and C-
sections.
8. Family-Centered Maternity Care
• Involvement of partner or family members during childbirth.
• Promotes skin-to-skin contact, rooming-in, and early initiation of
breastfeeding.
9. Focus on Adolescent and Reproductive Health
• Programs like RKSK and WIFS addressing teenage pregnancies,
menstrual hygiene, and contraception.
• Midwives trained to counsel and provide care to young mothers.
10. Emphasis on Natural Birth and Alternative Birth Positions
• Encouraging upright positions, use of birthing balls, squatting, and
water birthing in select hospitals.
• Reduction in over-medicalization of birth.
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11. Postpartum Mental Health Care

• Increased focus on screening for postpartum depression, anxiety, and
psychological support.
• Integration of mental health services in maternal care.
12. Interdisciplinary Team Approach
• Collaboration between OBG doctors, midwives, neonatologists,
anesthetists, and nurses for comprehensive maternal and newborn care.
13. Expansion of Community-Based Midwifery Services
• Midwives and ASHAs conducting home visits, postnatal care, and
awareness programs at village level.
• Strengthens continuity of care and early complication detection.
14. Increased Institutional Deliveries and Emergency Obstetric Care
(EmOC)
• Due to Janani Suraksha Yojana, JSSK, and PMSMA programs.
• Reduced maternal and neonatal mortality in institutional settings.
3. Global Influences on Midwifery Trends
• Alignment with SDG Goals (especially Goal 3 – Ensure healthy lives and
promote well-being for all)
• WHO’s “Year of the Nurse and Midwife (2020)” – Highlighted the need
to invest in midwifery
• ICM’s efforts to standardize midwifery education and practice
worldwide
Possible Exam Questions
Two Marks
1. Define respectful maternity care.
2. Mention any two current trends in midwifery practice.
Five Marks
1. Write a short note on midwifery-led care units (MLCUs).
2. List and explain five current trends in OBG nursing.
Ten Marks
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1. Describe the current trends in midwifery and their impact on maternal

and newborn care in India.
2. Explain how competency-based midwifery education is shaping future
nursing practice.
Respectful Maternity and Newborn Care (RMNC)
1. Introduction
• Respectful Maternity and Newborn Care (RMNC) is a rights-based
approach that ensures dignity, privacy, informed consent, and freedom
from abuse for women and newborns during pregnancy, childbirth, and
postnatal care.
• Endorsed by WHO, MoHFW (India), and incorporated in programs like
SUMAN to reduce maternal and newborn morbidity and mortality and
promote humanized care.
2. Definition
• RMNC is defined as care that maintains the dignity, privacy, and
confidentiality of the woman and newborn, ensures freedom from harm
and mistreatment, and enables informed choice and continuous support
during labor and childbirth.
3. Principles of RMNC
1. Dignity and Respect
o Treating women and newborns with courtesy, compassion, and
empathy.
2. Privacy and Confidentiality
o Ensuring physical and information privacy during examinations
and procedures.
3. Freedom from Harm and Ill-Treatment
o Preventing verbal, physical, or emotional abuse or neglect during
care.
4. Informed Consent and Refusal
o Educating and seeking permission before any procedure or
intervention.
5. Non-Discrimination

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o No discrimination based on age, caste, religion, income, or HIV

status.
6. Timely and Effective Care
o Prompt attention, appropriate interventions, and emergency
referrals.
7. Companion of Choice
o Allowing presence of a family member or birth companion during
labor.
8. Continuous Support During Labor
o Emotional and physical support throughout labor and delivery.
9. Right to Information
o Clear communication about health conditions, care options, and
procedures.
[Link] Care with Dignity
• Immediate skin-to-skin contact, delayed cord clamping, breastfeeding
initiation, and respectful handling of newborns.
4. Components of RMNC in Clinical Practice
• Antenatal Care (ANC):
o Confidential counseling, informed decisions, safe environment.
• Intranatal Care (Labor and Delivery):
o Respectful communication, birthing positions, pain management,
informed procedures.
• Postnatal Care:
o Breastfeeding support, maternal and newborn hygiene, mental
health care.
• Emergency Care:
o Rapid response without judgment or delay in life-threatening
conditions.
5. Importance of RMNC
• Builds trust and confidence in the healthcare system.

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• Improves health-seeking behavior and increases institutional deliveries.

• Reduces trauma, stress, and postpartum depression.
• Encourages exclusive breastfeeding and better newborn outcomes.
• Enhances satisfaction and positive birthing experience.
6. Government Initiatives Supporting RMNC
• SUMAN (Surakshit Matritva Aashwasan):
o Ensures free and respectful care for mothers and newborns in
public facilities.
• LaQshya (Labour Room Quality Improvement Initiative):
o Improves quality and respect in intrapartum care.
• Midwifery-Led Care Units (MLCUs):
o Promote natural births with respectful and evidence-based care.
• Maternal and Newborn Health Toolkits and Guidelines by MoHFW
and WHO.
7. Role of Nurse/Midwife in Promoting RMNC
• Ensure empathetic, respectful communication.
• Maintain privacy and confidentiality.
• Obtain informed consent before every procedure.
• Allow birth companion of choice.
• Support non-supine birthing positions.
• Provide immediate newborn care and encourage skin-to-skin contact.
• Educate mother about postnatal care and breastfeeding.
8. Barriers to RMNC Implementation
• Lack of staff training
• High workload and overcrowded labor rooms
• Cultural biases and gender discrimination
• Poor infrastructure and privacy arrangements
• Absence of accountability mechanisms

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Possible Exam Questions

Two Marks
1. Define Respectful Maternity and Newborn Care.
2. Mention any two principles of RMNC.
Five Marks
1. Write a short note on SUMAN and its role in RMNC.
2. List five key principles of respectful maternity care.
Ten Marks
1. Describe the principles and importance of respectful maternity and
newborn care.
2. Discuss the role of a nurse in promoting respectful maternity care during
labour and childbirth.
Midwifery-Led Care Units (MLCU)
1. Introduction
• Midwifery-Led Care Units (MLCUs) are dedicated units within
hospitals or maternity facilities that offer safe, respectful, woman-
centered care to women with low-risk pregnancies, led primarily by
trained midwives.
• Based on WHO and ICM recommendations to strengthen natural
childbirth, reduce unnecessary interventions, and improve maternal
and newborn outcomes.
2. Definition
• MLCU is a midwife-managed birthing center, where trained Nurse
Practitioners in Midwifery (NPMs) provide comprehensive antenatal,
intranatal, and postnatal care for low-risk women, with physician
backup available when needed.
3. Objectives of MLCU
• Provide natural, respectful, and evidence-based birthing care.
• Promote normal vaginal deliveries without unnecessary interventions.
• Ensure continuity of care from pregnancy through postpartum.

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• Enhance respectful maternity care (RMC) and reduce maternal

mortality.
• Empower midwives as independent skilled care providers.
4. Features of MLCU
• Operated by Skilled Birth Attendants (SBAs), particularly Nurse
Practitioners in Midwifery (NPM).
• Cater to low-risk pregnancies with emergency referral systems.
• Located within or near government district hospitals or medical
colleges.
• Encourage minimal use of medical interventions (no routine
episiotomies, inductions, or C-sections).
• Promote informed choices, birth companionship, and freedom of
movement during labor.
• Use of non-pharmacological pain relief (massage, breathing techniques,
birthing balls).
5. Services Provided in MLCU
• Antenatal check-ups and birth preparedness.
• Intranatal care with labor support and monitoring.
• Postnatal monitoring and counseling.
• Breastfeeding support and newborn care.
• Emergency referral services in case of complications.
6. Training and Staffing
• MLCUs are staffed by Nurse Practitioners in Midwifery (NPMs)
trained under 18-month Midwifery Education Program.
• Supported by obstetricians and pediatricians on call for complications.
• Staff receive training in RMC, life-saving skills, and emergency
management.
7. Advantages of MLCUs
• Increased satisfaction among mothers due to personalized care.
• Lower rates of cesarean sections and instrumental deliveries.

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• Reduced maternal and neonatal morbidity.

• Improved breastfeeding outcomes and early bonding.
• Empowerment of midwives as leaders in maternal health.
• Decongestion of high-load tertiary obstetric units.
8. Government Initiatives
• Government of India has initiated setting up of MLCUs in public health
facilities under the Midwifery Services Initiative (2018).
• First MLCUs operational in states like Kerala, Maharashtra, and Tamil
Nadu.
• Supportive policies under National Health Mission (NHM) and
LaQshya.
9. Differences Between MLCU and Traditional Hospital Delivery Unit
Aspect MLCU Traditional Delivery Unit

Care Provider Midwife-led Doctor-led (OBG)

Target Group Low-risk pregnant women All cases including high-risk

Birth Medicalized, higher

Natural, minimal intervention
Philosophy intervention rates

Labor Support One-on-one, continuous Often limited

Minimized (e.g., episiotomy,

Interventions More common
induction)

Birth Positions Flexible and woman’s choice Usually supine

Pain Non-pharmacological and

Primarily pharmacological
Management holistic
10. Challenges in Implementation
• Shortage of trained midwifery educators and NPMs.
• Resistance from existing medical systems.
• Need for infrastructure, protocols, and community awareness.
• Sustained funding and political will.

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11. Role of Nurse/Midwife in MLCU

• Conduct normal deliveries independently.
• Provide antenatal and postnatal care.
• Support laboring women with respect and dignity.
• Identify danger signs and initiate emergency referral.
• Counsel on nutrition, newborn care, and birth preparedness.
Possible Exam Questions
Two Marks
1. Define Midwifery-Led Care Unit.
2. Mention two services offered by MLCU.
Five Marks
1. Write a short note on the objectives and advantages of MLCU.
2. List differences between MLCU and traditional delivery units.
Ten Marks
1. Discuss the concept, services, and benefits of MLCUs in improving
maternal care in India.
2. Describe the role of nurse-midwives in managing MLCUs and promoting
natural childbirth.
Women-Centered Care, Physiologic Birthing, and Demedicalization of Birth
1. Women-Centered Care
Definition
• A holistic approach to maternity services that places the woman’s
individual needs, values, choices, and experiences at the center of all
clinical decisions and care.
Key Elements
• Respect and dignity in care
• Informed decision-making and autonomy
• Continuity of care from known providers
• Emotional, physical, social support
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• Culturally safe and responsive care

• Birth companionship and personalized birth plans
Objectives
• Promote positive birthing experience
• Empower women as active participants in childbirth
• Improve maternal and newborn outcomes
• Encourage natural, non-interventionist care
Role of Midwife in Women-Centered Care
• Advocate for the woman’s preferences
• Support natural birth and emotional well-being
• Provide clear, respectful communication
• Ensure privacy, confidentiality, and informed consent
2. Physiologic (Natural) Birthing
Definition
• A natural, spontaneous process of labor and birth that occurs without
routine medical interventions, guided by the woman’s body and instincts.
Characteristics
• Spontaneous onset of labor
• Use of natural pain relief methods (breathing, massage, water therapy)
• Freedom of movement during labor
• Birth in a calm, private environment
• Use of alternative birth positions (squatting, side-lying, kneeling)
• Immediate skin-to-skin contact and delayed cord clamping
• Initiation of exclusive breastfeeding within 1 hour
Benefits of Physiologic Birth
• Reduced need for C-section, forceps, episiotomy
• Faster recovery for mother
• Enhanced bonding and breastfeeding success
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• Less postpartum pain and fewer complications

• Improved newborn adaptation (respiration, thermoregulation)
Supportive Strategies
• One-on-one continuous labor support
• Birth plans and woman’s choice in birthing positions
• Calm environment with dim lighting and quiet surroundings
• Use of birthing balls, music, aromatherapy, etc.
3. Demedicalization of Birth
Definition
• The shift away from routine, unnecessary medical interventions in
childbirth toward natural and woman-led birthing practices.
Why Demedicalization?
• Rising rates of C-sections, inductions, and instrumental births
• Over-reliance on technology and interventions
• Disempowerment and dissatisfaction among birthing women
Examples of Medicalized vs. Demedicalized Care
Aspect Medicalized Birth Demedicalized Birth

Onset of
Often induced Spontaneous labor onset
labor

Breathing, movement, massage,

Pain relief Epidural, analgesics
hydrotherapy

Woman’s choice (upright,

Birth position Supine (doctor’s preference)
squatting, etc.)

Avoided unless medically

Episiotomy Often routine
necessary

Continuous electronic fetal Intermittent auscultation (for low-

Monitoring
monitoring risk)

Environment Clinical and bright Home-like, calm, supportive

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Benefits of Demedicalization
• Promotes normal physiology of labor
• Reduces maternal and neonatal complications
• Enhances satisfaction and mental well-being
• Increases autonomy and self-confidence in women
• Aligns with Respectful Maternity Care (RMC) principles
Integration of All Three Concepts in Practice
• Midwifery-led models (e.g., MLCUs) promote all three:
o Women-centered care through informed choice and
empowerment
o Physiologic birth by avoiding routine interventions
o Demedicalization through natural support and respect for body’s
process
• WHO and Indian Health Ministry recommend integrating these models
into public healthcare through programs like SUMAN, LaQshya, and
Midwifery Services Initiative.
Possible Exam Questions
Two Marks
1. Define physiologic birthing.
2. Mention two features of women-centered care.
Five Marks
1. Write a short note on demedicalization of birth.
2. List benefits of physiologic birth for mother and baby.
Ten Marks
1. Describe the concepts of women-centered care, physiologic birth, and
demedicalization of birth and explain how they promote positive maternal
outcomes.
2. Discuss the role of the midwife in supporting a demedicalized, woman-
centered birthing experience.
Birthing Centers, Water Birth, and Lotus Birth
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1. Birthing Centers
Definition
• Birthing centers are home-like healthcare facilities that provide family-
centered, low-intervention birthing care for low-risk pregnancies,
usually managed by midwives or nurse practitioners.
Features
• Designed to support natural childbirth
• Offer privacy, comfort, and personalized care
• Provide antenatal, intranatal, and postnatal services
• Equipped with emergency referral systems to hospitals
• Encourage birth companion presence
• Often use alternative birthing positions and pain-relief methods
Types
• Freestanding birthing centers: Located away from hospitals
• Hospital-attached birthing centers: Located within hospital premises
• Home-based birthing services (community midwives)
Advantages
• Reduced medical interventions (e.g., episiotomies, C-sections)
• Lower healthcare costs than hospital births
• More personalized and respectful maternity care
• Support for natural birth, breastfeeding, and early bonding
Limitations
• Not suitable for high-risk pregnancies
• Emergency services may be delayed in freestanding centers
• Limited pain management options (e.g., epidurals often not available)
Examples in India
• Midwifery-Led Care Units (MLCUs) in government settings
• Private birthing centers like BirthVillage, Sanctum, etc.

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2. Water Birth
Definition
• A method of childbirth where a woman labors and/or gives birth in a
tub of warm water, facilitated by a trained midwife or healthcare
provider.
Purpose
• To provide a soothing, low-stress environment that supports natural
birth and reduces pain.
Phases of Use
• Only during labor (commonly) or
• During both labor and delivery (if conditions allow)
Benefits
• Pain relief without drugs
• Promotes muscle relaxation
• Increases mobility and comfort during labor
• May reduce duration of first and second stages of labor
• Improves blood circulation and oxygen supply
• Baby transitions gently from water to air
Contraindications
• High-risk pregnancy (e.g., preterm labor, breech, twins)
• Maternal infections (HIV, hepatitis)
• Meconium-stained liquor
• Need for continuous fetal monitoring
Nursing Role
• Assess eligibility and consent
• Monitor maternal vitals and fetal heart rate
• Maintain water temperature (36–37.5°C)
• Ensure infection control and hygiene

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• Be ready to assist immediate newborn care

Precautions
• Clean, sterilized tub
• Woman should stay hydrated and monitored
• Emergency support should be available nearby
3. Lotus Birth
Definition
• A practice where the umbilical cord is not cut after birth. Instead, the
cord and placenta remain attached to the newborn until they
naturally separate, typically in 3–10 days.
Beliefs and Purpose
• Based on spiritual, naturalistic, or cultural values
• Belief that it provides gentle transition for the baby
• Some suggest it allows complete transfer of placental blood
Procedure
• After birth, the placenta is delivered and cleaned
• It is placed in a cloth or bowl and often sprinkled with salt and herbs to
prevent odor
• The placenta is kept close to the baby until it naturally detaches
Advantages (claimed)
• No risk of cord clamping injury
• Potential immune benefits (unproven)
• Promotes bonding and calm transition
Risks and Concerns
• Infection risk due to decomposing placenta
• Limited mobility for the baby
• No proven scientific benefit
• Not recommended by WHO or medical authorities

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Nursing Responsibilities
• Provide neutral, respectful education on risks and lack of evidence
• Ensure hygiene, proper cord care if practiced
• Monitor for signs of infection or distress
• Encourage evidence-based care
Comparison Table
Feature Birthing Center Water Birth Lotus Birth

Facility (midwife- Water tub (in

Setting Home or birthing center
led) center/home)

Midwives or Midwives, trained Usually parents, with

Care Provider
nurse-midwives professionals midwife oversight

No intervention after
Interventions Minimal Minimal
birth

Safe for low-risk Safe for selected Not recommended

Safety
pregnancies cases medically

Evidence Lacking scientific

Strong Moderate
Support support

Low with proper

Infection Risk Low (if sterile) High if not monitored
hygiene
Possible Exam Questions
Two Marks
1. Define birthing center.
2. Mention one benefit of water birth.
Five Marks
1. Write a short note on the advantages of birthing centers.
2. Describe the procedure and precautions in water birth.
Ten Marks
1. Compare birthing centers, water birth, and lotus birth. Discuss their
benefits and limitations.
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2. Describe the concept of lotus birth and the role of the nurse in educating
the mother.
Essential Competencies for Midwifery Practice (as per ICM – International
Confederation of Midwives)
1. Introduction
• The International Confederation of Midwives (ICM) has developed a
globally recognized framework outlining essential competencies that
every midwife must possess to deliver safe, effective, evidence-based,
and respectful maternal and newborn care.
• These competencies guide education, practice, regulation, and
midwifery leadership worldwide.
• India also follows these in developing its Midwifery Services Initiative
and Midwifery-Led Care Units (MLCUs).
2. ICM Essential Competencies – Overview
ICM classifies the essential competencies into four main categories:
1. General Competencies
2. Pre-Pregnancy and Antenatal Care
3. Care During Labour and Birth
4. Ongoing Care of Women and Newborns
3. General Competencies
• Professional accountability in practice
• Apply ethical and legal standards
• Use evidence-based practices
• Communicate effectively with women, families, and health team
• Maintain confidentiality and privacy
• Promote human rights and dignity
• Provide woman-centered, culturally sensitive care
• Maintain records and documentation
• Work in inter-professional collaboration
• Provide emergency and life-saving interventions when needed
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4. Competencies for Pre-Pregnancy and Antenatal Care

• Educate and counsel on family planning and reproductive health
• Promote preconception health (nutrition, infection prevention, etc.)
• Provide comprehensive antenatal assessment
• Identify risk factors, complications, and refer appropriately
• Promote healthy lifestyle during pregnancy
• Provide emotional and psychological support
• Prepare women and families for labor, birth, breastfeeding, and
parenting
• Ensure birth preparedness and complication readiness
5. Competencies for Care During Labour and Birth
• Monitor the progress of labor using partograph and clinical skills
• Provide supportive care throughout labor and delivery
• Assist with normal vaginal birth
• Manage complications such as postpartum hemorrhage, preeclampsia,
obstructed labor, etc.
• Use infection prevention and control measures
• Promote non-pharmacological pain relief
• Provide respectful and dignified care during childbirth
• Initiate early skin-to-skin contact and breastfeeding
6. Competencies for Ongoing Care of Women and Newborns
• Conduct postnatal assessments for mother and baby
• Support breastfeeding and newborn care
• Identify and manage common postpartum issues (e.g., mastitis, PPH)
• Educate on family planning and child spacing
• Screen for postpartum depression and refer as needed
• Monitor neonatal growth and development
• Recognize and manage newborn danger signs

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• Encourage immunization and follow-up visits

7. Cross-Cutting Themes in All Competencies
• Respect for human rights
• Gender equity and cultural competence
• Evidence-based care
• Lifelong learning and continuing education
• Use of digital tools and health information systems
• Leadership and advocacy in midwifery practice
• Disaster preparedness and emergency care response
8. Importance of ICM Competencies in Practice
• Standardizes global midwifery education and practice
• Helps midwives deliver safe, skilled, and respectful care
• Reduces maternal and neonatal mortality
• Enhances professional recognition and autonomy of midwives
• Forms the basis for curriculum design, training, and licensure
ICM Competencies Implementation in India
• India's Midwifery Services Initiative (MSI) is based on ICM
competencies
• Training of Nurse Practitioners in Midwifery (NPM) follows these
guidelines
• Focuses on midwife-led natural birth, evidence-based practice, and
woman-centered care
Possible Exam Questions
Two Marks
1. List any two general competencies of a midwife according to ICM.
2. Name two competencies required during antenatal care as per ICM.
Five Marks
1. Write a short note on the ICM essential competencies for labor and birth
care.
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2. List competencies required during postnatal care as per ICM.

Ten Marks
1. Describe the essential competencies for midwifery practice according to
ICM and explain their importance in providing safe maternal and
newborn care.
2. Discuss how ICM competencies guide midwifery education and practice
in India.
Universal Rights of Childbearing Women
1. Introduction
• The Universal Rights of Childbearing Women are part of the global
movement for Respectful Maternity Care (RMC).
• Promoted by the White Ribbon Alliance and recognized by WHO, these
rights ensure that women are treated with dignity, respect, and equality
during pregnancy, labor, birth, and postpartum care.
• These rights align with human rights principles and aim to eliminate
mistreatment, abuse, and neglect in maternal health services.
2. The 7 Universal Rights of Childbearing Women
1. The Right to be Free from Harm and Ill Treatment
• Women must not be subjected to physical, verbal, or emotional abuse
during maternity care.
• Includes protection from unnecessary interventions, discrimination, or
neglect.
• Ensures care in safe, clean, and respectful environments.
2. The Right to Information, Informed Consent and Refusal, and Respect
for Choices and Preferences
• Women have the right to receive complete and understandable
information about their health and available options.
• They can accept or refuse any procedure (e.g., C-section, episiotomy).
• Includes respecting birth plans, companion of choice, and preferred
birthing position.
3. The Right to Privacy and Confidentiality

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• Women’s personal and medical information must be kept private and

secure.
• Physical privacy during examination and childbirth must be ensured (e.g.,
using curtains, closed doors).
• Conversations must happen in a confidential manner.
4. The Right to be Treated with Dignity and Respect
• Women should be treated kindly, courteously, and without
discrimination.
• Includes non-judgmental care regardless of age, caste, religion, income,
or HIV status.
• Promotes cultural sensitivity in care.
5. The Right to Equality, Freedom from Discrimination, and Equitable
Care
• Women should receive fair and equal care, regardless of social status,
ethnicity, or background.
• Healthcare providers must avoid biased or unequal treatment.
• Supports universal access to skilled maternal care.
6. The Right to Healthcare and to the Highest Attainable Level of Health
• Every woman has the right to timely, quality maternal and newborn
care.
• Includes access to emergency obstetric services, respectful referrals,
and essential drugs and supplies.
• Encourages continuity of care throughout the perinatal period.
7. The Right to Liberty, Autonomy, Self-Determination, and Freedom from
Coercion
• Women have the right to make autonomous decisions about their care.
• They must not be detained or forced into procedures or hospital stays.
• Includes freedom to move, choose care providers, and have birth
companions.
3. Importance in Midwifery and Maternal Care
• Ensures patient-centered care and improved maternal satisfaction.
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• Reduces maternal morbidity and mortality.

• Promotes trust and cooperation between women and healthcare
providers.
• Addresses issues like obstetric violence, discrimination, and neglect.
• Supports ethical and professional midwifery practice.
4. Role of Midwives in Upholding These Rights
• Educate women on their rights during antenatal care.
• Provide respectful, non-discriminatory, and woman-centered care.
• Advocate for informed choice and consent.
• Maintain confidentiality and privacy at all stages.
• Document care properly and communicate clearly.
• Identify and report abuse, neglect, or rights violations.
• Support policy development and quality improvement in maternity
services.
5. Application in Indian Context
• Incorporated in initiatives like:
o LaQshya – Labour Room Quality Improvement Initiative
o SUMAN – Surakshit Matritva Aashwasan
o Midwifery Services Initiative
• Training programs for midwives and healthcare workers now include
modules on Respectful Maternity Care (RMC).
• Promotes zero tolerance for mistreatment during childbirth in public
health facilities.
Possible Exam Questions
Two Marks
1. List any two universal rights of childbearing women.
2. What does RMC stand for?
Five Marks

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1. Explain the role of a midwife in protecting the rights of childbearing

women.
2. List the 7 universal rights of childbearing women.
Ten Marks
1. Describe in detail the universal rights of childbearing women and their
significance in promoting respectful maternity care.
2. Discuss how these rights are integrated into maternal healthcare services
in India.
Sexual and Reproductive Health and Rights (SRHR)
1. Introduction
• Sexual and Reproductive Health and Rights (SRHR) is a global
public health and human rights concept that recognizes every person's
right to make informed choices about their body, sexuality,
reproduction, and relationships.
• These rights are essential for achieving gender equality, improving
maternal and child health, and ensuring dignified healthcare.
2. Definitions
• Sexual Health: A state of physical, emotional, mental, and social well-
being related to sexuality. It requires a positive and respectful approach
to sexuality and sexual relationships.
• Reproductive Health: A state of complete well-being in matters related
to the reproductive system and its functions and processes, including the
ability to reproduce and decide when and how often.
3. Key Components of SRHR
1. Right to Sexual Health Services
o Access to safe, affordable, and confidential sexual health care
o Prevention and treatment of sexually transmitted infections
(STIs) including HIV/AIDS
o Safe and respectful services for sexual minorities and adolescents
2. Right to Reproductive Health Services
o Access to contraceptives, family planning

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o Safe pregnancy care, delivery, and postnatal services

o Prevention and management of infertility, cancers, abortions, and
reproductive tract infections
3. Right to Information and Education
o Comprehensive, evidence-based sexuality education
o Awareness about safe sex, consent, and bodily autonomy
o Promotes informed and responsible decision-making
4. Right to Make Reproductive Choices
o Decide freely and responsibly on the number, timing, and spacing
of children
o Choose contraceptive methods
o Access to safe and legal abortion (as per national laws)
5. Right to Privacy and Confidentiality
o Personal health information and services must be protected
o Ensures respect, dignity, and security in care
6. Freedom from Coercion, Discrimination, and Violence
o Protection from forced sterilization, child marriage, honor
crimes, female genital mutilation, and sexual violence
o Equal access to services regardless of gender, class, religion, caste,
or marital status
4. SRHR in India – Legal and Programmatic Framework
• Constitutional Rights
o Right to life and health (Article 21)
o Right to equality and non-discrimination (Articles 14–15)
• Key Laws Supporting SRHR
o Medical Termination of Pregnancy (MTP) Act – Safe and legal
abortion
o Protection of Children from Sexual Offences (POCSO) Act
o Prohibition of Child Marriage Act

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o Domestic Violence Act

o Pre-Conception and Pre-Natal Diagnostic Techniques
(PCPNDT) Act – Prevents sex-selective abortions
• National Programs Promoting SRHR
o RMNCH+A (Reproductive, Maternal, Newborn, Child +
Adolescent Health)
o Mission Parivar Vikas – Family planning and contraceptive
services
o RKSK (Rashtriya Kishor Swasthya Karyakram) – Adolescent
reproductive health
5. Role of Midwives and Nurses in SRHR
• Provide non-judgmental, respectful, and confidential care
• Offer contraceptive counseling and services
• Support adolescent sexual health education
• Prevent and manage STIs and reproductive health issues
• Advocate for gender equity and human rights in healthcare
• Identify and report violence or abuse
6. Barriers to SRHR
• Cultural taboos and stigma around sexuality
• Lack of awareness and sex education
• Gender discrimination and patriarchy
• Limited access to rural or underserved areas
• Poor adolescent and LGBTQ+ inclusion
• Fear of judgment or breach of confidentiality
7. Importance of SRHR in Nursing and Midwifery
• Empowers women and adolescents to take charge of their health
• Reduces unintended pregnancies, maternal deaths, and unsafe
abortions
• Promotes gender equality and social justice

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• Builds a more informed, healthy population

Possible Exam Questions
Two Marks
1. Define reproductive health.
2. Name any two components of SRHR.
Five Marks
1. Write a short note on the rights covered under SRHR.
2. List the national programs that support SRHR in India.
Ten Marks
1. Explain the key components of Sexual and Reproductive Health and
Rights (SRHR) and the role of midwives in promoting them.
2. Discuss the legal and programmatic framework of SRHR in India and its
importance in maternal and adolescent health.
Women's Expectations and Choices About Care
1. Introduction
• Women have the right to make informed decisions about their maternity
care.
• Understanding their expectations and preferences helps improve the
quality, safety, and satisfaction of maternal health services.
• Midwives must provide woman-centered care that respects individual
choices, autonomy, and dignity.
2. Common Expectations of Women During Maternity Care
1. Respectful and Dignified Care
o To be treated with kindness, empathy, and without
discrimination
o To feel respected, regardless of age, marital status, caste, religion,
or economic status
2. Privacy and Confidentiality
o Assurance that personal health information and procedures will
be handled privately

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3. Effective Communication
o To receive clear explanations in a language they understand
o Opportunity to ask questions and get answers
4. Involvement in Decision-Making
o To be informed and consulted before procedures
o To participate in decisions regarding birth plan, pain relief, and
mode of delivery
5. Emotional Support
o Presence of a birth companion of choice
o Support from nurses, midwives, and family members
6. Safe and Evidence-Based Care
o Access to qualified health professionals and emergency care
o Care that follows scientific guidelines and avoids unnecessary
interventions
7. Continuity of Care
o Same caregiver or team throughout pregnancy, labor, and
postpartum
o Smooth referrals when needed
8. Cultural Sensitivity
o Acknowledgement of cultural beliefs, traditions, and practices
o Avoiding disrespect of cultural or religious customs
9. Clean and Comfortable Environment
o Expectation of a clean, hygienic, and private birthing area
o Availability of basic amenities like clean toilets, water, and clean
bedding
[Link] Support
• Help with breastfeeding, newborn care, and family planning
• Emotional support and mental health screening

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3. Women's Choices in Maternity Care

1. Choice of Birth Setting
o Hospital, Birthing center, or Home birth (if low-risk and safe)
2. Choice of Birth Attendant
o Doctor, Midwife, or Traditional Birth Attendant (TBA) (where
culturally relevant)
3. Choice of Birth Position
o Upright (squatting, sitting), lying down, or water birth
4. Pain Management Options
o Pharmacologic: Epidural, spinal analgesia
o Non-pharmacologic: Breathing, massage, warm baths, movement
5. Choice of Birth Companion
o Husband, mother, sister, doula, or anyone the woman trusts
6. Consent for Procedures
o Cesarean section, episiotomy, labor induction, internal examination
7. Breastfeeding and Newborn Care Practices
o Exclusive breastfeeding, rooming-in, delayed bathing
8. Family Planning Choices
o Postpartum contraception options: IUD, pills, injectables,
sterilization, condoms
4. Role of the Nurse or Midwife
• Listen actively to the woman’s concerns and preferences
• Provide accurate information and education
• Support informed decision-making
• Ensure respectful maternity care (RMC)
• Advocate for safe and culturally acceptable choices
• Communicate non-judgmentally and empathetically
5. Benefits of Respecting Women’s Expectations and Choices

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• Enhances trust and compliance

• Reduces birth trauma and stress
• Increases maternal satisfaction and confidence
• Encourages positive childbirth experiences
• Promotes breastfeeding, early bonding, and postnatal recovery
Possible Exam Questions
Two Marks
1. Mention any two common expectations of women during childbirth.
2. Name two choices women may make during labor.
Five Marks
1. Explain the role of the nurse in supporting women’s choices during
childbirth.
2. List five expectations of women from the maternity care system.
Ten Marks
1. Discuss women’s expectations and choices in maternity care. How can
nurses ensure respectful, woman-centered care?
2. Describe how understanding and supporting women’s expectations
improves quality of midwifery services.
Legal Provisions in Midwifery Practice in India
1. Introduction
• Legal provisions in midwifery are designed to ensure safe, ethical, and
standardized maternal care.
• Midwives and nurses must be aware of laws that govern their scope of
practice, patient rights, and accountability.
• Legal knowledge protects both the healthcare provider and the client.
2. Key Legal Provisions Relevant to Midwifery Practice in India
1. Indian Nursing Council (INC) Act, 1947
• Regulates nursing education and practice in India.
• Empowers INC to set standards for midwifery training and practice.

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• Provides for licensure and registration of midwives and nurses.

2. Medical Termination of Pregnancy (MTP) Act, 1971 (Amended in 2021)
• Legalizes abortion under specific conditions.
• Midwives must ensure:
o Consent is obtained.
o Procedures are conducted in authorized centers.
o Confidentiality is maintained.
3. The Pre-Conception and Pre-Natal Diagnostic Techniques (PCPNDT)
Act, 1994
• Prevents sex-selective abortion and misuse of prenatal diagnostic
techniques.
• Midwives must:
o Avoid involvement in illegal gender determination.
o Report suspicious activities.
4. Consumer Protection Act, 2019
• Patients are considered consumers, and midwives are service providers.
• Legal action can be taken for negligence, lack of informed consent, or
improper care.
5. Indian Penal Code (IPC), 1860 – Sections Relevant to Midwifery
• Section 304A – Death caused by negligence
• Section 312–316 – Offenses related to illegal abortion
• Section 319–338 – Injuries and harm due to medical negligence
• Section 354 – Assault or force to outrage modesty of a woman
6. Protection of Women from Domestic Violence Act, 2005
• Midwives should identify and report signs of domestic abuse.
• Provide referral and emotional support to victims.
7. POCSO Act (Protection of Children from Sexual Offences), 2012
• Mandates mandatory reporting of sexual offenses against girls under
18.
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• Midwives must maintain sensitivity and confidentiality.

8. Registration with State Nursing Councils
• Midwives must be registered with the respective State Nursing
Council.
• Practice without registration is illegal.
3. Rights and Responsibilities of Midwives Under Law
• Provide safe, ethical, and evidence-based care
• Maintain confidentiality and respect for patient dignity
• Obtain informed consent before procedures
• Keep accurate records and documentation
• Report any abuse, neglect, or rights violations
• Refer promptly in case of complications
• Avoid unauthorized procedures or medication administration
4. Legal Protection for Midwives
• Practicing within legal scope protects midwives from litigation.
• Documentation is a strong legal defense in case of complaint.
• Knowledge of laws helps midwives to avoid negligence and ethical
errors.
5. Ethical Considerations in Midwifery Practice
• Autonomy – Respect the woman's decisions.
• Beneficence – Act in the best interest of the mother and baby.
• Non-maleficence – Do no harm.
• Justice – Provide equal care to all without discrimination.
• Confidentiality – Keep patient information private.
6. Institutional Protocols and Legal Reporting
• Every healthcare institution should have:
o Legal cell for handling medico-legal issues
o Protocols for documentation, consent, and referral

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o Training for midwives on laws and rights

Possible Exam Questions
Two Marks
1. Name any two legal acts related to midwifery practice in India.
2. Mention one legal responsibility of a midwife during delivery.
Five Marks
1. Write a short note on the importance of legal knowledge in midwifery
practice.
2. Explain the role of the MTP Act in safe abortion care.
Ten Marks
1. Describe in detail the legal provisions governing midwifery practice in
India.
2. Discuss the role of a midwife in ensuring legal and ethical maternity care.
INC / MoHFW Regulations Related to Midwifery Practice
1. Introduction
• Midwifery practice in India is guided and regulated by two key
authorities:
o Indian Nursing Council (INC) – a statutory body under the
Government of India.
o Ministry of Health and Family Welfare (MoHFW) – responsible
for health policy, programs, and standards.
• These bodies aim to standardize education, ensure quality care, and
enhance the midwifery workforce to meet national health goals.
2. Indian Nursing Council (INC) Regulations
1. INC Act, 1947
• Establishes INC as the regulatory authority for nursing and midwifery
education and practice in India.
• Empowers INC to:
o Prescribe curriculum, qualifications, and standards.
o Maintain a central register of qualified nurses/midwives.
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o Recognize nursing institutions.

o Inspect institutions for compliance with norms.
2. INC Regulations for Midwifery Education
• Prescribes syllabus and duration for GNM, BSc Nursing, and
Midwifery training programs.
• Recommends clinical hours and practical exposure (e.g., antenatal,
intranatal, postnatal, neonatal care).
• Faculty qualifications and student-teacher ratio (1:10) must be
maintained.
• Mandatory registration with the State Nursing Council to practice
legally.
3. Scope of Midwifery Practice (INC 2021 Framework)
• Midwives are trained to:
o Conduct normal deliveries
o Provide antenatal, intranatal, postnatal and newborn care
o Detect complications and refer promptly
o Promote family planning and reproductive health
o Counsel on nutrition, hygiene, and breastfeeding
• Midwives are independent practitioners in midwifery-led care units.
4. Competency-Based Midwifery Curriculum (as per ICM standards)
• Focus on hands-on skills, ethical practice, respectful care, and
emergency handling.
• Includes simulation labs, clinical postings, and rural/urban postings.
3. Ministry of Health & Family Welfare (MoHFW) Regulations
1. National Midwifery Services Initiative (NMSI), 2018
• Aims to create a new cadre of Nurse Practitioners in Midwifery
(NPM).
• Focus on:
o Establishing Midwifery-Led Care Units (MLCU) in hospitals.

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o Providing natural, respectful, and woman-centered birth care.

o Achieving Sustainable Development Goals (SDGs) by reducing
maternal and neonatal mortality.
• Aligns with International Confederation of Midwives (ICM)
standards.
2. RMNCH+A Strategy
• Reproductive, Maternal, Newborn, Child and Adolescent Health
(RMNCH+A) launched by MoHFW.
• Midwives play a central role in:
o Antenatal care, Safe delivery, Postnatal follow-up
o Adolescent reproductive health
o Promoting family planning and vaccinations
3. Guidelines for Midwifery Training Institutes
• MoHFW has approved National Midwifery Training Institutes
(NMTIs) and State Midwifery Training Institutes (SMTIs).
• Training based on:
o 12-month residential midwifery education program
o Mentored by national and international experts
o Graduates posted in MLCUs across India
4. LaQshya Program (Labour Room Quality Improvement Initiative)
• Launched under MoHFW to improve quality of maternal care in labor
rooms and maternity OTs.
• Emphasizes:
o Respectful Maternity Care (RMC)
o Cleanliness, infection control, prompt referral
o Continuous presence of skilled birth attendants (SBAs) like
midwives
4. Collaborative Functions of INC and MoHFW
• INC sets educational standards; MoHFW implements policies and funds
services.
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• Both promote:
o High-quality midwifery education
o Deployment of skilled midwives
o Infrastructure for MLCUs and training
o Monitoring and evaluation of outcomes
o Research and policy reforms for improving midwifery services
5. Importance of These Regulations in Practice
• Ensures standardized, ethical, and evidence-based midwifery care.
• Empowers midwives to function independently and confidently.
• Reduces maternal and neonatal morbidity and mortality.
• Promotes respectful care, women's rights, and community trust in health
systems.
Possible Exam Questions
Two Marks
1. Name the two major regulatory bodies for midwifery practice in India.
2. What does MLCU stand for?
Five Marks
1. Write a short note on the role of MoHFW in strengthening midwifery
services.
2. List any four functions of INC.
Ten Marks
1. Discuss in detail the INC and MoHFW regulations related to midwifery
education and practice in India.
2. Explain how National Midwifery Services Initiative (NMSI) is
transforming maternity care in India.
ICM Code of Ethics for Midwives
(ICM = International Confederation of Midwives)
1. Introduction

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• The ICM Code of Ethics serves as a global ethical framework for

midwifery practice.
• It ensures respectful, competent, and professional care for women,
newborns, and families.
• Midwives are expected to follow this code to uphold human rights,
dignity, and safety in care.
2. Purpose of the ICM Code of Ethics
• To guide professional conduct of midwives.
• To ensure woman-centered, culturally sensitive, and ethical care.
• To promote global standards of midwifery.
• To protect the rights of women, newborns, and communities.
• To define accountability in midwifery practice.
3. Four Domains of the ICM Code of Ethics
1. Midwives and Women
• Respect the dignity and human rights of all women.
• Provide individualized, culturally sensitive, and non-judgmental care.
• Promote informed choice and consent in all care decisions.
• Maintain confidentiality and privacy at all times.
• Encourage women’s autonomy and empowerment.
• Provide care that is safe, evidence-based, and free from abuse or
coercion.
2. Midwives and the Practice of Midwifery
• Practice according to scientific knowledge, legal standards, and
professional guidelines.
• Maintain competency through lifelong learning and skill updates.
• Be accountable for own actions and decisions.
• Avoid any discrimination, dishonesty, or unethical behavior.
• Promote normal birth and avoid unnecessary interventions.
• Uphold professional boundaries.

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3. Midwives and Society

• Respect and advocate for the health needs of individuals and
communities.
• Participate in health education, public health, and awareness campaigns.
• Work towards eliminating gender discrimination, harmful practices
(e.g., FGM), and violence.
• Promote environmental health, safety, and social justice.
• Encourage community participation in maternal and child health.
4. Midwives and Their Colleagues
• Collaborate with other healthcare providers to ensure continuity of care.
• Promote mutual respect, support, and interdisciplinary teamwork.
• Avoid conflict, gossip, or undermining colleagues.
• Share knowledge, mentor others, and contribute to professional
development.
• Respect the roles and expertise of other professionals.
4. Responsibilities of Midwives According to ICM Code
• Protect the interests and rights of mothers and newborns.
• Deliver compassionate, competent, and holistic care.
• Advocate for evidence-based practices and policy changes.
• Report ethical violations, abuse, or unsafe practices.
• Take leadership in improving midwifery education and service delivery.
5. Application in Indian Context
• The ICM Code complements the INC’s code of professional conduct.
• It is aligned with:
o Respectful Maternity Care Charter
o RMNCH+A goals
o Midwifery-led care model promoted by MoHFW
• Midwives in India must incorporate ICM ethics in rural and urban
practice settings to improve maternal and newborn outcomes.
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Possible Exam Questions

Two Marks
1. Name any two ethical principles under the ICM Code of Ethics.
2. Mention one responsibility of a midwife towards her colleagues.
Five Marks
1. Explain the ethical responsibilities of a midwife towards the woman and
society.
2. List the four domains of the ICM Code of Ethics and describe any one.
Ten Marks
1. Describe the ICM Code of Ethics for Midwives in detail and its
importance in midwifery practice.
2. How can midwives apply ICM ethical standards in providing respectful
and evidence-based care?
Ethical Issues in Maternal and Neonatal Care
1. Introduction
• Maternal and neonatal care involves complex ethical challenges as it
deals with two lives: the mother and the fetus/newborn.
• Ethical issues arise when rights, beliefs, or medical needs of the mother
and fetus conflict, or when care decisions impact dignity, safety, or
autonomy.
• Midwives and nurses must follow ethical principles to ensure safe,
respectful, and just care.
2. Common Ethical Principles in Maternal and Neonatal Care
1. Autonomy – Respecting the woman’s right to make informed choices.
2. Beneficence – Acting in the best interest of the mother and baby.
3. Non-maleficence – Doing no harm to mother or fetus/newborn.
4. Justice – Providing equal and fair care to all women and newborns.
5. Confidentiality – Protecting the privacy of patient information.
6. Fidelity – Being honest, loyal, and committed to patient welfare.
3. Common Ethical Issues in Maternal Care
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1. Informed Consent
• Performing procedures (e.g., cesarean section, episiotomy) without
explaining and obtaining proper consent violates autonomy.
• In emergencies, life-saving decisions may override consent, creating
ethical tension.
2. Right to Refuse Care
• Pregnant women have the right to refuse treatment (e.g., pain relief,
surgery), even if it may harm the fetus.
• Midwives must respect the decision while educating on risks.
3. Teenage Pregnancy
• Involves issues of consent, confidentiality, and parental involvement.
• Balancing minor’s autonomy and parental rights is ethically
challenging.
4. HIV-positive Mothers
• Ethical dilemmas regarding disclosure of HIV status to partners, risk of
transmission to the baby, and consent for testing.
5. Cultural and Religious Beliefs
• Refusal of blood transfusion, abortion, or contraception based on belief
systems may conflict with medical recommendations.
6. Domestic Violence During Pregnancy
• Deciding whether to report abuse against the woman's wish creates
ethical tension between confidentiality and safety.
4. Common Ethical Issues in Neonatal Care
1. Neonatal Resuscitation and Life Support
• Questions about when to initiate or withdraw life support in extremely
premature or severely ill newborns.
• Decisions must consider quality of life, viability, and family wishes.
2. Parental Consent
• For invasive procedures or surgeries, ethical issues arise if parents refuse
treatment due to financial, cultural, or personal reasons.

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3. Gender Discrimination
• Ethical concerns in neglect or refusal of care for female neonates in
patriarchal communities.
4. Genetic Testing and Disclosure
• Performing and disclosing prenatal genetic tests raises concerns of
privacy, discrimination, and informed consent.
5. Breastfeeding Choices
• Conflict may arise when a mother refuses to breastfeed despite medical
advice.
• Ethical duty is to inform, not force.
5. Ethical Responsibilities of Midwives and Nurses
• Respect women’s autonomy and choices in care and childbirth.
• Provide non-judgmental, confidential, and culturally sensitive care.
• Report any abuse, neglect, or violation of rights.
• Protect the best interests of the newborn while respecting parental
authority.
• Document care and decisions clearly and truthfully.
• Advocate for women and infants in vulnerable situations.
6. Legal and Institutional Support for Ethical Practice
• Refer to national guidelines and laws (MTP Act, POCSO, PCPNDT).
• Use hospital ethics committees in case of complex dilemmas.
• Provide ethical education and supervision for junior staff and students.
Possible Exam Questions
Two Marks
1. Define informed consent in maternal care.
2. Mention any one ethical issue in neonatal care.
Five Marks
1. Write a short note on ethical dilemmas in HIV-positive pregnancy.
2. List and explain any four ethical principles in maternal and neonatal care.
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Ten Marks
1. Discuss ethical issues commonly encountered in maternal and neonatal
care.
2. How can midwives and nurses ensure ethical decision-making in
maternal health services?
Adoption Laws, MTP Act, PNDT Act, and Surrogacy Regulations
1. Adoption Laws in India
Definition
• Adoption is a legal process by which a child becomes the lawful child of
adoptive parents with all rights, responsibilities, and privileges.
Regulatory Bodies
• Central Adoption Resource Authority (CARA) – under the Ministry of
Women and Child Development.
• Governed by the Juvenile Justice (Care and Protection of Children)
Act, 2015.
Eligibility Criteria for Adoptive Parents
• Indian, Non-resident Indian (NRI), or Overseas Citizen of India (OCI).
• Stable mental and financial condition.
• Single or married individuals can adopt (conditions vary).
• Minimum age difference between child and adoptive parent should be 25
years.
Eligibility of Children
• Orphaned, abandoned, or surrendered children declared legally free for
adoption.
Process
• Registration → Home Study → Matching → Legal adoption order →
Follow-up visits.
Nurse's Role in Adoption
• Provide counseling to biological and adoptive parents.
• Educate about legal and emotional aspects.

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• Assist in documentation and referrals.

2. Medical Termination of Pregnancy (MTP) Act
Definition
• A law that legalizes abortion under specific conditions to ensure safe
and accessible services.
Acts and Amendments
• MTP Act, 1971, amended in 2021 to increase safety and access.
Key Provisions (MTP Amendment Act, 2021)
• Up to 20 weeks: One registered medical practitioner’s opinion required.
• 20–24 weeks: Two doctors’ opinion for special categories (rape victims,
minors, etc.).
• Above 24 weeks: Allowed only under serious fetal abnormalities with
approval from a state medical board.
• Marital status not a barrier – Unmarried women included.
• Confidentiality – Name and details of the woman must be kept private.
Conditions for Legal Abortion
• Risk to the woman’s life or health.
• Fetal abnormalities.
• Pregnancy due to rape or incest.
• Contraceptive failure (including unmarried women).
Nurse's Role
• Provide pre- and post-abortion counseling.
• Ensure informed consent.
• Support in physical and emotional recovery.
• Maintain strict confidentiality.
3. Pre-Natal Diagnostic Techniques (Regulation and Prevention of Misuse)
Act – PNDT Act, 1994
Objective

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• To prevent sex-selective abortion and control the misuse of prenatal

diagnostic techniques.
Now Known As
• PCPNDT Act (2003) – Pre-Conception and Pre-Natal Diagnostic
Techniques Act.
Provisions
• Bans sex selection before or after conception.
• Regulates use of ultrasound, amniocentesis, and other techniques.
• Mandatory registration of all diagnostic clinics.
• Strict record-keeping and reporting required.
• Punishment for violations: imprisonment up to 5 years, fine up to ₹1 lakh,
cancellation of license.
Permitted Diagnostic Purposes
• Detection of chromosomal abnormalities, genetic disorders, or sex-linked
diseases (not gender).
Nurse's Role
• Do not disclose or discuss fetal sex.
• Ensure ethical use of diagnostic tools.
• Report violations if witnessed.
• Educate pregnant women about their rights
4. Surrogacy in India
Definition
• Surrogacy is a method where a woman carries and delivers a child for
another person or couple.
Regulation
• Governed by the Surrogacy (Regulation) Act, 2021.
Key Features
• Only altruistic surrogacy is allowed (no commercial gain).
• Only Indian citizens can opt for surrogacy.

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• Intended parents must be legally married, aged:

o Woman: 23–50 years
o Man: 26–55 years
• Surrogate must be:
o A close relative
o Aged 25–35 years
o Have at least one child of her own
o Surrogate only once in her lifetime
• Medical indication of infertility must be certified.
Prohibited Acts
• Commercial surrogacy.
• Foreigners or NRIs seeking surrogacy in India.
• Sex-selective surrogacy.
Nurse’s Role
• Ensure surrogate mother’s physical and psychological health.
• Provide antenatal and postnatal care.
• Educate families about legal, emotional, and ethical aspects.
• Maintain confidentiality and non-judgmental support.
Possible Exam Questions
Two Marks
1. Name any two eligibility criteria for adoptive parents.
2. What is the full form of PCPNDT Act?
3. Define surrogacy.
Five Marks
1. Write a short note on the key provisions of the MTP Amendment Act,
2021.
2. Explain the role of the nurse in the adoption process.

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3. List the major conditions under which abortion is permitted by law in

India.
Ten Marks
1. Discuss the legal and ethical aspects of surrogacy in India.
2. Explain the PCPNDT Act and its relevance to midwifery practice.
3. Describe the legal framework governing adoption, abortion, and
surrogacy in India.
Roles and Responsibilities of a Midwife / Nurse Practitioner Midwife (NPM) in
Different Settings (Hospital / Community)
1. Introduction
• A midwife or Nurse Practitioner Midwife (NPM) is a trained
professional who provides comprehensive maternal and newborn care
across the reproductive continuum: preconception, antenatal, intranatal,
postnatal, and neonatal periods.
• Midwives work in both hospital and community settings and play a
critical role in promoting safe, respectful, evidence-based care to reduce
maternal and infant morbidity and mortality.
2. General Roles and Responsibilities of a Midwife/NPM
• Promote normal childbirth and reduce unnecessary interventions.
• Provide emotional, psychological, and clinical support to the mother
and family.
• Ensure timely referral and emergency care when complications arise.
• Deliver care based on ICM competencies, national guidelines, and
legal/ethical frameworks.
• Educate families on maternal and child health, nutrition, breastfeeding,
and family planning.
3. Responsibilities in a Hospital Setting
Antenatal Care
• Conduct antenatal assessments: BP, weight, fundal height, fetal heart
rate.
• Monitor pregnancy progress and identify high-risk signs.

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• Provide nutrition counseling, immunizations (TT), and iron-folic acid

supplementation.
• Maintain antenatal records and schedule regular follow-ups.
• Educate on danger signs and prepare for birth planning.
Intranatal Care (Labour and Delivery)
• Monitor labour progress using a partograph.
• Provide emotional support and pain management.
• Conduct normal vaginal deliveries with aseptic techniques.
• Recognize and manage complications (e.g., PPH, obstructed labor) and
refer as needed.
• Ensure newborn resuscitation when required.
Postnatal Care
• Monitor mother’s vitals, uterine involution, and lochia.
• Support early initiation of breastfeeding.
• Educate on postnatal hygiene, family planning, and newborn care.
• Detect signs of postpartum complications like infections or depression.
Newborn Care
• Perform immediate newborn assessment (Apgar score).
• Ensure warmth, cord care, immunization, and breastfeeding support.
• Monitor for jaundice, hypothermia, or sepsis.
Documentation and Communication
• Maintain accurate records of mother and baby.
• Communicate with obstetricians, pediatricians, and nursing team.
4. Responsibilities in a Community Setting
Health Promotion and Education
• Conduct home visits for ANC and PNC.
• Organize health awareness programs on MCH, hygiene, and nutrition.
• Promote safe motherhood and institutional deliveries.

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Antenatal Services
• Identify pregnant women through surveys and registers.
• Conduct screening camps and provide referral services.
• Distribute iron tablets, calcium, and educate on danger signs.
Intranatal Care
• Assist or conduct home deliveries if needed (only when safe).
• Encourage referral to primary health centers or MLCUs.
• Ensure clean birth practices and post-delivery follow-up.
Postnatal and Neonatal Services
• Monitor mother and newborn in the first 42 days post-delivery.
• Provide advice on nutrition, breastfeeding, newborn immunization, and
rest.
• Detect and refer cases of puerperal infections, neonatal sepsis, or
depression.
Family Planning Services
• Provide contraceptive counseling (OCPs, condoms, IUCD insertion).
• Motivate for sterilization if required.
Record-Keeping and Reporting
• Maintain maternal and child tracking records (Mother & Child Protection
Card).
• Report vital events: births, deaths, immunization coverage.
Coordination
• Collaborate with ASHA, ANM, Anganwadi workers, and medical
officers.
• Participate in Village Health and Nutrition Days (VHND).
5. Additional Responsibilities of NPM (Nurse Practitioner Midwife)
• Work autonomously in Midwifery-led Care Units (MLCUs).
• Prescribe basic medications and handle emergency obstetric care.
• Participate in policy-making, training, and supervision of junior staff.
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• Conduct evidence-based practice, audits, and research.

• Promote respectful maternity care (RMC) and uphold patient rights.
6. Competencies (As per ICM & MoHFW Guidelines)
• Clinical skills in antenatal, intranatal, and postnatal care.
• Emergency care (eclampsia, PPH, retained placenta).
• Communication and counselling.
• Community engagement and advocacy.
• Leadership, teamwork, and accountability.
Possible Exam Questions
Two Marks
1. Name any two roles of a midwife in the hospital setting.
2. Mention two responsibilities of a midwife in a community.
Five Marks
1. Write a short note on the responsibilities of a midwife in intranatal care.
2. Describe the role of a midwife in newborn care.
Ten Marks
1. Discuss the roles and responsibilities of a Nurse Practitioner Midwife
(NPM) in hospital and community settings.
2. Explain the comprehensive duties of a midwife during antenatal,
intranatal, and postnatal periods.
Scope of Practice for Midwives
1. Introduction
• The scope of practice defines the roles, responsibilities, and limits
within which a midwife operates legally, ethically, and professionally.
• It includes clinical care, health promotion, counseling, and
collaborative practice throughout the reproductive cycle—from
preconception to postpartum and newborn care.
• Based on ICM competencies, INC guidelines, and the Midwifery
Services Initiative (MSI) by MoHFW (India).

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2. General Scope of Midwifery Practice

• Provide comprehensive, autonomous care to healthy women during:
o Pre-pregnancy
o Antenatal
o Intranatal
o Postnatal
o Newborn care
• Detect deviations from normal and refer when necessary.
• Educate women, families, and communities about reproductive and
sexual health.
• Promote respectful maternity care and women’s rights.
• Participate in policy making, research, and health system
strengthening.
3. Clinical Scope of Practice
Preconception and Family Planning
• Counsel couples on fertility, spacing, and family planning.
• Prescribe or administer contraceptives (OCPs, IUCD, injectables).
Antenatal Care
• Conduct routine ANC check-ups: vitals, fetal monitoring, lab
investigations.
• Identify high-risk pregnancies and refer accordingly.
• Educate on nutrition, hygiene, warning signs, and birth preparedness.
• Provide iron-folic acid, calcium, and TT immunization.
Intranatal Care
• Conduct normal vaginal deliveries using aseptic techniques.
• Monitor labor using a partograph.
• Perform episiotomy and repair if trained.
• Manage third stage of labor (active management).

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• Handle complications like PPH, retained placenta in emergency.

• Initiate newborn resuscitation if required.
Postnatal Care
• Monitor mother’s physical and mental recovery (vitals, lochia, uterine
involution).
• Counsel on breastfeeding, contraception, and newborn care.
• Detect and manage puerperal complications.
Newborn Care
• Perform Apgar scoring, assess newborn reflexes.
• Provide cord care, warmth, and early breastfeeding.
• Identify common neonatal issues (jaundice, infection) and refer.
4. Community Scope of Practice
• Participate in home visits, outreach, and immunization.
• Collaborate with ASHA, ANM, and Anganwadi workers.
• Conduct health education on MCH, adolescent health, nutrition, and
hygiene.
• Organize Village Health and Nutrition Days (VHNDs).
• Mobilize communities for institutional deliveries.
5. Educational and Leadership Scope
• Provide clinical teaching to nursing and midwifery students.
• Supervise junior staff or community workers.
• Participate in research, quality assurance, and health promotion
campaigns.
• Advocate for maternal and reproductive rights.
6. Midwife-Led Care Units (MLCUs)
• In India, trained Nurse Practitioner Midwives (NPMs) may work
independently in MLCUs.
• Offer continuum of care, manage low-risk pregnancies, and refer
complications.

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• Promote natural birthing practices, minimize medical interventions.

7. Legal and Ethical Scope
• Work within the guidelines of:
o INC (Indian Nursing Council)
o ICM (International Confederation of Midwives)
o PCPNDT Act, MTP Act, and Surrogacy Regulation Act
• Ensure informed consent, confidentiality, and non-discriminatory
care.
8. Limitations of Scope (When to Refer)
• High-risk pregnancies (e.g., severe anemia, eclampsia).
• Multiple gestation or malpresentation.
• Surgical or instrumental delivery required.
• Neonatal distress or congenital anomalies.
• Mental health issues or domestic violence requiring advanced support.
Possible Exam Questions
Two Marks
1. Define the term “scope of practice” in midwifery.
2. Name two services provided by midwives during intranatal care.
Five Marks
1. Describe the scope of community-based practice of a midwife.
2. Explain the scope of midwifery care in the postnatal period.
Ten Marks
1. Discuss the comprehensive scope of practice for midwives across
different levels of care.
2. Explain the responsibilities and limitations of midwives in maternal and
newborn care.

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Unit – 02
Anatomy and Physiology of Human Reproductive
System and Conception (Maternal, Fetal &
Newborn Physiology)

1. Female Reproductive System: Anatomy & Physiology

External Genitalia (Vulva)
• Mons pubis: Fatty tissue over pubic bone.
• Labia majora & minora: Protect internal structures.
• Clitoris: Highly sensitive organ; sexual stimulation.
• Vestibule: Contains urethral and vaginal openings.
• Bartholin’s glands: Lubrication during intercourse.
Internal Genital Organs
• Vagina: Muscular canal; passage for menstruation, intercourse, and
childbirth.
• Uterus: Pear-shaped organ for implantation and fetal development.
o Divided into fundus, body, isthmus, and cervix.
• Fallopian tubes: Site of fertilization.
• Ovaries: Produce ova (eggs) and hormones (estrogen, progesterone).
Hormonal Regulation
• Controlled by hypothalamic-pituitary-ovarian axis.
o FSH (Follicle Stimulating Hormone) – Maturation of follicles.
o LH (Luteinizing Hormone) – Ovulation.
o Estrogen and Progesterone – Regulate menstruation and prepare
uterus for pregnancy.
2. Male Reproductive System: Anatomy & Physiology
External Organs

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• Penis: Organ for copulation and urine excretion.

• Scrotum: Sac containing testes; maintains temperature for
spermatogenesis.
Internal Organs
• Testes: Produce sperm and testosterone.
• Epididymis: Stores and matures sperm.
• Vas deferens: Transports sperm.
• Seminal vesicles, Prostate gland, Bulbourethral glands: Contribute to
seminal fluid.
3. Physiology of Menstrual Cycle
• Average cycle: 28 days (range 21–35).
• Phases:
o Menstrual phase (Day 1–5): Shedding of endometrium.
o Proliferative (Follicular) phase (Day 6–14): Estrogen stimulates
endometrial growth.
o Ovulation (Day 14): Release of ovum from ovary.
o Secretory (Luteal) phase (Day 15–28): Progesterone prepares
uterus for implantation.
4. Fertilization and Conception
• Fertilization: Union of ovum and sperm in the ampulla of fallopian tube.
• Zygote: Formed after fertilization (46 chromosomes).
• Begins cleavage → Morula → Blastocyst (implants in uterine wall by
Day 6–10).
• Hormone hCG produced to support pregnancy.
5. Maternal Physiological Changes During Pregnancy
Cardiovascular
• ↑ Blood volume by 40–50%
• Mild cardiac hypertrophy
• ↑ Heart rate, ↓ BP in early pregnancy

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Respiratory
• ↑ Oxygen demand
• Diaphragm elevated
• ↑ Tidal volume, ↓ residual volume
Renal
• ↑ Renal blood flow and GFR
• Pressure on bladder causes frequency
Gastrointestinal
• ↓ Gastric motility → constipation
• Nausea and vomiting common in 1st trimester
Endocrine
• ↑ Estrogen, progesterone, hCG, hPL
• Thyroid function slightly increased
Musculoskeletal
• Softening of ligaments (Relaxin hormone)
• Lordosis due to abdominal weight
6. Fetal Physiology and Development
Placenta
• Formed by 12 weeks.
• Provides nutrition, gas exchange, hormone production, and waste
elimination.
Fetal Circulation
• Ductus venosus: Bypasses liver.
• Foramen ovale: Right to left atrium.
• Ductus arteriosus: Pulmonary artery to aorta.
Growth Stages
• Pre-embryonic (0–2 weeks)
• Embryonic (3–8 weeks): Major organs formed.
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• Fetal stage (9 weeks–birth): Maturation of organs.

7. Newborn Physiology (Neonatal Adaptation)
Respiratory
• First breath inflates lungs.
• Surfactant production essential for alveolar stability.
Cardiovascular
• Closure of:
o Foramen ovale (within 24–48 hrs)
o Ductus arteriosus (functional closure in 12–24 hrs)
Thermoregulation
• Newborns prone to heat loss.
• Use brown fat for heat production.
Renal
• Immature kidneys; risk of fluid imbalance.
Gastrointestinal
• Stomach capacity: 20–30 ml.
• Meconium passed within 24 hrs.
Immune System
• Passive immunity via maternal IgG.
• Active immunity begins after birth.
Possible Exam Questions
Two Marks
1. Define ovulation.
2. Mention the role of hCG in pregnancy.
3. Name two maternal physiological changes during pregnancy.
Five Marks
1. Explain the phases of the menstrual cycle.

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2. Write a short note on fetal circulation.

3. Describe maternal cardiovascular and respiratory changes during
pregnancy.
Ten Marks
1. Discuss the anatomy and physiology of the female reproductive system.
2. Explain the process of fertilization and fetal development.
3. Describe the physiological adaptations of the newborn at birth.
Female Organs of Reproduction
1. Introduction
• The female reproductive system consists of external and internal
organs.
• These organs function in reproduction, menstruation, sexual response,
pregnancy, and childbirth.
• Regulated by hormones from the hypothalamus, pituitary gland, and
ovaries.
2. External Organs (Vulva)
Collectively known as vulva, these structures protect internal genitalia and
support sexual function.
a) Mons Pubis
• Fatty pad covering the pubic bone.
• Contains sebaceous and sweat glands.
b) Labia Majora
• Outer skin folds with hair.
• Protects inner structures.
c) Labia Minora
• Inner hairless folds of skin.
• Rich in blood supply and nerve endings.
d) Clitoris
• Erectile tissue similar to male penis.

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• Main organ of female sexual arousal.

e) Vestibule
• Space between labia minora containing:
o Urethral opening
o Vaginal orifice
o Ducts of Bartholin’s glands (secrete mucus for lubrication)
3. Internal Organs of Reproduction
a) Vagina
• Muscular, elastic canal (approx. 9–10 cm).
• Extends from vulva to cervix.
• Functions:
o Passage for menstrual flow
o Receives penis during intercourse
o Birth canal during delivery
b) Uterus
• Hollow, pear-shaped muscular organ.
• Located between bladder and rectum.
• Size: ~7.5 cm long, 5 cm wide.
• Divisions:
o Fundus: Dome-shaped top
o Body (Corpus): Middle portion
o Isthmus: Narrow lower segment
o Cervix: Lower neck-like portion opening into the vagina
Functions:
• Site of implantation and fetal development
• Contracts to expel fetus and placenta
Layers:

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1. Perimetrium (outer)
2. Myometrium (muscular middle layer)
3. Endometrium (inner layer, sheds during menstruation and supports
implantation)
c) Fallopian Tubes (Oviducts)
• 10–12 cm long tubes connecting ovaries to uterus.
• Divisions:
o Infundibulum: Fimbriae capture ovum
o Ampulla: Site of fertilization
o Isthmus: Connects to uterus
• Functions:
o Transport ovum
o Site for fertilization
d) Ovaries
• Paired, almond-shaped glands located on either side of uterus.
• Functions:
o Produce ova (eggs)
o Secrete estrogen and progesterone
4. Accessory Structures
a) Skene’s Glands
• Located near the urethra.
• Contribute to lubrication.
b) Bartholin’s Glands
• Secrete mucus to lubricate the vagina during intercourse.
5. Hormonal Regulation

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Hormone Function

FSH (Follicle Stimulating

Stimulates follicle development
Hormone)

LH (Luteinizing Hormone) Triggers ovulation

Builds endometrial lining, secondary sex

Estrogen
characteristics

Progesterone Maintains endometrium, supports pregnancy

Maintains corpus luteum during early

hCG
pregnancy
6. Diagram Suggestion
Draw a labeled diagram of:
• External genitalia (vulva)
• Internal genitalia (sagittal section showing vagina, cervix, uterus, tubes,
ovaries)
Possible Exam Questions
Two Marks
1. Name the parts of the uterus.
2. What is the function of fallopian tubes?
Five Marks
1. Describe the internal organs of the female reproductive system.
2. Draw and label the female reproductive organs.
Ten Marks
1. Discuss the anatomy and functions of the female reproductive system in
detail.
Female Pelvis – Bones, Joints, Ligaments, Planes, Diameters, Landmarks,
Inclination, Pelvic Variations
1. Introduction
• The female pelvis is a bony ring that forms the lower part of the trunk
and plays a critical role in childbirth.

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• It supports the pelvic organs and provides a birth canal for the fetus.
• Structurally different from the male pelvis to accommodate pregnancy
and delivery.
2. Bones of the Pelvis
The pelvis is formed by four bones:
• Two innominate (hip) bones: Each formed by fusion of:
o Ilium
o Ischium
o Pubis
• Sacrum
• Coccyx
Together, these bones form:
• Pelvic brim
• True pelvis
• False pelvis
3. Joints of the Pelvis
• Sacroiliac joints (2): Between sacrum and ilium (partially movable).
• Pubic symphysis (1): Between pubic bones (fibrocartilaginous).
• Sacrococcygeal joint (1): Between sacrum and coccyx (allows coccyx to
move backward during childbirth).
4. Ligaments of the Pelvis
Provide stability and support:
• Sacrotuberous ligament
• Sacrospinous ligament
• Inguinal ligament
• Broad ligament of uterus
• Round ligament of uterus
• Uterosacral ligament

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• Cardinal ligament (Mackenrodt's ligament) – important in supporting

the uterus
5. Pelvic Planes
These imaginary planes are used to assess fetal passage during labor:
1. Pelvic Inlet (Brim)
o Formed by sacral promontory, alae of sacrum, iliopectineal line,
and pubic crest.
2. Pelvic Cavity (Mid-pelvis)
o Space between inlet and outlet.
3. Pelvic Outlet
o Boundaries: coccyx (posteriorly), ischial tuberosities (laterally),
pubic arch (anteriorly).
6. Pelvic Diameters
At the Inlet
Diameter Measurement Description

Anteroposterior (True
~11 cm Promontory to top of symphysis
conjugate)

Obstetric conjugate ~10.5 cm Shortest AP diameter

Diagonal conjugate ~12.5 cm Measured clinically

Between widest parts of pelvic

Transverse ~13 cm
brim

From SI joint to iliopectineal

Oblique ~12 cm
eminence
At the Mid-Pelvis
Diameter Measurement

Interspinous (transverse) ~10.5 cm

Anteroposterior ~11.5 cm
At the Outlet

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Diameter Measurement

Anteroposterior ~11.5–13 cm (increases with coccyx movement)

Transverse (bituberous) ~11 cm

7. Landmarks of the Pelvis

Important for obstetric examination:
• Ischial spines: Help determine station of fetal head.
• Sacral promontory
• Symphysis pubis
• Coccyx
• Pubic arch
8. Inclination of the Pelvis
• The angle between the plane of the pelvic inlet and the horizontal plane
when standing upright.
• Normally around 55–60°.
• Affects the descent and engagement of the fetal head during labor.
9. Pelvic Types / Pelvic Variations (Caldwell & Moloy Classification)
Suitability for Vaginal
Type Features
Delivery

Rounded inlet, wide subpubic

Gynecoid Most favorable
angle

Difficult labor, may need C-

Android Heart-shaped, narrow pubic arch
section

Oval AP, narrow transverse

Anthropoid Favors occiput posterior
diameter

Flat pelvis, wide transverse

Platypelloid Not favorable
diameter
10. Clinical Relevance in Midwifery

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• Understanding pelvic dimensions helps assess cephalopelvic

disproportion (CPD).
• Affects decision on mode of delivery.
• Important for conducting pelvimetry (clinical or imaging-based).
Possible Exam Questions
Two Marks
1. Name the bones forming the female pelvis.
2. What is the obstetric conjugate?
Five Marks
1. Write short notes on types of female pelvis.
2. Describe the diameters of the pelvic inlet.
Ten Marks
1. Describe the anatomy of the female pelvis including its bones, joints,
ligaments, and diameters.
2. Explain the pelvic types and their significance in labor.
Fetal Skull – Bones, Sutures, Fontanelles, Diameters, Moulding
1. Introduction
• The fetal skull is the most important part of the fetus during labor
because:
o It is largest, hardest, and least compressible.
o Knowledge of its anatomy helps understand engagement,
moulding, presentations, and positions.
o Designed to adapt during birth (due to sutures and fontanelles).
2. Bones of the Fetal Skull
The fetal skull is divided into 3 regions:
a) Vault (Calvaria) – Flexible
• 2 frontal bones
• 2 parietal bones
• 1 occipital bone
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b) Base – Rigid and Ossified

• Made up of sphenoid, temporal, ethmoid, and part of occipital bones.
c) Face
• Facial bones: fused and do not play a major role in labor.
3. Sutures
• Sutures are membranous joints connecting the bones of the fetal skull.
• Allow for moulding during labor and brain growth after birth.
Suture Name Location

Sagittal suture Between two parietal bones (midline)

Coronal suture Between frontal and parietal bones

Lambdoid suture Between parietal and occipital bones

Frontal (Metopic) suture Between two frontal bones

4. Fontanelles
• Fontanelles are membrane-covered spaces where sutures meet.
• Useful landmarks during vaginal examination to determine fetal
position.
Closes
Fontanelle Location Shape
by

Anterior fontanelle Junction of sagittal, coronal, Diamond- 18

(Bregma) and frontal sutures shaped months

Posterior fontanelle Junction of sagittal and 6–8

Triangular
(Lambda) lambdoid sutures weeks
5. Diameters of the Fetal Skull
Understanding these helps assess engagement and presentation during labor.
a) Anteroposterior Diameters

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Diameter Measurement From – To Presentation

Below occiput to center Vertex

Suboccipitobregmatic 9.5 cm
of anterior fontanelle (flexed)

Below occiput to frontal

Suboccipitofrontal 10 cm Partial flexion
bone

Occipital protuberance to
Occipitofrontal 11.5 cm Deflexed
glabella

Chin to highest point of

Mentovertical 13.5 cm Brow
vertex

Below chin to center of

Submentobregmatic 9.5 cm Face
bregma

Partial
Submentovertical 11.5 cm Below chin to vertex
extension
b) Transverse Diameters
Diameter Measurement From – To

Biparietal diameter (BPD) 9.5 cm Between two parietal eminences

Bitemporal diameter 8.0 cm Between temporal bones

6. Moulding
Definition:
• Moulding is the overlapping of the fetal skull bones at the sutures
during labor to allow passage through the birth canal.
Importance:
• Facilitates descent and delivery.
• More prominent in primigravida and prolonged labor.
Degrees of Moulding:
Degree Description

0 Bones are just touching

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Degree Description

+1 Bones are overlapping but reducible

+2 Bones are overlapping and not reducible (suggests obstructed labor)

7. Clinical Significance
• Palpation of sutures and fontanelles helps assess:
o Fetal position and attitude
o Engagement and station
o Moulding (progress or obstruction)
• Biparietal diameter (BPD) is the engaging diameter in vertex
presentation
8. Diagram Suggestions
• Labeled diagram of:
o Fetal skull (lateral view)
o Fontanelles and sutures (top view)
o AP diameters of fetal skull
Possible Exam Questions
Two Marks
1. Name the four sutures of the fetal skull.
2. What is the normal value of biparietal diameter?
Five Marks
1. Describe the fontanelles of the fetal skull.
2. Write a short note on moulding of the fetal skull.
Ten Marks
1. Describe the anatomy of the fetal skull with diameters and their obstetric
importance.
2. Explain the bones, sutures, fontanelles, and diameters of the fetal skull.
Fetopelvic Relationship
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1. Introduction
• Fetopelvic relationship refers to the relationship between the fetal
presenting part and the mother’s pelvis during labor and delivery.
• Understanding this relationship is essential to:
o Determine the progress of labor
o Detect malpresentations
o Plan for safe delivery
2. Components of Fetopelvic Relationship
a) Lie
• Relationship between the long axis of the fetus and the long axis of the
uterus (mother).
Type Description

Longitudinal lie Fetal spine parallel to maternal spine (most common)

Transverse lie Fetal spine perpendicular to maternal spine

Oblique lie Fetal spine at an angle to maternal spine

b) Presentation
• The part of the fetus that enters the pelvic inlet first.
Type Presenting Part

Cephalic Head (most common – ~96%)

Breech Buttocks or feet

Shoulder (Transverse lie) Shoulder (rare and abnormal)

c) Presenting Part
• The most dependent part of the presentation felt during vaginal
examination.
Presentation Presenting Part

Vertex Occiput

Brow Forehead

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Presentation Presenting Part

Face Mentum (chin)

Breech Sacrum

Shoulder Acromion
d) Attitude (Posture)
• Relationship of fetal parts to each other (especially the head, limbs, and
trunk).
Attitude Description

Flexion (Normal) Head flexed, chin on chest, limbs flexed

Deflexion Head partially or fully extended

Extension Associated with brow or face presentations

e) Position
• Relationship between a reference point on the presenting part and
quadrants of maternal pelvis (Right or Left, Anterior or Posterior).
For Vertex presentation (Occiput):
• Occipito-Anterior (OA)
• Occipito-Posterior (OP)
• Right Occipito-Anterior (ROA)
• Left Occipito-Posterior (LOP), etc.
f) Denominator
• The bony point on the presenting part used to describe position.
Presentation Denominator

Vertex Occiput

Face Mentum

Breech Sacrum

Shoulder Acromion

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g) Engagement
• When the largest transverse diameter of the presenting part (usually
biparietal diameter – 9.5 cm) passes through the pelvic inlet.
• In primigravida, usually occurs before labor; in multigravida, occurs
during labor.
3. Station of the Presenting Part
• Measured in relation to the ischial spines (0 station).
• Above spines = negative station (−1 to −5)
• Below spines = positive station (+1 to +5)
• 0 Station: Presenting part at level of ischial spines = Engaged
4. Clinical Significance
• Helps to assess:
o Whether labor will progress normally
o Mode of delivery (normal vaginal vs operative)
o Cephalopelvic disproportion
• A malposition or malpresentation may lead to:
o Prolonged labor
o Obstructed labor
o Need for assisted or cesarean delivery
5. Diagram Suggestions
• Diagram showing:
o Different fetal lies
o Positions of occiput in maternal pelvis
o Levels of station related to ischial spines
Possible Exam Questions
Two Marks
1. Define fetal lie.
2. What is the presenting part in vertex presentation?

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Five Marks
1. Write a short note on fetal attitude and engagement.
2. Describe fetal positions with the help of a diagram.
Ten Marks
1. Explain the fetopelvic relationship with all components and their obstetric
significance.
2. Describe types of fetal presentations and positions.
Physiology of Menstrual Cycle and Menstrual Hygiene
1. Introduction to Menstrual Cycle
• The menstrual cycle is a regular natural change that occurs in the female
reproductive system to prepare for pregnancy.
• It is regulated by hormones and involves the ovaries, uterus, pituitary
gland, and hypothalamus.
• Average cycle duration: 28 days (range 21–35 days).
2. Phases of the Menstrual Cycle
The cycle is divided into two main phases based on ovarian activity and
corresponding changes in the uterus.
A. Ovarian Cycle
1. Follicular Phase (Day 1–14)
o Begins with menstruation.
o FSH from anterior pituitary stimulates growth of ovarian follicles.
o Dominant follicle secretes estrogen.
o Estrogen promotes endometrial proliferation.
2. Ovulation (Day 14)
o Surge in LH causes rupture of mature follicle.
o Release of ovum (ovulation).
o Best time for fertilization.
3. Luteal Phase (Day 15–28)
o Ruptured follicle becomes corpus luteum.
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o Corpus luteum secretes progesterone and some estrogen.

o Progesterone prepares endometrium for implantation.
o If no fertilization: corpus luteum degenerates → hormone levels
drop → menstruation begins.
B. Uterine Cycle
1. Menstrual Phase (Day 1–5)
o Shedding of endometrial lining due to drop in estrogen and
progesterone.
o Average blood loss: 30–40 mL.
2. Proliferative Phase (Day 6–14)
o Estrogen from developing follicles causes endometrial
regeneration.
o Endometrium thickens.
3. Secretory Phase (Day 15–28)
o Under influence of progesterone.
o Endometrium becomes more glandular and vascular.
o Prepares for possible implantation.
3. Hormonal Regulation
Hormone Source Function

GnRH Hypothalamus Stimulates release of FSH & LH

FSH Anterior pituitary Stimulates follicle growth

LH Anterior pituitary Triggers ovulation

Estrogen Ovary (follicles) Proliferates endometrium

Progesterone Ovary (corpus luteum) Maintains endometrium

Inhibin Ovary Inhibits FSH secretion

4. Menstrual Hygiene

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A. Importance
• Promotes health and comfort.
• Prevents reproductive tract infections (RTIs) and urinary tract
infections (UTIs).
• Reduces risk of skin irritation, odor, and psychosocial stress.
B. Hygiene Practices
• Use clean and absorbent sanitary products (pads, tampons, menstrual
cups).
• Change sanitary materials every 4–6 hours.
• Wash genital area with clean water (mild soap if needed).
• Maintain hand hygiene before and after changing pads.
• Proper disposal of used products (in covered bins or burn pits).
C. Challenges in Menstrual Hygiene (especially in rural areas)
• Lack of awareness and education.
• Limited access to affordable menstrual products.
• Poor sanitation facilities.
• Social taboos and stigma.
D. Health Education for Adolescent Girls
• Teach normal menstrual physiology.
• Explain hygienic practices and disposal.
• Promote open discussion to reduce shame and myths.
5. Diagram Suggestions
• Graph showing hormonal changes over the 28-day cycle.
• Diagram of endometrial changes in uterine cycle phases.
Possible Exam Questions
Two Marks
1. Name the hormone responsible for ovulation.
2. What is the duration of the average menstrual cycle?

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Five Marks
1. Explain the phases of the uterine cycle.
2. Write a short note on menstrual hygiene.
Ten Marks
1. Describe the physiology of the menstrual cycle with hormonal regulation
and endometrial changes.
2. Explain menstrual hygiene and its importance in adolescent health
Fertilization, Conception, and Implantation
1. Introduction
• Fertilization, conception, and implantation are sequential events that
mark the beginning of pregnancy.
• They involve:
o The union of sperm and ovum
o Formation of zygote
o Embryo travel to uterus
o Embedding into the uterine lining
2. Fertilization
Definition:
• Fertilization is the union of the male sperm and the female ovum,
forming a zygote.
Site:
• Usually occurs in the ampulla of the fallopian tube.
Process:
1. Capacitation:
o Functional changes in sperm within the female reproductive tract
that enhance motility and ability to penetrate the ovum.
2. Acrosomal reaction:
o Enzymes from the acrosome (sperm head) break down the outer
layer of the ovum.

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3. Penetration of sperm:
o One sperm enters the ovum → triggers cortical reaction →
prevents other sperms from entering.
4. Fusion of nuclei:
o Male and female pronuclei fuse to form diploid zygote (46
chromosomes).
3. Conception
Definition:
• Conception is the formation of the zygote (fertilized egg), marking the
beginning of pregnancy.
After fertilization:
• Zygote undergoes cleavage (mitotic divisions).
• Becomes a morula (16–32 cells).
• Then forms a blastocyst (~day 5).
• Blastocyst travels through fallopian tube to reach uterine cavity
4. Implantation
Definition:
• Implantation is the embedding of the blastocyst into the endometrial
lining of the uterus.
Time:
• Occurs 6–10 days after fertilization.
Site:
• Normally occurs in the upper posterior wall of the uterus
(endometrium in secretory phase).
Phases:
1. Apposition:
o Blastocyst aligns near the endometrial lining.
2. Adhesion:
o Trophoblast cells adhere to endometrium.

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3. Invasion:
o Trophoblasts penetrate endometrium and start forming placenta
5. Hormonal Influence
Hormone Role

Estrogen Prepares endometrium for implantation

Progesterone Maintains endometrium for nourishing embryo

hCG (from Maintains corpus luteum → continues progesterone

trophoblasts) production
6. Clinical Significance
• Successful implantation is essential for pregnancy maintenance.
• Ectopic pregnancy occurs if implantation happens outside the uterus
(commonly in fallopian tube).
• Failure of implantation may result in early pregnancy loss.
7. Diagram Suggestions
• Fertilization process with sperm reaching ovum.
• Zygote to blastocyst movement through fallopian tube.
• Implantation stages into uterine lining.
Possible Exam Questions
Two Marks
1. Define fertilization.
2. Where does implantation normally occur?
Five Marks
1. Describe the process of implantation.
2. Write a short note on conception and the formation of zygote.
Ten Marks
1. Explain the processes of fertilization, conception, and implantation with
hormonal regulation.

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2. Describe the journey of the fertilized ovum from fallopian tube to uterine
implantation.
Embryological Development
1. Introduction
• Embryological development is the process of growth and differentiation
from a zygote to a fully formed fetus.
• The first 8 weeks (56 days) after fertilization is known as the embryonic
period.
• After 8 weeks, the conceptus is called a fetus, and the period is known as
the fetal period.
2. Stages of Embryological Development
A. Pre-Embryonic Stage (Fertilization to Day 14)
• Day 1–4: Zygote → cleavage → morula
• Day 5–6: Morula becomes a blastocyst
• Day 6–10: Blastocyst implants into the endometrium
• Trophoblast develops into placenta
• Inner cell mass develops into embryo
B. Embryonic Stage (3rd to 8th week)
• Period of organogenesis (formation of organs)
• Major structures and organ systems are established
Week Key Developments

Week 3 Primitive streak, neural plate, somites

Week 4 Neural tube closes, heart begins to beat

Week 5 Limb buds appear, brain develops rapidly

Week 6 Eye pits and external ear begin forming

Week 7 Arm and leg bones begin ossifying

Week 8 All major organs formed, facial features develop

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3. Germ Layers and Derivatives

After implantation, the inner cell mass differentiates into three germ layers:
Germ Layer Organs/Structures Formed

Ectoderm CNS, skin, eyes, ears, hair, nails

Mesoderm Muscles, bones, heart, blood, kidneys

Endoderm Lining of digestive tract, lungs, bladder, liver, pancreas

4. Development of Key Systems

• Nervous System: Forms from neural tube (Week 3–4)
• Cardiovascular System: First functional system (heart beats by Week 4)
• Musculoskeletal System: Limb buds by Week 5–6; ossification begins
by Week 7
• Gastrointestinal System: Primitive gut tube forms by Week 4
• Respiratory System: Lung buds develop in Week 4
• Genitourinary System: Kidneys and gonads begin forming in Week 5–6
5. Embryonic Membranes and Structures
Structure Function

Amnion Produces amniotic fluid, protects fetus

Chorion Helps form placenta

Yolk sac Produces early blood cells

Allantois Contributes to umbilical cord and urinary bladder

6. Clinical Significance
• Embryonic stage is most sensitive to teratogens (drugs, infections,
radiation).
• Structural birth defects commonly occur during organogenesis.
• Proper nutrition (especially folic acid) is crucial during this stage to
prevent defects like neural tube defects.

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7. Diagram Suggestions
• Timeline diagram showing Week 1 to Week 8 developments
• Germ layers and their derivatives (color-coded)
• Cross-sectional image of embryonic disk showing ectoderm, mesoderm,
endoderm
Possible Exam Questions
Two Marks
1. Name the three germ layers formed in the embryo.
2. At what week does the fetal heart begin to beat?
Five Marks
1. Write a short note on embryonic development during the first 8 weeks.
2. Explain the functions of embryonic membranes.
Ten Marks
1. Describe the process of embryological development and organ formation
from fertilization to 8 weeks.
2. Explain the derivatives of ectoderm, mesoderm, and endoderm with
clinical significance.
Placental Development and Function, Placental Barrier
1. Introduction
• The placenta is a temporary fetal-maternal organ that supports fetal
growth and development throughout pregnancy.
• It begins forming soon after implantation and is fully functional by the
end of the first trimester (12 weeks).
2. Development of the Placenta
A. Origin
• Formed from:
o Fetal side: Trophoblast of the blastocyst (chorion frondosum)
o Maternal side: Decidua basalis of endometrium
B. Timeline of Development

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Week Development

Trophoblast differentiates into cytotrophoblast and

Week 2–3
syncytiotrophoblast

Chorionic villi form and begin maternal blood flow into intervillous
Week 4
spaces

Week 8–
Placenta takes over hormone production
10

Week 12 Placenta fully developed and functional

3. Structure of the Placenta
Component Description

Shape Discoid (round, flat)

Weight ~500 grams at term

Diameter ~15–20 cm

Thickness ~2–3 cm

Surfaces
• Fetal surface: Smooth, covered by amnion, with umbilical cord
attachment
• Maternal surface: Rough, reddish with 15–20 cotyledons |
4. Circulation in the Placenta
A. Fetal Circulation
• Umbilical vein (1): Carries oxygenated blood from placenta to fetus
• Umbilical arteries (2): Carry deoxygenated blood from fetus to
placenta
B. Maternal Circulation
• Spiral arteries supply blood to intervillous spaces where exchange
occurs
• No direct mixing of maternal and fetal blood due to placental barrie
5. Functions of the Placenta

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Function Description

Respiratory Exchange of oxygen and carbon dioxide

Transfer of glucose, amino acids, fatty acids, vitamins,

Nutrition
minerals

Excretory Removal of fetal waste products like urea, uric acid, creatinine

Produces hCG, estrogen, progesterone, hPL (supports

Endocrine
pregnancy and fetal growth)

Transfers maternal antibodies (especially IgG) for passive

Immunological
immunity

Barrier Protects fetus from some infections and drugs

6. Placental Barrier
A. Definition
• A semipermeable membrane that separates maternal and fetal blood,
allowing selective exchange of substances.
B. Layers (early pregnancy)
1. Syncytiotrophoblast
2. Cytotrophoblast
3. Basement membrane of trophoblast
4. Fetal connective tissue
5. Endothelium of fetal capillary
In late pregnancy, the barrier becomes thinner as some layers disappear (e.g.,
cytotrophoblast).
C. Permits Passage Of:
• Gases (O₂, CO₂)
• Nutrients (glucose, amino acids, water)
• Waste products (urea, creatinine)
• Drugs (e.g., alcohol, nicotine, some medications)
• Antibodies (especially IgG)

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D. Prevents Passage Of:

• Most bacteria
• Large molecules
• Certain viruses and harmful drugs may still pass (e.g., HIV, rubella)
7. Clinical Significance
• Abnormalities like placenta previa, placental abruption, or
insufficiency can lead to:
o Preterm birth
o Intrauterine growth restriction (IUGR)
o Fetal hypoxia or death
• Drugs and infections crossing the barrier can harm the fetus
• Placental health is critical for fetal survival
8. Diagram Suggestions
• Structure of the placenta (fetal and maternal surfaces)
• Circulation (fetal and maternal blood flow)
• Placental barrier layers
Possible Exam Questions
Two Marks
1. Name two hormones secreted by the placenta.
2. What is the function of the umbilical vein?
Five Marks
1. Write a short note on functions of the placenta.
2. Explain the placental barrier and its significance.
Ten Marks
1. Describe the development and functions of the placenta. Add a note on
placental barrier.
2. Explain fetal and maternal circulations in the placenta and how exchange
of substances occurs.

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Fetal Growth and Development

1. Introduction
• Fetal growth and development refer to the progressive maturation of the
fetus from conception to birth.
• It includes cellular multiplication, differentiation, organ development,
and maturation to prepare the fetus for extrauterine life.
2. Stages of Intrauterine Development
Stage Duration Key Features

Pre- Fertilization to 2 Rapid cell division, implantation, basic

embryonic weeks germ layers

Organogenesis (formation of all major

Embryonic 3–8 weeks
organs)

Fetal 9 weeks to birth Growth and maturation of organs

3. Fetal Growth by Trimester
First Trimester (0–12 Weeks)
• Week 1–2: Fertilization, zygote formation, implantation
• Week 3–4: Heart begins to beat
• Week 5–6: Brain, spinal cord, and limb buds form
• Week 7–8: Facial features begin to form
• Week 9–12:
o All organs formed (organogenesis complete)
o External genitalia begin to differentiate
o Fetus ~9 cm long, weighs ~15–20 grams
Second Trimester (13–28 Weeks)
• Week 13–16:
o Lanugo (fine body hair) appears
o Sucking movements begin
o Gender can be determined by ultrasound

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• Week 17–20:
o Fetal movements felt by mother (quickening)
o Vernix caseosa (white waxy coating) appears
o Heart sounds audible with Doppler
• Week 21–28:
o Eyelids open, nails form
o Lungs produce surfactant (by week 24)
o Fetus grows rapidly; ~25–30 cm long, ~800 g weight
Third Trimester (29–40 Weeks)
• Week 29–32:
o Brain and nervous system mature
o Fat deposition under skin
• Week 33–36:
o Fetal growth accelerates
o Body becomes plump
• Week 37–40:
o Full-term fetus
o Organs mature and ready for birth
o Average weight: ~2.5–3.5 kg; Length: ~48–52 cm
4. Fetal Circulation Overview
• Involves three shunts:
o Ductus venosus: Bypasses liver
o Foramen ovale: Between right and left atria
o Ductus arteriosus: Between pulmonary artery and aorta
• Ensures oxygenated blood from placenta reaches brain and heart
5. Factors Affecting Fetal Growth

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Factor Effect on Growth

Maternal nutrition Protein, iron, and folic acid are essential

Uteroplacental May lead to intrauterine growth restriction

insufficiency (IUGR)

Infections (e.g., TORCH) Can cause congenital anomalies

Smoking, alcohol, drugs Low birth weight, developmental delays

Genetics Chromosomal abnormalities affect growth

Multiple pregnancies Shared nutrition leads to smaller babies

6. Assessment of Fetal Growth
• Ultrasound: Measures Biparietal Diameter (BPD), Femur Length (FL),
Abdominal Circumference (AC)
• Fundal height: Correlates with weeks of gestation
• Fetal kick count: Reflects fetal well-being
• Doppler studies: Assess blood flow in umbilical and uterine arteries
7. Graph: Fetal Growth Curve by Gestational Age
• X-axis: Weeks of Gestation
• Y-axis: Weight in grams
• Shows S-shaped growth curve (slow early, rapid mid-trimester, plateau at
term)
8. Diagram Suggestions
• Timeline of fetal development by trimester
• Diagram of fetal circulation
• Growth chart of fetal weight vs gestational age
9. Nursing Responsibilities
• Provide antenatal education on nutrition and fetal development
• Monitor maternal health and fetal growth during visits
• Identify and refer high-risk pregnancies

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• Encourage compliance with supplements and vaccines

• Support ultrasound and diagnostic test schedules
10. Possible Outcome Questions
Two Marks
1. What is quickening and when does it occur?
2. Name any two fetal circulation shunts.
Five Marks
1. Describe the fetal development in the second trimester.
2. List the factors affecting fetal growth and development.
Ten Marks
1. Explain fetal growth and development across all trimesters.
2. Describe fetal circulation and its significance in intrauterine life.
Fetal circulation & nutrition
1. Introduction
• Fetal circulation is the system of blood flow in the fetus that allows
oxygen and nutrients from the placenta to reach the developing organs.
• Fetal nutrition is provided entirely through the placenta, as the fetus
does not breathe or eat independently in utero.
2. Unique Characteristics of Fetal Circulation
• Lungs are non-functional, so most blood bypasses them.
• Oxygenation occurs in the placenta, not in the lungs.
• Involves three shunts to redirect blood flow:
Shunt Location Function

Ductus Between umbilical vein &

Bypasses the liver
venosus inferior vena cava

Foramen Allows oxygen-rich blood to

Between right and left atrium
ovale reach brain and heart

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Shunt Location Function

Ductus Between pulmonary artery & Diverts blood from lungs

arteriosus descending aorta directly to aorta
3. Flow of Blood in Fetal Circulation
1. Oxygenated blood from placenta enters fetus via umbilical vein.
2. Most of it bypasses liver through ductus venosus and enters inferior
vena cava (IVC).
3. From IVC → Right atrium →
o Most flows via foramen ovale into left atrium → left ventricle →
aorta → brain and upper body.
o Some enters right ventricle, pumped into pulmonary artery →
diverted to aorta via ductus arteriosus.
4. Deoxygenated blood returns to placenta via umbilical arteries.
4. Changes After Birth
Before Birth After Birth

Lungs collapsed Lungs expand, pulmonary circulation begins

Foramen ovale open Closes due to pressure changes

Ductus arteriosus open Functionally closes within 24–48 hours

Ductus venosus functional Closes shortly after birth

5. Diagram Suggestion
• Flowchart of fetal circulation
• Color-coded diagram showing oxygenated (red) and deoxygenated (blue)
pathways
• Comparison chart: Fetal vs. Postnatal circulation
6. Placental Nutrition
• Placenta acts as the lifeline between mother and fetus.
• Functions as:

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o Transporter of oxygen, glucose, amino acids, fatty acids

o Waste remover (CO₂, urea)
o Barrier to harmful substances (partially)
o Hormone producer (hCG, progesterone, estrogen
7. Nutrients Supplied to Fetus
Nutrient Role in Development

Oxygen Vital for cellular respiration

Glucose Primary energy source

Amino acids Protein synthesis for tissue growth

Fatty acids Brain and nervous system development

Vitamins (A, D, K) Bone growth, immunity, clotting

Minerals (Iron, Ca) Hemoglobin formation, skeletal development

Water Maintains amniotic fluid balance

8. Factors Affecting Fetal Nutrition
Factor Effect

Maternal malnutrition Intrauterine Growth Restriction (IUGR)

Anemia in mother Low oxygen-carrying capacity, fetal hypoxia

Smoking, alcohol, drugs Poor placental perfusion, fetal abnormalities

Placental insufficiency Reduced nutrient and oxygen transfer

Maternal diseases (e.g., HTN) Affect blood flow to placenta

9. Nursing Responsibilities
• Monitor maternal nutrition and hemoglobin levels
• Educate pregnant women about balanced diet
• Ensure antenatal supplements: Iron, Folic Acid, Calcium
• Monitor fetal growth via fundal height, ultrasound, kick counts
• Recognize signs of fetal distress or IUGR
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10. Possible Outcome Questions

Two Marks
1. Name the three shunts in fetal circulation.
2. What is the role of ductus arteriosus?
Five Marks
1. Describe fetal circulation with a labeled diagram.
2. List the nutrients supplied to the fetus and their importance.
Ten Marks
1. Explain the process of fetal circulation and changes after birth.
2. Describe how the fetus receives nutrition and factors affecting it.

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Unit – 03
Assessment and management of
normal pregnancy (ante-natal)

Pre-pregnancy Care
1. Introduction to Antenatal Care
• Antenatal care (ANC) refers to the systematic and regular care given to
pregnant women during pregnancy.
• Pre-pregnancy care (also known as preconception care) aims to prepare
a woman physically and mentally before conception occurs.
• Ensures a healthy pregnancy outcome for both mother and fetus.
2. Objectives of Pre-pregnancy Care
• Optimize the woman’s health before conception.
• Identify and manage existing medical conditions.
• Reduce the risk of maternal and fetal complications.
• Educate couples about healthy reproductive choices.
• Ensure immunization status and genetic counseling if required.
3. Components of Pre-pregnancy Care
A. Medical History and Physical Examination
• Detailed health history:
o Chronic illnesses (e.g., diabetes, hypertension, thyroid)
o Past obstetric history (e.g., abortions, stillbirths)
o Family history of genetic disorders
o Gynecological conditions (e.g., PCOD, endometriosis)
• Physical exam:
o General health status
o BMI and nutrition status

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o Pelvic examination
B. Laboratory Investigations
• Blood group and Rh typing
• Hemoglobin level
• Blood sugar levels (to detect diabetes)
• Thyroid function test
• Rubella IgG titer
• HIV, Hepatitis B & C, VDRL
• Urinalysis
C. Immunization
• Rubella: If not immune, vaccinate at least 1 month before conception.
• Hepatitis B: If not vaccinated.
• Tetanus and Diphtheria: Booster if not up to date.
• HPV vaccine: Recommended before conception age (not during
pregnancy).
D. Nutritional Counseling
• Maintain a healthy BMI (18.5–24.9)
• Encourage balanced diet rich in:
o Iron
o Calcium
o Folic acid
o Protein
o Omega-3 fatty acids
• Avoid:
o Junk food, excessive caffeine
o Alcohol and smoking
E. Folic Acid Supplementation
• Start 400–800 mcg daily at least 3 months before conception
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• Prevents neural tube defects (e.g., spina bifida)

F. Lifestyle Modifications
• Quit smoking, alcohol, and drug use
• Encourage regular physical activity
• Maintain mental health and stress reduction
• Avoid exposure to radiation, chemicals, infections
G. Genetic Counseling
• Indicated for:
o Family history of genetic disorders
o Advanced maternal age (>35 years)
o Consanguineous marriage
H. Psychological Preparation
• Emotional readiness for pregnancy
• Education about changes during pregnancy
• Supportive environment
4. Health Education and Counseling
• Importance of antenatal check-ups
• Signs of pregnancy
• Planning for birth and parenting
• Birth spacing and contraception if delaying pregnancy
5. Role of Nurse in Pre-pregnancy Care
• Assess health status and risk factors
• Educate about nutrition and hygiene
• Provide counseling and emotional support
• Coordinate referrals (e.g., for specialist care or immunizations)
6. Diagram Suggestions
• Flowchart of pre-pregnancy care process

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• Checklist table for assessment (history, physical, investigations)

Possible Exam Questions
Two Marks
1. What is the ideal dose of folic acid before conception?
2. Name any two immunizations given in pre-pregnancy care.
Five Marks
1. Write short notes on objectives and components of pre-pregnancy care.
2. Explain the role of nurse in preconception counseling.
Ten Marks
1. Describe the components of pre-pregnancy care and its importance in
antenatal management.
2. Explain how a nurse assesses and prepares a woman for conception,
including health education and risk identification.
Review of Sexual Development
1. Introduction
• Sexual development is a biological and psychological process by which
individuals develop physical and emotional traits related to sex and
gender.
• Begins before birth (prenatal period) and continues through childhood,
puberty, and adulthood.
2. Stages of Sexual Development
A. Prenatal Stage
• Genetic sex is determined at fertilization (XX = female, XY = male).
• Gonadal sex is established by 6–8 weeks of gestation:
o Testes in males
o Ovaries in females
• Internal and external genitalia differentiate based on presence or
absence of hormones:
o Testosterone promotes male structures

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o Absence leads to female development

B. Childhood (0–10 years)
• Period of sexual latency
• Sexual organs are present but inactive
• Basic gender identity is established (~2–3 years)
C. Puberty (Usually 10–18 years)
• Initiated by the activation of the hypothalamic-pituitary-gonadal axis
• Gonadotropin-releasing hormone (GnRH) stimulates release of:
o LH and FSH → stimulate gonads to produce sex hormones
• Development of secondary sexual characteristics:
Feature Male Female

Hormone Testosterone Estrogen, Progesterone

Facial hair, voice deepening, Breast development, menstruation,

Changes
muscle growth fat distribution

Growth
Later than females Earlier onset
spurt
D. Adulthood
• Reproductive maturity is achieved
• Sex hormones regulate:
o Spermatogenesis in males
o Ovulation and menstruation in females
E. Aging and Sexual Changes
• Females: Menopause (~45–55 years), decline in estrogen, cessation of
menstruation
• Males: Gradual decline in testosterone, reduced libido and sperm count
3. Psychological and Emotional Aspects of Sexual Development
• Gender identity: Personal sense of being male, female, or other
• Sexual orientation: Romantic/sexual attraction to others

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• Psychosocial influences: Family, culture, media, peer groups

4. Factors Influencing Sexual Development
Factor Role

Genetic Chromosomal and gonadal sex

Androgens and estrogens influence development of secondary

Hormonal
sex characteristics

Environmental Nutrition, exposure to endocrine-disrupting chemicals

Cultural Beliefs about gender roles and sexual expression

Psychological Self-concept, body image, experiences

5. Common Disorders Related to Sexual Development
Disorder Description

Female with underdeveloped ovaries, short

Turner Syndrome (XO)
stature, infertility

Klinefelter Syndrome Male with low testosterone, infertility,

(XXY) gynecomastia

Androgen Insensitivity Genetically male but phenotypically female due

Syndrome to androgen receptor defect

Congenital Adrenal Excess androgen exposure in female fetus leads

Hyperplasia (CAH) to ambiguous genitalia
6. Nursing Role in Supporting Sexual Development
• Provide health education during adolescence
• Promote positive body image and self-esteem
• Counsel parents on normal sexual development
• Identify and refer for psychosexual disorders or endocrine issues
• Address menstrual health, contraceptive counseling, and puberty
concerns
7. Diagram/Table Suggestions
• Timeline of sexual development (prenatal to adulthood)

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• Table of male vs female secondary sexual characteristics

• Hormonal regulation chart during puberty
Possible Exam Questions
Two Marks
1. Name the hormone responsible for initiating puberty.
2. At what age does menopause typically occur?
Five Marks
1. Write short notes on psychological aspects of sexual development.
2. Describe hormonal changes during puberty in females.
Ten Marks
1. Explain the stages of sexual development from prenatal to adulthood.
2. Discuss the role of hormones and psychosocial factors in sexual
development.
Socio-Cultural Aspects of Human Sexuality (Self-Learning)
1. Introduction
• Human sexuality is not just a biological concept; it is also deeply
influenced by social, cultural, and religious factors.
• Understanding these aspects helps healthcare professionals provide
holistic and sensitive care, especially in maternal and child health
settings.
2. Definition
• Human sexuality refers to how individuals experience and express
themselves sexually, including:
o Biological sex
o Gender identity
o Sexual orientation
o Sexual behavior
o Intimacy and relationships
3. Cultural Aspects of Human Sexuality

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Aspect Influence on Sexuality

Define what is considered appropriate or taboo in sexual

Beliefs and Values
behavior

Customs and
Influence age of marriage, sexual roles, and expectations
Traditions

May shape or restrict communication about sex or

Language
reproductive health

Prescribe specific behaviors for males and females (e.g.,

Gender Roles
dominance vs. submissiveness)

Religious Impact views on contraception, abortion, premarital sex,

Teachings and sexual orientation

4. Social Influences on Sexuality

Factor Role

Primary source of beliefs about sex, relationships,

Family
modesty

Shape attitudes during adolescence about dating,

Peers
relationships, and sexuality

Access to sex education influences knowledge, behavior,

Education
and health choices

Powerful influence on sexual attitudes, norms, and

Media
behaviors

Socioeconomic Affects access to reproductive health services,

Status contraception, and awareness

Urban vs Rural Differences in exposure to information, acceptance of

Settings gender equality, and sexual health resources
5. Socio-Cultural Taboos and Misconceptions
• Sex as a forbidden topic, especially for women
• Myths related to menstruation, virginity, masturbation

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• Homosexuality often considered abnormal or immoral in many cultures

• Sexuality in older adults often ignored or denied
• Misconceptions lead to poor communication, inadequate sex
education, and unsafe practices
6. Gender and Sexuality
• Gender roles and identity are socially constructed.
• Gender discrimination impacts sexual autonomy, reproductive rights,
and access to care.
• LGBTQ+ individuals often face stigma, discrimination, and limited
access to healthcare
7. Importance of Cultural Sensitivity in Nursing Practice
• Understand and respect the patient's cultural background regarding
sexuality.
• Provide non-judgmental, confidential, and supportive care.
• Use inclusive language and avoid assumptions.
• Encourage open dialogue when appropriate, especially in reproductive
health counseling
8. Nursing Implications
• Be aware of your own values and biases regarding sexuality.
• Promote safe, responsible, and respectful sexual behavior.
• Educate individuals and families in a culturally appropriate manner.
• Ensure informed consent and respect for bodily autonomy in all care.
• Advocate for comprehensive sex education and gender equity in care
delivery.
9. Diagram/Table Suggestions
• Chart comparing cultural norms related to sexuality across different
communities
• Flowchart of influences on human sexuality: Biological + Cultural +
Social + Psychological
• Table showing traditional vs. modern views on gender and sexual roles

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Possible Exam Questions

Two Marks
1. Define human sexuality.
2. Name two socio-cultural factors influencing sexual behavior.
Five Marks
1. Explain the cultural aspects of human sexuality.
2. Describe the role of family and education in shaping human sexuality.
Ten Marks
1. Discuss socio-cultural influences on human sexuality and the nurse’s role
in promoting sexual health.
2. Describe misconceptions and taboos related to sexuality and how they
affect reproductive health in India
Preconception Care
1. Introduction
• Preconception care refers to the medical and psychological care
provided to individuals (especially women of reproductive age) before
conception to improve maternal and fetal outcomes.
• The goal is to identify and modify risk factors that could affect a future
pregnancy.
2. Objectives of Preconception Care
• Promote optimal physical and mental health before conception.
• Identify and manage medical, genetic, and social risk factors.
• Educate about healthy lifestyle and reproductive planning.
• Prevent congenital anomalies and maternal complications.
• Increase the chances of a healthy pregnancy and birth outcome.
3. Components of Preconception Care
A. Health Assessment
• Complete medical, surgical, obstetric, and family history.
• Review of menstrual history and fertility awareness.

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• Screen for chronic illnesses: diabetes, hypertension, thyroid disorders,

epilepsy.
• Assessment of BMI, nutrition, substance use, and mental health.
• Physical examination and pelvic assessment.
B. Laboratory Investigations
• Hemoglobin level
• Blood group and Rh typing
• Blood sugar and thyroid function tests
• HIV, HBsAg, VDRL
• Rubella immunity (IgG), toxoplasmosis screening
• Urine routine and culture
C. Immunizations
• Rubella (at least 1 month before conception if non-immune)
• Hepatitis B
• Tetanus-diphtheria (if not up to date)
• Varicella and HPV vaccines (if appropriate and before pregnancy)
D. Nutritional Counseling
• Encourage balanced diet rich in:
o Folic acid (400–800 mcg/day for neural tube defect prevention)
o Iron, calcium, protein, and vitamins
• Assess for anemia and malnutrition
• Advise on weight management
E. Lifestyle Modifications
• Avoid alcohol, smoking, and recreational drugs
• Encourage physical activity and stress reduction
• Avoid exposure to harmful chemicals or radiation
• Promote safe sexual practices and STI prevention
F. Psychosocial Counseling
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• Mental health screening (e.g., for anxiety, depression)

• Relationship and partner support evaluation
• Intimate partner violence screening
• Address emotional readiness for parenthood
G. Genetic Counseling
• For couples with:
o Family history of genetic disorders
o Consanguineous marriage
o Advanced maternal age (>35 years)
H. Fertility Awareness and Planning
• Educate about ovulation, fertile window, and cycle tracking
• Discuss contraceptive options if pregnancy is being delayed
4. Role of Nurse in Preconception Care
• Conduct initial assessments and referrals
• Provide education on reproductive health
• Administer immunizations
• Offer emotional support and counseling
• Guide about nutrition, supplements, and lifestyle adjustments
• Identify and manage risk factors
5. Diagram/Table Suggestions
Table: Key Nutrients in Preconception Care
Nutrient Function Source

Folic Acid Prevents neural tube defects Leafy greens, supplements

Iron Prevents anemia Red meat, legumes

Calcium Bone health Milk, dairy

Protein Fetal tissue development Eggs, pulses

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Nutrient Function Source

Iodine Brain development Iodized salt

Possible Exam Questions
Two Marks
1. Mention any two objectives of preconception care.
2. What is the recommended daily dose of folic acid before pregnancy?
Five Marks
1. Write the components of preconception care.
2. Discuss the role of a nurse in preconception counseling.
Ten Marks
1. Define preconception care. Explain its importance and describe its major
components.
2. Describe in detail the health assessment and management involved in
preconception care.
Pre-conception Counseling (Including Awareness Regarding Normal Birth) &
Genetic Counseling (Self Learning)
1. Pre-conception Counseling
Definition:
• Pre-conception counseling is the educational and health service
provided to couples or individuals before pregnancy to ensure a healthy
pregnancy and outcome.
2. Objectives of Pre-conception Counseling
• Promote reproductive health awareness
• Identify and manage risk factors before conception
• Encourage healthy lifestyle choices
• Ensure couples are emotionally and physically prepared
• Educate about normal pregnancy, labor, and childbirth
3. Components of Pre-conception Counseling
A. Medical Evaluation
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• Personal and family history

• Menstrual and obstetric history
• Existing health conditions (e.g., diabetes, hypertension)
• Medication review
B. Physical Examination
• BMI assessment
• General health screening
• Reproductive system evaluation
C. Laboratory Investigations
• CBC, blood group, Rh typing
• HIV, HBsAg, VDRL
• Rubella, TSH, blood sugar
• Urinalysis
D. Immunization
• Rubella
• Hepatitis B
• Tetanus booster
E. Nutritional Advice
• Balanced diet
• Folic acid (400–800 mcg/day)
• Iron and calcium supplementation
F. Lifestyle Counseling
• Avoid tobacco, alcohol, and drugs
• Promote physical activity
• Manage stress
G. Psychosocial and Emotional Support
• Partner relationship evaluation

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• Address fears and anxieties

• Promote readiness for parenting
4. Awareness Regarding Normal Birth
• Educate about:
o Normal physiology of labor
o Stages of labor
o Breathing and relaxation techniques
o Birth preparedness and complication readiness
• Promote confidence in vaginal delivery
• Discuss benefits:
o Faster recovery
o Fewer complications
o Bonding with baby
5. Role of Nurse in Pre-conception Counseling
• Provide accurate information
• Guide on diet, hygiene, lifestyle
• Educate about pregnancy and normal birth
• Encourage participation in birth preparedness classes
• Promote regular antenatal checkups after conception
6. Genetic Counseling
Definition:
• Genetic counseling is the process of advising individuals and families
about the risks, diagnosis, and implications of inherited conditions and
birth defects.
7. Objectives of Genetic Counseling
• Identify couples at risk of transmitting genetic disorders
• Help families understand and adapt to medical, psychological, and
familial implications

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• Provide support in decision-making regarding conception and testing

8. Indications for Genetic Counseling
• Family history of genetic diseases (e.g., thalassemia, hemophilia)
• Recurrent miscarriages or stillbirths
• Previous child with birth defect or genetic disorder
• Consanguineous marriage
• Maternal age >35 years
• Exposure to teratogens
• Abnormal prenatal screening results
9. Steps in Genetic Counseling
1. Pre-test Counseling
o Collect family history
o Assess risk
o Discuss implications
2. Diagnostic Testing
o Blood tests
o Karyotyping
o Prenatal tests (amniocentesis, chorionic villus sampling)
3. Post-test Counseling
o Explain test results
o Options for pregnancy (continuation, termination)
o Risk for future pregnancies
o Supportive care
10. Role of Nurse in Genetic Counseling
• Identify at-risk individuals/families
• Educate on testing options
• Provide emotional and psychological support

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• Refer to genetic specialists

• Follow up and support decision-making
11. Diagram/Table Suggestions
Table: Comparison Between Pre-conception and Genetic Counseling
Feature Pre-conception Counseling Genetic Counseling

Focus General health and readiness Inherited/genetic risks

Timing Before pregnancy Before or during pregnancy

Involves Lifestyle, medical, nutrition Family history, genetic testing

Provided by Nurse/midwife/general doctor Genetic counselor/doctor

Possible Exam Questions
Two Marks
1. What is the dose of folic acid recommended during pre-conception?
2. Mention any two indications for genetic counseling.
Five Marks
1. Write the role of the nurse in pre-conception counseling.
2. List components and objectives of genetic counseling.
Ten Marks
1. Define pre-conception counseling. Describe its components and
importance in preparing for pregnancy.
2. Explain the process of genetic counseling and its role in preventing birth
defects.
Planned Parenthood
1. Introduction
• Planned parenthood refers to the ability of individuals and couples to
anticipate and attain their desired number of children and the spacing and
timing of their births.
• It is achieved through contraceptive methods, fertility awareness,
sexual health education, and access to reproductive health services.

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2. Objectives of Planned Parenthood

• Promote maternal and child health
• Reduce unintended pregnancies
• Empower women with reproductive choices
• Improve family well-being and economic stability
• Ensure safe and healthy pregnancies
• Support population control and reduce overpopulation
3. Components of Planned Parenthood
A. Education and Counseling
• Educate couples on:
o Sexual and reproductive health
o Fertility and menstrual cycles
o Contraceptive choices
o Benefits of birth spacing
• Provide premarital and preconception counseling
B. Contraceptive Services
• Offer a variety of contraceptive methods based on:
o Age
o Parity
o Health status
o Personal preference
C. Fertility Regulation
• Help couples conceive when ready
• Provide services for infertility management when needed
D. Maternal and Child Health Care
• Promote antenatal, intranatal, postnatal care
• Encourage institutional deliveries

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• Support breastfeeding and immunization

E. Prevention and Management of STIs and RTIs
• Provide screening and treatment for sexually transmitted infections
• Educate about safe sex practices
F. Adolescent and Youth Counseling
• Sexuality education
• Menstrual hygiene
• Responsible sexual behavior
4. Contraceptive Methods in Planned Parenthood
Type Method Examples

Temporary Barrier Condoms, diaphragm

Hormonal Oral pills, injectables, implants

Intrauterine Copper-T, hormonal IUD

Safe period, withdrawal, lactational

Natural
amenorrhea

Permanent Male sterilization Vasectomy

Female
Tubectomy
sterilization
5. Role of Nurse in Planned Parenthood
• Educate individuals and couples about:
o Family planning
o Contraceptive methods
o Side effects and benefits
• Provide counseling and support decision-making
• Maintain confidentiality and non-judgmental attitude
• Ensure availability of contraceptive supplies
• Refer to specialists when needed

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• Support maternal and child care before and after birth

6. Importance of Planned Parenthood in Public Health
• Reduces maternal mortality and morbidity
• Lowers infant and child mortality rates
• Reduces illegal and unsafe abortions
• Enhances gender equality and women empowerment
• Supports sustainable population growth
7. National Programs Supporting Planned Parenthood
• Family Welfare Program
• National Population Policy
• RMNCH+A (Reproductive, Maternal, Newborn, Child, and Adolescent
Health)
• Mission Parivar Vikas
8. Diagram/Table Suggestions
Table: Spacing vs Permanent Methods of Contraception
Feature Spacing Methods Permanent Methods

Duration Temporary Lifelong

Reversible Yes No

Examples Oral pills, IUD Tubectomy, vasectomy

Users Men and women Men and women

Chart: Benefits of Planned Parenthood
• Healthy mother → Healthy pregnancy
• Healthy birth spacing → Reduced maternal exhaustion
• Controlled family size → Improved child care and education
Possible Exam Questions
Two Marks
1. What is meant by planned parenthood?

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2. Name any two spacing contraceptive methods.

Five Marks
1. Write the role of nurse in planned parenthood services.
2. List the advantages of planned parenthood.
Ten Marks
1. Define planned parenthood. Explain its importance and describe the role
of nurse in promoting it.
2. Explain various contraceptive methods used in planned parenthood and
their advantages and limitations.
Normal Pregnancy – Physiological Changes During Pregnancy
1. Introduction
• Pregnancy is a normal physiological state in which a woman carries a
developing fetus in her uterus.
• To support the growing fetus, a woman’s body undergoes systemic
physiological and anatomical changes in almost all body systems.
2. Duration of Pregnancy
• Average duration: 280 days or 40 weeks (calculated from the first day of
the Last Menstrual Period - LMP).
• Divided into 3 trimesters:
o 1st trimester: 1–12 weeks
o 2nd trimester: 13–28 weeks
o 3rd trimester: 29–40 weeks
3. General Overview of Changes
System Type of Change

Reproductive Enlargement of uterus, softening of cervix

Endocrine Increased hormone levels (estrogen, progesterone, hCG, etc.)

Cardiovascular Increased blood volume, cardiac output

Respiratory Increased tidal volume and oxygen consumption

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System Type of Change

Gastrointestinal Nausea, vomiting, constipation

Urinary Increased frequency, GFR increases

Musculoskeletal Lordosis, relaxation of ligaments

Skin Pigmentation, stretch marks

Psychological Mood swings, anxiety, maternal bonding

4. System-wise Physiological Changes
A. Reproductive System
• Uterus:
o Grows from 50 g (non-pregnant) to 1000 g (term)
o Increased blood flow
o Braxton Hicks contractions from second trimester
• Cervix:
o Softens (Goodell's sign)
o Bluish discoloration (Chadwick’s sign)
o Increased mucus secretion (mucus plug)
• Vagina:
o Increased vascularity and leukorrhea
• Breasts:
o Enlargement and tenderness
o Darkening of areola
o Montgomery’s tubercles prominent
o Colostrum production starts ~16 weeks
B. Endocrine System
• hCG: Maintains corpus luteum in early pregnancy
• Estrogen: Promotes uterine growth, blood supply
• Progesterone: Relaxes uterus, maintains endometrium
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• Prolactin: Prepares breast for lactation

• hPL (Human Placental Lactogen): Increases maternal insulin resistance
C. Cardiovascular System
• Blood volume increases by 30–50%
• Cardiac output increases by 30–40%
• Heart rate increases by 10–15 bpm
• Physiological anemia due to hemodilution
• Blood pressure may decrease slightly in mid-pregnancy
D. Respiratory System
• Oxygen consumption increases
• Tidal volume increases
• Diaphragm elevated due to enlarging uterus
• Shortness of breath is common in late pregnancy
E. Gastrointestinal System
• Nausea and vomiting (morning sickness) due to hCG
• Delayed gastric emptying
• Constipation due to progesterone
• Heartburn and bloating due to relaxation of lower esophageal sphincter
F. Urinary System
• Renal blood flow and glomerular filtration rate increase
• Increased frequency of urination
• Risk of urinary tract infections
G. Musculoskeletal System
• Lordosis (spinal curvature) to balance weight
• Relaxation of pelvic joints and ligaments due to relaxin hormone
• Leg cramps common
H. Skin Changes

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• Linea nigra: Dark line on abdomen

• Chloasma (mask of pregnancy): Pigmentation on face
• Striae gravidarum (stretch marks) on abdomen, breasts
• Increased hair and nail growth
I. Psychological Changes
• Mood swings, emotional sensitivity
• Anxiety about childbirth, body image
• Development of maternal-fetal bonding
• Increased dependency on family/support system
5. Nursing Role in Managing Normal Physiological Changes
• Educate mother about normal changes and self-care
• Provide reassurance and support
• Encourage rest, balanced diet, hydration
• Monitor for signs of abnormal changes
• Promote antenatal visits and healthy behaviors
6. Diagram/Table Suggestions
Table: Hormones and Their Functions in Pregnancy
Hormone Source Function

hCG Placenta Maintains corpus luteum

Estrogen Placenta Uterine growth, vascularity

Progesterone Corpus luteum, placenta Maintains endometrium, relaxes uterus

Prolactin Pituitary Breast development

Relaxin Placenta Relaxes pelvic ligaments

Chart: Trimester-wise Common Symptoms
Trimester Common Symptoms

First Nausea, fatigue, breast tenderness

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Trimester Common Symptoms

Second Abdominal enlargement, skin changes

Third Backache, leg cramps, frequent urination

Possible Exam Questions
Two Marks
1. What is the average increase in blood volume during pregnancy?
2. Name two skin changes that occur during pregnancy.
Five Marks
1. List the physiological changes in the cardiovascular and urinary systems
during pregnancy.
2. Describe the endocrine changes during pregnancy.
Ten Marks
1. Explain in detail the physiological changes during pregnancy system-
wise.
2. Discuss the role of the nurse in helping the pregnant woman cope with
normal physiological changes
Assessment and Confirmation of Pregnancy – Diagnosis, Signs, Differential
Diagnosis, and Confirmatory Tests
1. Introduction
• Diagnosis of pregnancy is based on a combination of subjective
symptoms, clinical signs, and laboratory/imaging tests.
• Accurate and early confirmation is important to initiate antenatal care
and ensure a safe pregnancy outcome.
2. Objectives of Pregnancy Diagnosis
• Early confirmation of pregnancy
• To differentiate true pregnancy from other conditions
• To estimate gestational age
• To initiate timely antenatal care and counselin
3. Signs and Symptoms of Pregnancy

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A. Presumptive Signs (Subjective – Felt by the woman)

These are not conclusive, as they may occur in other conditions:
• Amenorrhea (absence of menstruation)
• Nausea and vomiting (morning sickness)
• Breast tenderness and enlargement
• Fatigue and drowsiness
• Frequent urination
• Increased pigmentation: chloasma, linea nigra
• Quickening (first fetal movement) around 18–20 weeks (multipara
earlier)
B. Probable Signs (Objective – Observed by the examiner)
More reliable but still not confirmatory:
• Abdominal enlargement
• Changes in uterus:
o Hegar’s sign: softening of the lower uterine segment
o Goodell’s sign: softening of the cervix
o Chadwick’s sign: bluish discoloration of cervix and vagina
• Ballottement (fetus rebounding when tapped)
• Braxton Hicks contractions
• Positive pregnancy tests (urine hCG)
C. Positive/Confirmatory Signs (Definitive)
These are conclusive evidence of pregnancy:
• Fetal heart sounds:
o Heard by Doppler by 10–12 weeks
o Heard by fetoscope by 18–20 weeks
• Fetal movements felt by the examiner (~20 weeks)
• Visualization of fetus by ultrasound:
o Gestational sac: 4–5 weeks
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o Fetal heartbeat: ~6 weeks

4. Laboratory Diagnosis of Pregnancy
A. Urine Pregnancy Test
• Detects hCG hormone in urine
• Usually positive by the missed period (4–5 weeks)
• Can be done at home or clinic
• False positives/negatives may occur
B. Blood hCG Test
• Quantitative test measuring hCG level
• Detects pregnancy earlier than urine test (as early as 8–10 days after
ovulation)
• Used to assess pregnancy viability and rule out ectopic pregnanc
5. Imaging Diagnosis – Ultrasound
• Transvaginal ultrasound:
o Detects pregnancy earlier (gestational sac at 4–5 weeks)
• Transabdominal ultrasound:
o Used after 6–7 weeks
• Confirms:
o Intrauterine pregnancy
o Fetal heartbeat
o Gestational age
6. Differential Diagnosis of Pregnancy
Conditions that may mimic signs of pregnancy:
• Pseudocyesis (false pregnancy – psychological)
• Uterine fibroid
• Ovarian cyst
• Molar pregnancy
• Hormonal disorders causing amenorrhea
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• Ectopic pregnancy (pain, bleeding – needs urgent evaluation)

7. Role of Nurse in Confirmation of Pregnancy
• Obtain complete history (menstrual, sexual, contraceptive)
• Assist with physical examination
• Educate about home pregnancy test use
• Collect and send samples for lab tests
• Provide emotional support and counseling
• Refer to physician for confirmation and further care
8. Table: Comparison of Signs of Pregnancy
Type of Sign Example Reliability

Presumptive Amenorrhea, nausea Least reliable

Probable Hegar’s, Goodell’s sign Moderately reliable

Positive Fetal heart tones, USG Conclusive

9. Diagram Suggestion
Flowchart: Diagnostic Approach to Pregnancy
1. Missed Period →
2. Urine Pregnancy Test →
3. Clinical Examination →
4. Blood hCG / Ultrasound →
5. Confirm Diagnosis
Possible Exam Questions
Two Marks
1. Name any two presumptive signs of pregnancy.
2. Mention any one confirmatory sign of pregnancy.
Five Marks
1. List the probable signs of pregnancy.
2. Write the role of a nurse in assessment and confirmation of pregnancy.

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Ten Marks
1. Describe the signs of pregnancy and explain confirmatory tests used in
diagnosis.
2. Define pregnancy diagnosis. Discuss signs and differential diagnosis of
pregnancy.
Review of Maternal Nutrition & Malnutrition
1. Introduction
• Maternal nutrition is the nutritional status of a woman before
conception, during pregnancy, and postpartum.
• Good nutrition is vital to ensure healthy fetal development, prevent
complications, and promote maternal well-being.
• Malnutrition (both undernutrition and overnutrition) can lead to adverse
maternal and neonatal outcomes.
2. Objectives of Maternal Nutrition
• Ensure proper fetal growth and development
• Maintain maternal health and energy
• Prepare the body for labor, delivery, and lactation
• Prevent nutritional deficiency disorders
• Reduce the risk of maternal mortality and morbidity
3. Caloric and Nutritional Requirements During Pregnancy
Daily Requirement During
Nutrient Importance
Pregnancy

+300 kcal/day (2nd & 3rd

Energy Fetal growth, maternal energy
trimester)

Protein 70–75 g/day Tissue building, fetal development

Prevents anemia, supports oxygen

Iron 35–60 mg/day
transport

Calcium 1000–1200 mg/day Fetal bone/teeth development

Folic acid 400–600 mcg/day Prevents neural tube defects

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Daily Requirement During

Nutrient Importance
Pregnancy

Vitamin
800–1000 mcg/day Vision, immunity
A

Vitamin
80–85 mg/day Iron absorption, tissue repair
C

Prevents cretinism, brain

Iodine 250 mcg/day
development

Water 2.5–3 liters/day Hydration, metabolism

4. Components of a Balanced Diet for Pregnant Women
• Carbohydrates: Rice, wheat, potatoes for energy
• Proteins: Eggs, milk, pulses, meat for tissue building
• Fats: Ghee, oil, nuts for energy and fat-soluble vitamins
• Vitamins & Minerals: Fruits, green leafy vegetables
• Fiber: Whole grains, vegetables for digestion
• Water: Adequate fluid intake
5. Food Items to Be Encouraged
• Whole grains
• Green leafy vegetables
• Seasonal fruits
• Milk and dairy products
• Iron-rich foods: jaggery, dates, spinach
• Folic acid sources: citrus fruits, legumes
• Omega-3 sources: flax seeds, fish (in moderation)
6. Food Items to Be Avoided or Limited
• Processed and junk foods
• Excessive caffeine
• Alcohol and tobacco

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• Raw or undercooked meat/eggs

• High-mercury fish (e.g., shark, swordfish)
7. Maternal Malnutrition
A. Definition
Malnutrition refers to both undernutrition (deficiency of
calories/proteins/micronutrients) and overnutrition (excessive intake leading to
obesity).
B. Types of Malnutrition in Pregnancy
Type Causes Effects

Protein-energy
Poor intake, poverty Low birth weight, anemia
malnutrition

Low iron Fatigue, poor fetal

Iron-deficiency anemia
intake/absorption oxygenation

Night blindness, weak

Vitamin A deficiency Inadequate diet
immunity

Iodine deficiency Lack of iodized salt Cretinism, goiter

Folic acid deficiency Lack of supplements Neural tube defects

Overeating, sedentary Gestational diabetes, pre-

Obesity
life eclampsia
8. Consequences of Maternal Malnutrition
On the Mother:
• Anemia
• Increased risk of infection
• Pre-eclampsia
• Prolonged labor
• Postpartum hemorrhage
• Maternal mortality
On the Fetus/Newborn:

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• Intrauterine Growth Restriction (IUGR)

• Low birth weight
• Preterm birth
• Congenital anomalies
• Neonatal mortality
• Poor cognitive development
9. Role of Nurse in Maternal Nutrition
• Assess dietary habits and nutritional status
• Counsel pregnant women on balanced diet
• Monitor weight gain during ANC visits
• Promote iron-folic acid (IFA) supplementation
• Identify and refer cases of malnutrition
• Collaborate with nutritionists/dietitians
• Educate about food hygiene and safe food practices
10. Table: Recommended Weight Gain During Pregnancy Based on BMI
BMI Category Recommended Weight Gain

Underweight (BMI <18.5) 12.5–18 kg

Normal weight (18.5–24.9) 11.5–16 kg

Overweight (25–29.9) 7–11.5 kg

Obese (BMI ≥30) 5–9 kg

Possible Exam Questions
Two Marks
1. Mention two effects of maternal anemia on the fetus.
2. List any two rich sources of folic acid.
Five Marks
1. Write the role of nurse in improving maternal nutrition.
2. List the common nutritional deficiencies in pregnancy and their effects.

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Ten Marks
1. Explain the importance of maternal nutrition and describe the dietary
requirements during pregnancy.
2. Define malnutrition. Describe the types, causes, and consequences of
malnutrition during pregnancy.
Building Partnership with Women Following Respectful Maternity Care (RMC)
Protocol
1. Introduction
• Respectful Maternity Care (RMC) is a universal human right of every
woman during pregnancy, childbirth, and postpartum.
• Building a partnership with women involves respectful, dignified,
culturally appropriate, and evidence-based care.
• It empowers women to participate in decisions and ensures positive birth
experiences.
2. Objectives of RMC-Based Partnership
• Promote woman-centered care
• Enhance trust and communication between caregiver and woman
• Uphold dignity, privacy, and autonomy
• Prevent abuse, neglect, and discrimination
• Ensure informed decision-making and satisfaction
3. Key Principles of RMC Protocol (As per WHO & Government of India)
1. Freedom from harm and ill-treatment
2. Right to information, informed consent, and refusal
3. Confidentiality and privacy
4. Dignity and respect
5. Non-discrimination
6. Supportive care
7. Liberty, autonomy, self-determination
8. Right to timely and quality healthcare

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4. Building Partnership: Nurse's Role

A. Effective Communication
• Use simple, understandable language
• Provide complete and honest information
• Listen to concerns, preferences, and cultural beliefs
• Maintain non-judgmental and empathetic tone
B. Ensuring Informed Choices
• Explain options, procedures, benefits, and risks
• Respect the woman’s right to accept or refuse
• Support shared decision-making
C. Respect and Dignity
• Greet by name, maintain a friendly attitude
• Provide care without bias (based on caste, class, religion, age)
• Maintain privacy during examination and procedures
• Allow birth companion of choice when permitted
D. Emotional and Physical Support
• Offer comfort measures during labor (position change, massage)
• Allow free movement unless contraindicated
• Encourage participation in birth process
• Address pain relief preferences
E. Cultural Sensitivity
• Acknowledge and incorporate cultural and traditional practices if safe
• Avoid imposing personal or institutional beliefs
F. Postpartum Support
• Counsel on breastfeeding, hygiene, newborn care
• Promote bonding and skin-to-skin contact
• Encourage early initiation of breastfeeding

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5. Respectful Maternity Care Checklist (Sample)

Aspect Action

Introduction Greets, explains name and role

Consent Seeks permission before exams

Privacy Uses curtains/screens

Information Explains procedures, seeks questions

Non-discrimination Provides same care to all

Companion Allows presence of birth companion

Emotional support Talks gently, encourages

Pain management Offers comfort measures

6. Outcomes of Respectful Care Partnership
• Increased maternal satisfaction and trust
• Improved utilization of maternal health services
• Reduced birth trauma and psychological distress
• Decreased maternal and neonatal morbidity/mortality
7. Challenges to RMC Implementation
• Overcrowding in facilities
• Shortage of trained staff
• Lack of privacy infrastructure
• Cultural insensitivity or provider bias
• Inadequate monitoring or supervisio
8. Strategies to Promote RMC
• Orientation and training of health staff on RMC protocols
• Use of RMC Charters and Posters in labor wards
• Accountability mechanisms (grievance redressal)
• Involving birth companions and family

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Possible Exam Questions

Two Marks
1. What is the full form of RMC?
2. Name any two principles of Respectful Maternity Care.
Five Marks
1. List the nurse's role in building partnership with women following RMC
protocol.
2. Write any five key principles of RMC.
Ten Marks
1. Define Respectful Maternity Care. How does a nurse build a partnership
with women following the RMC protocol?
2. Discuss the importance and challenges of implementing RMC in
maternity settings.
Fathers’ Engagement in Maternity Care
1. Introduction
• Fathers' engagement in maternity care refers to their active participation
throughout the pregnancy, childbirth, and postnatal period.
• It strengthens the family support system, improves maternal and
neonatal outcomes, and promotes shared responsibility in parenting.
2. Importance of Fathers’ Involvement
• Enhances emotional support to the pregnant woman
• Increases maternal satisfaction and comfort
• Encourages shared decision-making
• Supports birth preparedness and complication readiness
• Improves bonding between father and child
• Reduces maternal stress, depression, and anxiety
• Promotes exclusive breastfeeding and newborn care involvement
3. Areas of Involvement
A. During Pregnancy

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• Attending antenatal checkups with the partner

• Understanding physiological and emotional changes
• Supporting dietary and lifestyle modifications
• Encouraging rest, positivity, and routine care
• Learning about birth preparedness (transport, finances)
B. During Labor and Childbirth
• Serving as a birth companion (where permitted)
• Providing emotional reassurance and comfort
• Assisting with non-pharmacological pain relief
• Supporting informed decisions during labor
• Encouraging and advocating for respectful maternity care
C. Postpartum Period
• Participating in newborn care (bathing, diapering, holding)
• Supporting exclusive breastfeeding
• Helping the mother during postpartum recovery
• Recognizing and responding to postpartum depression
• Involvement in family planning decisions
4. Barriers to Fathers’ Participation
• Cultural norms and traditional gender roles
• Lack of awareness and sensitization
• Institutional policies that exclude men
• Unfriendly healthcare environment
• Time constraints due to work
• Shyness or fear of medical settings
5. Strategies to Encourage Father Involvement
• Educate both partners during antenatal visits
• Include fathers in prenatal counseling sessions

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• Display educational materials promoting paternal roles

• Allow fathers as birth companions
• Train healthcare workers to promote father-friendly care
• Involve men in community health programs
6. Role of the Nurse
• Encourage father's presence during antenatal visits
• Provide education about pregnancy, childbirth, and newborn care
• Promote emotional preparation for parenting
• Create a supportive environment for both parents
• Advocate for inclusive policies and infrastructure
• Facilitate communication between the couple and care providers
7. Benefits of Father Engagement
To the Mother To the Father To the Baby

Better emotional support Stronger bonding Healthy growth

Improved ANC/PNC Empowerment in

Timely immunization
attendance parenting

Awareness of maternal Better cognitive

Reduced complications
needs development
Possible Exam Questions
Two Marks
1. Mention two roles of the father during pregnancy.
2. List any two benefits of father engagement in maternity care.
Five Marks
1. Explain the nurse’s role in promoting father involvement during
pregnancy and childbirth.
2. List the barriers to father participation in maternity care and suggest
solutions.
Ten Marks

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1. Define father engagement in maternity care. Discuss its importance,

barriers, and nursing strategies to promote active participation of fathers
in maternity care.
Ante-Natal Care (ANC)
1. Introduction
• Antenatal care (ANC) is the systematic and regular supervision of a
pregnant woman from the time of conception until the onset of labor.
• It aims to ensure the health of both mother and fetus, detect high-risk
conditions, and prepare the mother for labor, delivery, and parenting.
2. Objectives of Antenatal Care
• Promote and maintain the health of the pregnant woman and her fetus
• Detect and manage high-risk pregnancies early
• Prevent complications such as anemia, pre-eclampsia, and infections
• Educate the mother about self-care, nutrition, hygiene, and birth
preparedness
• Encourage institutional delivery and postnatal follow-up
3. Components of Antenatal Care
A. Initial Assessment
• Detailed history: obstetric, medical, surgical, menstrual, family, and
personal history
• Physical examination: general and obstetric examination
• Laboratory investigations:
o Hemoglobin
o Blood group and Rh typing
o Urine (albumin, sugar)
o VDRL, HIV, HBsAg
o Blood sugar
o Ultrasound (if indicated)
B. Routine ANC Visits

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• Minimum 4 visits recommended (WHO and Government of India):

o 1st visit: Up to 12 weeks
o 2nd visit: Between 14–26 weeks
o 3rd visit: Between 28–34 weeks
o 4th visit: Between 36 weeks and term
Note: WHO now recommends 8 ANC contacts for better outcomes (new
model).
C. Monitoring During Each Visit
• Weight and blood pressure
• Abdominal examination
o Fundal height
o Fetal heart sound (FHS)
o Fetal movements
• Urine testing
• Checking for signs of complications (edema, headache, blurred vision,
bleeding)
4. Essential Services During ANC
• Iron and folic acid supplementation
o 60 mg iron + 500 mcg folic acid daily for at least 100 days
• Tetanus and diphtheria (Td) immunization
o 1st dose: Early in pregnancy
o 2nd dose: 4–8 weeks after the first
• Deworming with albendazole after the first trimester
• Calcium supplementation: 1 g/day from 14 weeks onwards
• Counseling and health education on:
o Danger signs of pregnancy
o Nutrition and rest
o Hygiene and personal care

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o Birth preparedness and complication readiness

o Breastfeeding and newborn care
5. Birth Preparedness and Complication Readiness
• Planning place of delivery (preferably institutional)
• Identifying transport and accompanying persons
• Saving money for emergencies
• Awareness of danger signs:
o Vaginal bleeding
o Severe headache or blurred vision
o Swelling of face/hands
o Decreased fetal movement
o Severe abdominal pain
o Leaking of amniotic fluid
6. Nurse's Role in Antenatal Care
• Provide routine ANC services and schedule follow-up visits
• Educate and counsel the mother and family
• Detect high-risk pregnancies and refer appropriately
• Maintain accurate ANC records
• Support emotional and mental well-being of the mother
• Promote institutional delivery and postnatal follow-up
7. Table: WHO Recommended Antenatal Visit Schedule (8 Contacts)
Contact Number Timing

1st Before 12 weeks

2nd 20 weeks

3rd 26 weeks

4th 30 weeks

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Contact Number Timing

5th 34 weeks

6th 36 weeks

7th 38 weeks

8th 40 weeks
8. Flowchart: Overview of ANC Process
1. Registration and Initial Assessment
2. Physical Examination + Labs
3. Regular Monitoring and Counseling
4. Birth Preparedness
5. Delivery Planning
6. Postnatal Follow-up Advic
Possible Exam Questions
Two Marks
1. Mention two objectives of antenatal care.
2. List any two danger signs in pregnancy.
Five Marks
1. Write the essential services given during antenatal care.
2. List the nurse’s responsibilities in antenatal care.
Ten Marks
1. Define antenatal care. Explain the components and importance of ANC.
2. Describe the antenatal assessment, care, and role of nurse in promoting
maternal health during pregnancy.
First Trimester of Pregnancy
1. Introduction
• The first trimester includes the first 12 weeks (1–3 months) of
pregnancy, starting from the first day of the last menstrual period
(LMP).
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• It is a critical period of embryonic development, organ formation

(organogenesis), and physiological changes in the mother.
2. Physiological and Hormonal Changes in the First Trimester
System Changes

Enlarged uterus, softening of cervix (Goodell’s sign), bluish

Reproductive
discoloration of cervix/vagina (Chadwick’s sign)

Hormonal Increased hCG, progesterone, estrogen, relaxin

Cardiovascular Slight ↑ in blood volume and cardiac output

Gastrointestinal Nausea, vomiting (due to hCG), altered taste, constipation

Urinary Increased frequency of urination due to pressure on bladder

Enlargement, tenderness, pigmentation of areola,

Breast
Montgomery’s tubercles
3. Developmental Changes in the Embryo/Fetus
Week Development

Week 4 Heart starts beating

Week 5–6 Limb buds appear, brain and spinal cord develop

Week 8 All major organs are formed (organogenesis complete)

Week 10 Fingernails, eyelids start forming

Week 12 Genitalia begin to differentiate, fetal movements begin (not felt yet)
4. Common Signs and Symptoms
• Missed period (amenorrhea)
• Morning sickness (nausea/vomiting)
• Frequent urination
• Fatigue and weakness
• Breast tenderness and enlargement
• Mood swings
• Mild abdominal cramping or bloating
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5. Common Discomforts and Their Management

Discomfort Cause Nursing Advice

Eat small, frequent meals; avoid spicy

Nausea/vomiting hCG levels
foods; ginger tea

Hormonal
Fatigue Rest adequately; avoid overexertion
changes

Frequent Avoid caffeine; ensure hydration; empty

Uterine pressure
urination bladder frequently

Progesterone High fiber diet; adequate fluids; light

Constipation
effect exercise

Hormonal
Breast tenderness Supportive bra; avoid caffeine
changes
6. Antenatal Care During First Trimester
• Confirm pregnancy through urine or blood test
• First antenatal visit ideally before 12 weeks
• Initial assessment: history, physical exam, baseline investigations
• Lab tests: Hb, blood group, HIV, HBsAg, VDRL, urine analysis, blood
sugar
• Ultrasound (6–8 weeks): to confirm gestational age and viability
• Counseling: diet, rest, personal hygiene, avoidance of harmful substances
• Iron and folic acid supplementation starts in 2nd month
• Td1 immunization after 12 weeks
7. Health Education for the First Trimester
• Importance of early registration and regular ANC visits
• Avoiding smoking, alcohol, self-medication
• Balanced nutrition with folic acid-rich foods
• Rest and stress reduction
• Personal hygiene and comfortable clothing

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• Identifying danger signs and when to seek help

8. Danger Signs in First Trimester
• Severe abdominal pain
• Vaginal bleeding or spotting
• High fever
• Persistent vomiting (hyperemesis gravidarum)
• Painful urination
• Foul-smelling vaginal discharge
9. Nurse’s Role During First Trimester
• Early identification of pregnancy and risk factors
• Provide health education and emotional support
• Encourage compliance with supplements and follow-ups
• Guide in managing common discomforts
• Refer in case of complications like ectopic pregnancy or threatened
abortion
10. Summary Table: First Trimester at a Glance
Aspect Key Details

Duration 0–12 weeks

Fetal focus Organogenesis

Mother’s changes Hormonal, GI, urinary, emotional

ANC Focus Early registration, baseline labs, supplements

Education Danger signs, hygiene, rest, diet

Possible Exam Questions
Two Marks
1. List any two discomforts in the first trimester.
2. Name two hormonal changes in the first trimester.
Five Marks

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1. Write the nursing care and advice for a woman in the first trimester of
pregnancy.
2. Describe common physiological changes during the first trimester.
Ten Marks
1. Describe the fetal development and maternal changes during the first
trimester. Discuss the antenatal care and nurse’s role.
Antenatal Assessment History Taking, Physical Examination, Breast
Examination, Laboratory Investigations
1. Introduction
• Antenatal assessment is the initial and ongoing evaluation of a pregnant
woman’s health to ensure safe pregnancy and delivery outcomes.
• It includes history taking, physical and obstetric examinations, breast
examination, and relevant laboratory investigations.
2. Objectives of Antenatal Assessment
• Confirm pregnancy and determine gestational age
• Identify high-risk pregnancies
• Establish a baseline for monitoring throughout pregnancy
• Detect and manage pre-existing or current health issues
• Promote maternal and fetal well-being through early interventions
3. History Taking
A. Personal History
• Name, age, address, religion, education, occupation
• Marital status, consanguinity
B. Obstetric History
• Gravida, para, abortion, living children (G-P-A-L)
• Details of previous pregnancies:
o Year, duration, type of delivery, complications, outcome
• Menstrual history:

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o Age at menarche, regularity, last menstrual period (LMP), expected

date of delivery (EDD)
C. Medical and Surgical History
• History of:
o Hypertension, diabetes, epilepsy, tuberculosis, asthma, etc.
o Previous surgeries (e.g., cesarean section, appendectomy)
D. Family History
• Hereditary diseases (e.g., thalassemia, diabetes)
• Multiple births
E. Psychosocial and Lifestyle History
• Domestic violence, support system
• Smoking, alcohol, drug abuse
4. Physical Examination
A. General Examination
• Height and weight
• Vital signs: Blood pressure, pulse, temperature, respiration
• Nutritional status
• Edema (especially feet and face)
• Pallor (anemia), jaundice, cyanosis
• Lymph nodes (especially cervical)
• Thyroid enlargement
• Skin changes (e.g., chloasma, linea nigra)
B. Systemic Examination
• Cardiovascular system: Heart sounds, murmurs
• Respiratory system: Breath sounds, respiratory rate
• Abdomen: For obstetric examination
• Musculoskeletal system: Spinal curvature (lordosis, scoliosis)
5. Obstetrical (Abdominal) Examination
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Performed after 16 weeks of gestation

Method Purpose

Inspection Observe abdominal size, shape, skin changes

Leopold’s maneuvers to assess fetal lie, presentation, and

Palpation
engagement

Fetal heart sound (FHS) heard using fetoscope/Doppler (after 20

Auscultation
weeks)

Fundal height in cm (correlates with weeks of gestation after 24

Measurement
weeks)
6. Breast Examination
• To assess readiness for breastfeeding and identify abnormalities
• Check:
o Size, symmetry, tenderness
o Nipples (inverted, cracked, or normal)
o Presence of lumps or discharge
o Montgomery tubercles (sebaceous glands)
• Provide advice on nipple care and hygiene
7. Laboratory Investigations (Baseline Tests)
Test Purpose

Hemoglobin (Hb%) Detect anemia

Blood group and Rh typing For transfusion need and Rh incompatibility

Blood sugar
Detect gestational diabetes
(Fasting/Random)

VDRL, HBsAg, HIV test Detect infections (syphilis, hepatitis B, HIV)

Check for albumin (preeclampsia) and sugar

Urine analysis
(diabetes)

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Test Purpose

Thyroid function test (if

Assess thyroid dysfunction
required)

Confirm gestational age, fetal viability, detect

Ultrasound scan (USG)
abnormalities
8. Nurse's Role in Antenatal Assessment
• Establish rapport and ensure privacy
• Collect accurate and complete history
• Perform physical and breast examination
• Identify and refer high-risk conditions
• Educate on diet, hygiene, rest, and warning signs
• Encourage regular antenatal check-ups and follow-up
9. Chart: Summary of Antenatal Assessment
Component Purpose

History Taking Understand personal, obstetric, medical background

Physical Exam Detect early signs of complications

Breast Exam Assess for breastfeeding readiness

Lab Tests Identify risks like anemia, infections, diabetes

Possible Exam Questions
Two Marks
1. List any two baseline investigations in ANC.
2. Mention two points assessed during breast examination.
Five Marks
1. Write the components of history taking in antenatal assessment.
2. Describe the physical examination done during antenatal visit.
Ten Marks

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1. Describe in detail the antenatal assessment including history,

examination, and investigations.
2. Discuss the nurse’s role during antenatal assessment.
Identification and Management of Minor Discomforts of Pregnancy
1. Introduction
• Minor discomforts are common physiological changes experienced
during pregnancy due to hormonal, anatomical, and circulatory
changes.
• These are not pathological, but can cause significant inconvenience if
not managed properly.
2. Minor Discomforts During Pregnancy (Trimester-Wise)
A. First Trimester (0–12 weeks)
Discomfort Cause Nursing Advice

Small frequent meals, avoid spicy

Nausea and vomiting Increased hCG
foods, dry toast before getting up,
(Morning sickness) hormone
ginger tea

Excessive salivation Hormonal Frequent mouthwash, chewing

(Ptyalism) changes gum

Increased
Rest, balanced diet, adequate
Fatigue metabolic
sleep
demand

Hormonal
Breast tenderness Supportive bra, avoid caffeine
stimulation

Pressure of Avoid caffeine, urinate frequently,

Frequent urination
uterus on bladder maintain hydration

Hormonal Reassurance, emotional support,

Mood swings/irritability
fluctuations counseling if severe
B. Second Trimester (13–28 weeks)

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Discomfort Cause Nursing Advice

Relaxed cardiac Avoid spicy/fatty foods,

Heartburn/Acidity sphincter, pressure on eat small meals, sit upright
stomach after eating

Progesterone slows GI High-fiber diet, plenty of

Constipation
motility fluids, mild exercise

Use proper posture, firm

Postural changes,
Backache mattress, local heat
ligament relaxation
application

Leg elevation, calf-

Circulatory stasis, low
Leg cramps stretching exercises,
calcium
calcium intake

Avoid sudden position

Hypoglycemia or
Fainting/Dizziness changes, eat small frequent
postural hypotension
meals

Pigmentation of skin Estrogen and Reassurance, avoid sun

(chloasma, linea nigra) progesterone effects exposure
C. Third Trimester (29 weeks to term)
Discomfort Cause Nursing Advice

Dyspnea (Shortness Enlarged uterus presses Sleep in propped-up position,

of breath) on diaphragm avoid tight clothes

Pressure on pelvic Leg elevation, avoid standing

Ankle edema
veins, fluid retention long periods, avoid tight shoes

Anxiety, physical Relaxation techniques, warm

Insomnia
discomfort milk before bed

Increased venous Leg elevation, avoid standing

Varicose veins
pressure for long, support stockings

Stretch marks (Striae Gentle massage with

Skin stretching
gravidarum) oil/cream, reassurance

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Discomfort Cause Nursing Advice

Frequency of Fetal head pressing Avoid fluids before bedtime,

micturition (again) bladder empty bladder completely

Constipation, pelvic High-fiber diet, sitz bath, local

Hemorrhoids (Piles)
pressure creams as advised
3. General Nursing Management
• Provide reassurance and explain the physiological basis
• Promote healthy lifestyle and diet
• Encourage antenatal exercises
• Maintain personal hygiene
• Monitor for any danger signs that may suggest complications
• Refer to physician if discomforts are severe or persistent
4. Preventive Measures
• Early antenatal registration
• Balanced diet and adequate hydration
• Comfortable clothing and footwear
• Regular antenatal exercises (with advice)
• Emotional support and counseling
5. Chart: Summary of Common Minor Ailments and Advice
Discomfort Common Trimester Key Advice

Nausea 1st Small meals, ginger tea

Heartburn 2nd–3rd Avoid spicy food, upright after meals

Backache 2nd–3rd Good posture, firm mattress

Edema 3rd Leg elevation, avoid standing

Constipation All Fiber-rich diet, fluids

Cramps 2nd–3rd Calcium, exercise

Possible Exam Questions

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Two Marks
1. List two minor ailments of pregnancy seen in the first trimester.
2. Mention any two nursing advices to manage constipation during
pregnancy.
Five Marks
1. Write nursing management for any four minor discomforts during
pregnancy.
2. Describe the common causes and nursing advice for heartburn and
backache in pregnancy.
Ten Marks
1. Describe trimester-wise minor discomforts of pregnancy and explain their
nursing management in detail.
Antenatal Care as per Government of India (GoI) Guidelines
1. Introduction
• Antenatal Care (ANC) is the care provided to a pregnant woman to
ensure a healthy pregnancy, safe childbirth, and a healthy baby.
• The Government of India (GoI), under its RMNCH+A strategy, has
laid down specific ANC guidelines to ensure quality maternal and child
health services, particularly through Janani Suraksha Yojana (JSY),
Janani Shishu Suraksha Karyakram (JSSK), and Pradhan Mantri
Surakshit Matritva Abhiyan (PMSMA).
2. Objectives of ANC under GoI
• Early registration of pregnancy
• Ensure at least four ANC check-ups
• Detect and manage high-risk pregnancies
• Provide essential maternal and fetal care
• Promote institutional delivery
• Educate on birth preparedness and complication readiness
3. Recommended Schedule of Antenatal Visits

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Visit Timing (Gestational

Activity
No. Age)

1st Visit Within 12 weeks Early registration, baseline assessment

2nd
Between 14–26 weeks Screening for anemia, gestational diabetes
Visit

3rd Visit Between 28–34 weeks Fetal growth monitoring, BP, urine protein

Between 36 weeks and Birth preparedness and danger sign

4th Visit
term counseling
Note: High-risk pregnancies may require more frequent visits.
4. Key Components of ANC under GoI
A. Early Registration
• Should be done as early as possible, preferably before 12 weeks of
gestation.
• Maintain Mother and Child Protection (MCP) Card.
B. Antenatal Check-ups
At each visit, the following are done:
• Weight measurement
• Blood pressure (BP)
• Hemoglobin estimation
• Fetal heart sound (FHS) monitoring
• Abdominal examination
• Urine test (albumin/sugar)
C. Essential Investigations
• Hemoglobin
• Blood group and Rh typing
• HIV, HBsAg, VDRL
• Blood sugar (fasting/random)
• Urine routine and microscopy

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• Thyroid function (if needed)

• Ultrasound (as per trimester schedule)
D. Immunization
• Tetanus & Diphtheria (Td) vaccine:
o Td-1: Early in pregnancy
o Td-2: At least 4 weeks after Td-1
o Booster if completed in last 3 years
E. Iron and Folic Acid (IFA) Supplementation
• 100 tablets of 60 mg elemental iron + 500 mcg folic acid from 14
weeks of gestation
• If anemic, double dose (200 mg iron/day)
• Continue postnatally for 6 months
F. Calcium Supplementation
• 500 mg calcium + 250 IU Vitamin D3, twice daily for 6 months (from
second trimester onward)
G. Deworming
• Albendazole 400 mg once orally after first trimester (after 12 weeks),
especially in endemic areas
H. Counseling and Education
• Nutrition
• Personal hygiene
• Rest and sleep
• Danger signs
• Birth preparedness and emergency readiness
• Breastfeeding and postnatal care
• Family planning
5. Pradhan Mantri Surakshit Matritva Abhiyan (PMSMA)
• Launched in 2016

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• Provides free ANC services on 9th of every month at public health

facilities
• Targets pregnant women between 2nd and 3rd trimesters
• Focus:
o Detecting high-risk pregnancies
o Ensuring availability of specialists
o Ensuring minimum package of services
6. Danger Signs in Pregnancy (To be informed to mother)
• Bleeding per vagina
• Severe headache, blurring of vision
• Swelling of face and hands
• Decreased fetal movements
• Convulsions
• Leakage of amniotic fluid
• Persistent vomiting
• High fever
7. Government Schemes Supporting ANC
Scheme Benefit

JSY (Janani Suraksha

Financial incentive for institutional delivery
Yojana)

JSSK (Janani Shishu Free transport, drugs, diagnostics, blood, and

Suraksha Karyakram) diet during pregnancy and postnatal care

Free ANC check-up on 9th of every month by

PMSMA
specialists

PMMVY (Pradhan Mantri Rs. 5000 financial incentive in installments

Matru Vandana Yojana) for ANC, delivery, and immunization
8. Nurse’s Role in ANC as per GoI
• Early identification and registration

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• Educating mothers on diet, rest, hygiene

• Administering IFA, calcium, vaccines
• Monitoring and documenting vital parameters
• Referral of high-risk cases
• Educating about schemes and entitlements
• Supporting PMSMA services
• Ensuring counseling and family involvement
Possible Exam Questions
Two Marks
1. Mention two components of antenatal care as per GoI guidelines.
2. Name any two government schemes supporting antenatal care in India.
Five Marks
1. List the essential components of antenatal care as per GoI guidelines.
2. Describe the nurse’s role in providing ANC according to Government of
India.
Ten Marks
1. Write in detail the antenatal care as per Government of India guidelines.
Include services, supplements, and nurse’s responsibilities.
2. Discuss the objectives, schedule, and components of antenatal care under
the PMSMA initiative.
Antenatal Counseling
1. Introduction
• Antenatal counseling is an essential part of antenatal care, focused on
educating and supporting pregnant women (and their families) regarding
physical, emotional, social, and behavioral changes during pregnancy.
• It aims to promote safe motherhood, informed decision-making, and
healthy behaviors to ensure favorable outcomes for both mother and
baby.
2. Objectives of Antenatal Counseling
• Improve knowledge and awareness about pregnancy-related changes
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• Encourage healthy lifestyle habits

• Help in risk recognition and timely decision-making
• Build confidence in the woman for labor, delivery, and parenting
• Strengthen family support and partner involvement
3. Key Components of Antenatal Counseling
A. Lifestyle Modifications
• Encourage adequate rest and sleep
• Advise light-to-moderate physical activity, such as walking or prenatal
yoga, unless contraindicated
• Avoid exposure to radiation, toxic chemicals, smoke, and pollution
• Promote good personal hygiene and dental care
• Counsel on maintaining a regular daily routine
B. Nutritional Counseling
Focus Area Advice

Balanced Diet Include carbohydrates, proteins, fats, vitamins, and minerals

Start from 2nd trimester; promotes RBC production and

Iron & Folic Acid
prevents neural tube defects

Calcium & Support fetal bone development and prevent maternal

Vitamin D osteoporosis

Fluids 8–10 glasses of water daily

Raw meat, unpasteurized milk, excessive caffeine, artificial

Avoid
sweeteners, junk foods
• Small frequent meals advised if nausea is present
• Prevent excessive weight gain or undernutrition
C. Avoidance of Risky Behaviors
• Strictly advise against tobacco, alcohol, and drug use
• Educate about risks of self-medication and the importance of prescribed
drugs

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• Caution about exposure to infectious diseases (e.g., rubella,

toxoplasmosis)
D. Sexual Life During Pregnancy
• Safe in uncomplicated pregnancies, especially in the second trimester
• Counsel about:
o Avoiding sex in high-risk pregnancies (placenta previa,
threatened abortion, preterm labor, vaginal bleeding)
o Using comfortable positions to avoid pressure on the abdomen
• Reassure about emotional and hormonal changes affecting desire
E. Immunization
Vaccine Timing

Tetanus and Diphtheria (Td) 2 doses (Td1 early, Td2 after 4 weeks)

Influenza (if advised) During flu season

COVID-19 (as per policy) Safe during pregnancy

• Educate on importance of vaccine protection for mother and fetus
• Explain that live vaccines (e.g., rubella, varicella) are contraindicated
during pregnancy
F. Shared Decision-Making
• Involve the pregnant woman (and family) in:
o Choice of birth setting (hospital, birthing center)
o Mode of delivery (if options are available)
o Pain relief measures during labor
o Feeding choices (breastfeeding promotion)
o Emergency planning
• Use clear, simple language to ensure understanding
• Respect cultural and individual preferences
G. Birth Preparedness and Complication Readiness
• Educate about danger signs in pregnancy

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• Encourage creation of:

o Birth plan
o Emergency transport plan
o Financial planning for delivery
o Identification of a birth companion
4. Nurse’s Role in Antenatal Counseling
• Establish trust and effective communication
• Provide individualized, non-judgmental counseling
• Use visual aids, models, flipcharts, and leaflets
• Encourage partner and family involvement
• Clarify doubts, reinforce messages at each ANC visit
• Document counseling sessions and feedback
5. Chart: Summary of Antenatal Counseling Areas
Counseling Area Key Points

Lifestyle Rest, hygiene, avoid harmful exposure

Nutrition Balanced diet, iron, calcium

Behavior Avoid tobacco, alcohol, self-medication

Sexuality Safe if no complications, advise precautions

Immunization Td, Influenza, COVID (as per guidelines)

Decision-making Birth planning, preferences, readiness

Danger signs Bleeding, severe headache, swelling, fever

Possible Exam Questions
Two Marks
1. List any two components of antenatal counseling.
2. Mention two foods to avoid during pregnancy.
Five Marks

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1. Describe the nutritional advice given to a pregnant woman.

2. Write the role of a nurse in antenatal counseling.
Ten Marks
1. Discuss in detail the areas covered under antenatal counseling and the
role of nurses.
2. Write a comprehensive note on antenatal counseling with emphasis on
lifestyle, nutrition, and risky behaviors.
Danger Signs During Pregnancy
1. Introduction
• Pregnancy is a physiological process, but complications may arise
unexpectedly.
• Danger signs are warning symptoms that indicate the possibility of a
serious complication.
• Early identification and prompt action can prevent maternal and fetal
morbidity or mortality.
2. Importance of Recognizing Danger Signs
• Helps in early referral and treatment
• Reduces risk of maternal and neonatal death
• Improves outcome of high-risk pregnancies
• Encourages timely ANC visits and preparedness
3. List of Danger Signs During Pregnancy
Danger Sign Possible Indication

Threatened abortion, placenta previa,

Vaginal bleeding
abruptio placentae

Ectopic pregnancy, abruption, uterine

Severe abdominal pain
rupture

Pregnancy-induced hypertension (PIH),

Severe headache
preeclampsia

Blurred vision or seeing spots Preeclampsia or eclampsia

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Danger Sign Possible Indication

Swelling of face and hands Preeclampsia

Infection (e.g., UTI, malaria,

High-grade fever with chills
septicemia)

Painful urination or decreased urine Urinary tract infection, dehydration,

output renal issues

Persistent vomiting (Hyperemesis Risk of dehydration, electrolyte

gravidarum) imbalance

Leaking of fluid per vagina (before Premature rupture of membranes

labor) (PROM)

Convulsions or loss of consciousness Eclampsia, epilepsy

Absence or decrease in fetal

Fetal distress or intrauterine death
movements

Anemia, cardiac disorder, pulmonary

Breathlessness or chest pain
embolism

Pale complexion/extreme fatigue Severe anemia

4. Nurse’s Role in Managing Danger Signs
• Educate all pregnant women and their families during ANC visits about
recognizing danger signs
• Encourage immediate reporting to the nearest health facility if any
danger sign occurs
• Monitor for signs at each antenatal check-up
• Maintain emergency contact numbers and facilitate transport planning
• Refer high-risk cases without delay
• Provide emotional support and reassurance
• Document all findings and actions taken
5. Counseling Points for Pregnant Women
• Attend all scheduled ANC visits
• Keep the Mother and Child Protection (MCP) card updated
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• Have a birth preparedness and emergency plan (BPEP)

• Identify a birth companion and transport arrangements
• Know the nearest health facility with delivery services
6. Chart: Summary of Danger Signs
Symptom Suspected Cause

Vaginal bleeding Abortion, placenta previa

Severe headache & blurred vision PIH/preeclampsia

Swelling of face/hands Preeclampsia

No fetal movement Fetal death/distress

Fever/chills Infection

Fluid leakage PROM

Seizures Eclampsia
Possible Exam Questions
Two Marks
1. List any two danger signs during pregnancy.
2. What is the meaning of PROM?
Five Marks
1. Write a short note on the role of a nurse in educating about danger signs.
2. Describe any five danger signs and their possible causes.
Ten Marks
1. Explain the danger signs of pregnancy in detail and discuss the nurse’s
responsibility in managing them.
2. Discuss the importance of early identification of danger signs and actions
to be taken by a nurse.
Respectful Care and Compassionate Communication
1. Introduction

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• Respectful maternity care (RMC) refers to care that maintains a

woman’s dignity, privacy, and confidentiality, ensures freedom from harm
and mistreatment, and enables informed choice and continuous support
during childbirth.
• Compassionate communication involves empathetic, sensitive, and
patient-centered interaction between healthcare providers and pregnant
women.
2. Objectives of Respectful and Compassionate Care
• Promote positive birth experience
• Enhance maternal satisfaction and compliance
• Reduce fear, anxiety, and stigma
• Improve trust between healthcare providers and mothers
• Ensure human rights of childbearing women
3. Principles of Respectful Maternity Care
Principle Description

Treat every woman with courtesy regardless of

Dignity and respect
background

Privacy and
Maintain personal and medical privacy
confidentiality

Informed consent and Respect her right to receive information and make
choice decisions

Equal care to all regardless of caste, religion,

Non-discrimination
socioeconomic status

Freedom from abuse and

No physical, verbal, or emotional abuse
harm

Supportive care Allow birth companions, encourage involvement

Continuity of care Ensure proper follow-up and timely interventions

4. Components of Compassionate Communication

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Component Description

Active Listening Focus on the woman's concerns without interrupting

Empathy Understand her feelings and emotions

Clarity Use simple, non-technical language

Maintain eye contact, gentle touch, appropriate body

Non-verbal cues
language

Cultural
Respect beliefs, practices, and preferences
sensitivity

Encouragement Give positive feedback and assurance

Respectful tone Avoid rude or commanding voice

5. Nurse’s Role in Providing Respectful Care
• Greet the woman by her name, with a smile and warmth
• Provide privacy during examinations (use curtains/screens)
• Explain procedures before doing them
• Obtain informed consent and answer questions patiently
• Allow a birth companion if the woman desires (as per GoI guidelines)
• Reassure and provide emotional support
• Avoid harsh, discriminatory, or disrespectful behavior
• Maintain confidentiality of all records and discussions
• Educate and empower women about their rights and choices
6. Strategies to Promote Respectful Care at Facility Level
• Training staff on RMC principles
• Displaying patient rights posters in local language
• Grievance redressal systems
• Encouraging feedback from mothers
• Supportive supervision by senior staff
• Incorporating RMC into standard operating procedures

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7. Government of India Initiatives

• LaQshya Program: Launched by the MoHFW to improve quality of care
in labor rooms and maternity OTs, emphasizing respectful and dignified
care.
• PMSMA (Pradhan Mantri Surakshit Matritva Abhiyan) promotes
inclusion, empathy, and respectful behavior during ANC visits.
Possible Outcome Questions
Two Marks
1. Define respectful maternity care.
2. Mention two elements of compassionate communication.
Five Marks
1. Describe the nurse’s role in ensuring respectful and compassionate care.
2. Explain any five components of respectful maternity care.
Ten Marks
1. Discuss the principles of respectful maternity care and describe the
importance of compassionate communication during antenatal and
intranatal periods.
2. Write the responsibilities of nurses in promoting RMC and how it affects
maternal outcomes.
Recording and reporting as per the Government of India (GoI) Guidelines
1. Introduction
• Accurate recording and reporting are essential components of maternal
and child health services.
• It ensures continuity of care, supports monitoring and evaluation, aids
in decision-making, and is crucial for legal and medico-legal purposes.
• The Government of India (GoI) provides standard guidelines and tools
for maternal health documentation, particularly under RMNCH+A, JSY,
JSSK, and PMSMA programs.
2. Objectives of Recording and Reporting
• Ensure proper documentation of maternal and fetal health status
• Track progress of pregnancy, labor, delivery, and postnatal care
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• Enable early identification of high-risk pregnancies

• Support effective referral and follow-up
• Provide data for public health planning and resource allocation
• Facilitate monitoring of services and program implementation
3. Key Registers and Forms Used in Maternal Health
Tool/Record Purpose

Mother and Child Comprehensive record of ANC, delivery, PNC,

Protection (MCP) Card immunization, growth monitoring

Records all antenatal visits, investigations, and

ANC Register
findings

High-Risk Pregnancy For tracking and follow-up of women with

Register complications

Details of labor, mode of delivery, outcome,

Delivery Register
complications

Records PNC visits, maternal and neonatal

Postnatal Register
condition

JSY Beneficiary Register Records beneficiaries of JSY scheme

Maintains data for services provided on 9th of

PMSMA Register
every month

Maintains referral details with reasons and

Referral Register
outcomes

Stillbirth and Maternal Used for auditing and reporting adverse

Death Audit Forms outcomes

Records TT/TD doses and child immunization

Immunization Card
schedule
4. Essential Information to be Recorded
A. Antenatal Period
• Personal identification details
• LMP, EDD

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• Blood pressure, weight, hemoglobin

• Obstetric and medical history
• Lab investigations (Hb, HIV, VDRL, HBsAg, urine)
• IFA and calcium supplementation
• Danger signs and referrals
• Immunization status
• Counseling provided
B. Intranatal Period
• Onset and duration of labor
• Fetal heart rate monitoring
• Mode of delivery
• Condition of mother and baby
• Use of partograph
• Any complications and interventions
• Birth weight, Apgar score
• Placental examination (if done)
C. Postnatal Period
• Mother’s general condition
• Uterine involution, lochia, breastfeeding
• Neonatal assessment
• IFA continuation
• Family planning counseling
• PNC visits (at least 3 recommended: within 48 hours, 7–14 days, and 6
weeks)
5. Guidelines for Documentation as per GoI
• Use standardized formats issued by the Ministry of Health and Family
Welfare
• Ensure completeness, legibility, and accuracy of information

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• Timely entries—avoid retrospective recording

• Use black or blue ink only; overwriting or white ink not allowed
• Maintain confidentiality of personal health data
• Store records as per facility protocols—minimum 3–5 years or more as
per state law
6. Reporting Protocols
Level Report Submitted To Frequency

Sub-center PHC MO or ANM Supervisor Weekly/Monthly

PHC/CHC District Health Office Monthly

District State RMNCH+A Cell Quarterly/Annually

Ministry of Health & Family Welfare Annually / as

State
(MoHFW) needed
Common reports include:
• Monthly Maternal and Child Health Report
• JSY payment status report
• Maternal Death Review (MDR) reports
• PMSMA service delivery reports
7. Role of Nurse in Recording and Reporting
• Maintain accurate records during ANC, delivery, and PNC
• Ensure all government registers and cards are updated
• Identify and report high-risk pregnancies promptly
• Record and follow up on referrals and complications
• Participate in data compilation and audits (e.g., MDR)
• Educate patients on the importance of record keeping
• Submit timely reports to appropriate authorities
8. Common Errors to Avoid
• Incomplete entries

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• Incorrect or missing dates (LMP, EDD)

• Delayed or retrospective entries
• Not recording vital signs or follow-up visits
• Poor handwriting or use of local terms/slangs
• Not recording counseling and informed consent
Possible Exam Questions
Two Marks
1. Name any two registers used for maternal care under GoI guidelines.
2. What is the purpose of the MCP card?
Five Marks
1. Write a short note on the importance of recording and reporting in
maternal care.
2. Mention the nurse’s role in maintaining maternal health records.
Ten Marks
1. Describe the different types of records and reports used in antenatal,
intranatal, and postnatal care as per GoI guidelines.
2. Explain the significance of proper documentation in maternal health and
outline the role of the nurse in the same.
Role of Doula / ASHAs (Accredited Social Health Activists)
1. Introduction
• A Doula and an ASHA (Accredited Social Health Activist) both play
supportive roles during pregnancy, childbirth, and the postnatal period.
• While Doulas are trained companions providing emotional and physical
support during childbirth, ASHAs are community-based workers
appointed under the National Health Mission (NHM) by the
Government of India to promote access to healthcare in rural areas.
2. Who is a Doula?
• A Doula is a trained, non-medical professional who provides continuous
physical, emotional, and informational support to a woman before,
during, and shortly after childbirth.

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• Doulas are not involved in clinical decision-making or medical

interventions but work alongside healthcare teams.
Role of a Doula
Phase Support Provided

Emotional reassurance, information about pregnancy and birth

Antenatal
plans

Presence during labor for pain relief support (massage, breathing),

Intranatal
continuous encouragement

Breastfeeding assistance, newborn care support, emotional

Postnatal
counseling
• Help reduce anxiety and fear, promote normal birth, and improve birth
satisfaction
• Encourage birth partner involvement
• Act as a communication bridge between the woman and care providers
3. Who is an ASHA?
• ASHAs are local female health volunteers selected from the community
under NRHM (now NHM).
• Each ASHA covers a population of ~1000 in rural areas.
• They act as a link between the community and public health system.
Key Roles and Responsibilities of ASHA in Maternal and Child Health
Area Responsibilities

Antenatal
• Motivate women to register for ANC
• Promote at least 4 ANC check-ups
• Distribute IFA and calcium tablets
• Help in early identification of danger signs
• Support immunization of pregnant women |
| Intranatal |

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• Ensure institutional delivery by escorting the woman to health facility

• Assist in birth preparedness and complication readiness
• Promote safe delivery practices and birth companion support |
| Postnatal |
• Ensure early PNC check-up
• Support in newborn care practices (exclusive breastfeeding, warmth)
• Track immunization schedule
• Create awareness on family planning and postpartum contraception |
| General |
• Maintain health records of pregnant women and children
• Mobilize community for health days (VHND)
• Provide health education and behavior change communication
• Help implement government programs like JSY, PMSMA, JSSK |
4. Incentive-based Tasks for ASHAs
ASHAs receive performance-based incentives for:
• ANC registration
• Institutional delivery (JSY assistance)
• PNC follow-up
• Ensuring full immunization
• Family planning acceptance
• Health promotion activities
5. Difference Between Doula and ASHA
Criteria Doula ASHA

Emotional & physical support

Role Community health facilitator
during childbirth

Government-appointed health
Nature Private, non-clinical professional
worker

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Criteria Doula ASHA

Non-medical childbirth support

Training NRHM/NHM structured training
training

Area of Hospitals, birthing centers, home

Rural and tribal community areas
Work births

Public health promotion and

Focus Woman-centered birth support
linkage to services
6. Nurse’s Collaboration with ASHA and Doula
• Train and guide ASHA workers on maternal health issues
• Provide feedback and supervision for service quality
• Recognize the importance of Doulas in woman-friendly birthing
• Coordinate referrals and ensure proper documentation
• Respect and encourage community involvement and support
Possible Exam Questions
Two Marks
1. Who is an ASHA worker?
2. Mention any two roles of a Doula during childbirth.
Five Marks
1. Write the role of ASHA in maternal and child healthcare.
2. List any five responsibilities of a Doula during the antenatal and
intranatal period.
Ten Marks
1. Compare and contrast the role of Doula and ASHA in maternal care.
2. Discuss in detail the responsibilities of ASHA in the antenatal, intranatal,
and postnatal periods.
II Trimester of Pregnancy (Second Trimester)
1. Duration
• The second trimester of pregnancy extends from week 13 to week 28 of
gestation.

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• Often referred to as the "golden period" of pregnancy due to reduced

nausea and increased energy levels.
2. Maternal Physiological Changes
System Changes

Rapid growth of uterus, fundus rises above the symphysis

Uterus
pubis

Increase in blood volume and cardiac output, slight decrease

Cardiovascular
in BP

Respiratory Tidal volume increases, mild breathlessness

Gastrointestinal Decreased motility, constipation, heartburn

Musculoskeletal Back pain due to stretching ligaments, postural changes

Hyperpigmentation (chloasma, linea nigra), stretch marks

Skin
(striae gravidarum)

Placenta takes over hormone production (estrogen,

Endocrine
progesterone)

Urinary Increased kidney filtration rate, occasional urinary frequency

3. Fetal Development in Second Trimester
• Week 13–16: Sex of the baby can be identified; lanugo begins to form.
• Week 17–20: Mother may feel first fetal movements (quickening); vernix
caseosa appears.
• Week 21–24: Eyelashes and eyebrows develop; fetus begins to respond to
sound.
• Week 25–28: Lungs begin to develop surfactant; fetus gains weight.
4. Antenatal Care in Second Trimester
• Routine ANC visits every 4 weeks
• Monitoring of:
o Blood pressure
o Weight gain

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o Fetal heart rate (FHR)

o Fundal height
• Lab investigations:
o Hemoglobin (Hb)
o Blood sugar (GTT or GCT)
o Urine (protein, sugar)
o Repeat blood grouping and Rh typing if not done
• Ultrasound at 18–22 weeks (anomaly scan)
• Administer Td2 injection if not given in first trimester
• Reinforce:
o Iron-folic acid (IFA) supplementation
o Calcium tablets
o Nutritional advice
o Warning signs (e.g., bleeding, leaking, reduced fetal movements)
5. Common Complaints and Nursing Advice
Complaint Nursing Advice

Backache Use of proper posture, warm compress, light exercise

Constipation High-fiber diet, increased fluids

Leg cramps Gentle stretching, calcium/magnesium supplements

Varicose veins Elevate legs, avoid prolonged standing

Heartburn Small frequent meals, avoid spicy food

Mild edema Rest, avoid tight clothing

6. Health Education Points
• Importance of continued ANC visits
• Recognition of quickening (fetal movements)
• Dietary needs: protein, iron, calcium

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• Rest and sleep

• Maintain personal hygiene
• Avoid smoking, alcohol, over-the-counter drugs
• Prepare for birth planning and institutional delivery
7. Nurse’s Role
• Assess maternal and fetal well-being at each visit
• Monitor fetal movements and growth
• Screen for gestational diabetes, anemia, and PIH
• Provide emotional support
• Educate on normal and abnormal symptoms
• Ensure compliance with supplements and immunizations
• Encourage birth preparedness and complication readiness
Possible Outcome Questions
Two Marks
1. What is the duration of the second trimester?
2. Mention any two physiological changes during the second trimester.
Five Marks
1. List the fetal developments occurring during the second trimester.
2. What are the common discomforts of the second trimester and their
management?
Ten Marks
1. Describe the antenatal assessment, fetal development, and nursing
management during the second trimester of pregnancy.
2. Explain the nurse’s role in caring for a woman in her second trimester.
Antenatal Assessment – Abdominal Palpation, Fetal Assessment, Auscultation
of Fetal Heart Rate (FHR)
1. Introduction
Antenatal assessment is a routine clinical evaluation of both mother and fetus
during pregnancy to ensure their well-being. Key components include
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abdominal palpation, fetal assessment, and auscultation of fetal heart rate

(FHR) using Doppler and Pinard’s stethoscope.
2. Objectives of Antenatal Assessment
• To assess fetal growth and development
• To detect deviations from normal pregnancy
• To monitor the position, presentation, and lie of the fetus
• To ensure fetal well-being through heart rate monitoring
• To plan for appropriate interventions if needed
3. Abdominal Palpation (Leopold’s Maneuvers)
Performed after 20 weeks gestation to assess the fetal position, lie, and
presentation.
Preparation
• Ask the mother to empty her bladder
• Ensure privacy and explain the procedure
• Position the mother in a semi-recumbent position with knees slightly
flexed
• Use warm hands for comfort
Steps of Leopold's Maneuvers
Maneuver Purpose

1st Maneuver (Fundal Identify which fetal pole (head or breech) is in the
Grip) fundus

2nd Maneuver (Lateral

Locate the fetal back and limbs (for fetal lie)
Grip)

3rd Maneuver (Pelvic

Determine the presenting part in the lower uterus
Grip)

4th Maneuver (Pawlik’s Confirm engagement of the presenting part in the

Grip) pelvis
Findings
• Lie: Longitudinal, transverse, or oblique

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• Presentation: Cephalic (head), breech (buttocks), shoulder

• Position: Relation of fetal back to mother’s side
• Engagement: Descent of fetal head into pelvis
4. Fetal Assessment
A. Fetal Growth and Movements
• Symphysis fundal height (SFH) measured in cm (after 20 weeks =
roughly same as weeks of gestation)
• Abdominal girth helps monitor fetal size
• Fetal movements (quickening) felt by the mother after 18–20 weeks
o Normal: At least 10 movements in 12 hours
B. Fetal Presentation & Position
• Assessed by palpation (Leopold's maneuvers)
• Helps prepare for type of delivery (normal vaginal or C-section)
5. Auscultation of Fetal Heart Rate (FHR)
Fetal heart sounds (FHS) are a key indicator of fetal well-being.
A. Tools Used
1. Pinard’s Stethoscope
o Traditional method
o Requires skill; best heard after 24 weeks
2. Doppler Ultrasound Device
o Modern, electronic device
o Can detect FHR as early as 10–12 weeks
o More sensitive and easier to use
B. Normal Fetal Heart Rate
• Ranges between 110–160 beats per minute (bpm)
C. Procedure
• Locate fetal back (best place to hear FHR)
• Count for 1 full minute
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• Note rate, rhythm, and regularity

6. Interpretation of FHR
Finding Interpretation

110–160 bpm Normal

<110 bpm (Bradycardia) Possible fetal distress

>160 bpm (Tachycardia) May indicate infection, distress, or maternal fever

Irregular rhythm May indicate cardiac anomalies or distress

7. Nurse's Responsibilities
• Perform abdominal palpation skillfully and gently
• Accurately locate fetal heart using Doppler or Pinard's
• Record and interpret FHR findings
• Educate the mother about fetal movements
• Identify danger signs and report abnormal findings
• Maintain documentation in ANC register and MCP card
• Provide emotional support and health education
Possible Outcome Questions
Two Marks
1. What is the normal fetal heart rate range?
2. Name the instrument used for auscultating fetal heart sounds traditionally.
Five Marks
1. List the four Leopold’s maneuvers and their purpose.
2. Explain the use of Doppler and Pinard’s stethoscope for assessing fetal
heart rate.
Ten Marks
1. Describe the procedure and interpretation of abdominal palpation and
fetal heart rate assessment.
2. Discuss the role of a nurse in antenatal assessment with reference to fetal
position, presentation, and well-being.
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Assessment of Fetal Well-Being

1. Introduction
Assessment of fetal well-being helps to evaluate the health status of the fetus,
identify any risk of hypoxia, and guide decisions for safe maternal and fetal
outcomes. It is especially important in high-risk pregnancies.
2. Methods of Fetal Well-Being Assessment
I. Daily Fetal Movement Count (DFMC)
• Simple, non-invasive method used from 28 weeks onward
• Mother counts fetal movements over a specific time daily
Instructions
• Count in a quiet environment after food
• Lie in left lateral position
• Count until 10 movements are felt
Normal
• 10 or more movements in 12 hours
• <3 movements in 1 hour = requires immediate evaluation
II. Biophysical Profile (BPP)
• Combines ultrasound and fetal heart monitoring
• Total score: 10 points based on 5 parameters
Component Score (2 = normal, 0 = abnormal)

Fetal breathing movements ≥1 episode of ≥30 seconds in 30 minutes

Gross body movements ≥3 discrete movements

Fetal tone ≥1 episode of extension with return to flexion

Amniotic fluid volume ≥1 pocket of fluid ≥2 cm

Reactive Non-Stress Test (NST) 2 or more accelerations in 20 minutes

Interpretation
• 8–10: Normal

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• 6: Equivocal – repeat
• <4: Abnormal – may require delivery
III. Non-Stress Test (NST)
• FHR response to fetal movement is assessed
• Performed using cardiotocography (CTG) machine
Procedure
• Mother in semi-recumbent or left lateral position
• FHR monitored for 20–40 minutes
Interpretation
Result Features

Reactive NST (Normal) ≥2 accelerations (≥15 bpm for ≥15 sec) in 20 mins

Non-reactive NST <2 accelerations or absent variability

IV. Cardiotocography (CTG)

• Simultaneous recording of:
o Fetal heart rate (FHR)
o Uterine contractions
Purpose
• Monitors fetal distress during antenatal or intranatal period
Components Monitored
• Baseline FHR
• Variability (normal = 5–25 bpm)
• Accelerations and decelerations
• Contractions frequency, duration
V. Ultrasound (USG)
• Widely used in all trimesters for fetal monitoring
Uses in Fetal Well-being

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• Determine gestational age and growth

• Assess amniotic fluid index (AFI)
• Evaluate placental location and grading
• Detect congenital anomalies
• Measure fetal biometry (BPD, FL, HC, AC)
VI. Vibroacoustic Stimulation Test (VAST)
• Uses sound stimulus to elicit fetal heart rate accelerations
Procedure
• Sound applied to maternal abdomen near fetal head for 1–3 seconds
• Positive response: accelerations of ≥15 bpm lasting ≥15 seconds
VII. Biochemical Tests
Test Purpose

High in neural tube defects, low in

Alpha-fetoprotein (AFP)
Down’s syndrome

β-hCG, Estriol, Inhibin-A

Screen for chromosomal abnormalities
(Triple/Quad test)

Amniocentesis For karyotyping, genetic testing

Lecithin/Sphingomyelin (L/S) ratio Assess fetal lung maturity

Fetal fibronectin (fFN) Predict risk of preterm labor

3. Nurse’s Role in Fetal Monitoring
• Educate the mother about DFMC
• Prepare the mother for NST, BPP, or USG
• Monitor maternal vitals before and after the test
• Ensure proper positioning during NST/CTG
• Assist the doctor in interpreting findings
• Report any abnormal result immediately
• Maintain accurate documentation

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Possible Outcome Questions

Two Marks
1. What is the normal range of fetal heart rate in NST?
2. What is the full form of DFMC?
Five Marks
1. Write any four components of the biophysical profile.
2. Describe the role of a nurse during CTG.
Ten Marks
1. Explain the different methods used to assess fetal well-being.
2. Describe the biophysical profile and interpret its scoring system.
Antenatal Care (ANC)
1. Introduction
• Antenatal care (ANC) refers to the supervised care of a pregnant woman
from the time of conception until the onset of labor.
• The main objective is to ensure the health and safety of both the mother
and fetus and to prepare the woman for childbirth and parenthood.
2. Objectives of Antenatal Care
• Monitor the progress of pregnancy and detect complications early
• Provide health education about pregnancy, childbirth, newborn care, and
breastfeeding
• Promote maternal nutrition and hygiene
• Screen and manage high-risk pregnancies
• Prevent and treat anemia, hypertension, diabetes, infections
• Promote institutional delivery and safe motherhood
• Prepare for birth planning and complication readiness
3. Components of Antenatal Care
A. Registration and Record Maintenance
• Register pregnancy as early as possible (preferably before 12 weeks)

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• Maintain Mother and Child Protection (MCP) card

B. Minimum Recommended Visits
• WHO 2016 recommends at least 8 ANC contacts
• Government of India (GoI) recommends 4 minimum visits:
o 1st: within 12 weeks
o 2nd: 14–26 weeks
o 3rd: 28–34 weeks
o 4th: 36 weeks and after
C. Physical Examination
• General condition, height, weight, BMI
• Blood pressure and pulse
• Edema, pallor, jaundice
• Breast examination
• Abdominal palpation and fundal height
• Fetal heart rate and fetal movements
D. Laboratory Investigations
• Hemoglobin estimation
• Blood group and Rh typing
• VDRL (syphilis screening), HBsAg (hepatitis B), HIV
• Blood sugar (fasting and post-meal)
• Urine: albumin, sugar, microscopy
• Ultrasound for dating and fetal anomaly
E. Immunization
• 2 doses of Tetanus and Diphtheria (Td) vaccine
o 1st dose: As early as possible
o 2nd dose: 4 weeks after the first
o If previously immunized: Only 1 booster dose

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F. Supplementation
• Iron & Folic Acid (IFA):
o 1 tablet (60 mg elemental iron + 500 mcg folic acid) daily for 180
days
• Calcium:
o 2 tablets (500 mg each) daily for 6 months
• Deworming: Single dose of albendazole (400 mg) after 2nd trimester
G. Nutritional Advice
• Balanced diet with iron, protein, calcium, folic acid, and vitamins
• Encourage frequent small meals
• Avoid caffeine, junk food, and smoking
H. Health Education and Counseling
• Warning signs in pregnancy
• Birth preparedness and emergency planning
• Breastfeeding, hygiene, and rest
• Emotional support and stress management
• Family planning counseling
4. Danger Signs to Report Immediately
• Vaginal bleeding
• Severe headache or blurred vision
• Swelling of hands/face
• Severe abdominal pain
• No fetal movement
• High-grade fever
• Difficulty in breathing
• Convulsions or loss of consciousness
5. Respectful and Woman-Centered ANC
• Follow Respectful Maternity Care (RMC) protocol
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• Maintain privacy and dignity

• Build a trusting relationship
• Encourage the presence of a birth companion
• Document and report findings as per GoI guidelines
6. Role of Nurse in Antenatal Care
• Perform assessments and record findings
• Identify high-risk pregnancies
• Administer vaccinations and supplements
• Provide health education and emotional support
• Encourage institutional delivery
• Prepare mother for labor and parenthood
• Ensure follow-up and referrals as needed
7. Health Programs Promoting ANC in India
• Janani Suraksha Yojana (JSY)
• Pradhan Mantri Surakshit Matritva Abhiyan (PMSMA)
• Janani Shishu Suraksha Karyakram (JSSK)
• RMNCH+A strategy
Possible Outcome Questions
Two Marks
1. What is the full form of ANC?
2. When should the first antenatal visit be scheduled?
Five Marks
1. List any five components of antenatal care.
2. Write five danger signs during pregnancy.
Ten Marks
1. Describe the antenatal care services provided to pregnant women.
2. Discuss the role of a nurse in the antenatal period.

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Women-Centered Care
1. Introduction
Women-centered care is an approach that places the needs, preferences,
autonomy, and rights of the woman at the core of maternity services. It
emphasizes respect, dignity, partnership, and shared decision-making
throughout the childbirth continuum — from pregnancy to postpartum.
2. Definition
Women-centered care is a holistic, respectful, and empowering approach to
maternity care that honors the woman’s values, beliefs, and choices while
ensuring safe, evidence-based clinical care.
3. Core Principles of Women-Centered Care
• Respect and dignity: Every woman is treated respectfully regardless of
age, caste, religion, economic status, or education.
• Informed decision-making: Women receive full information and are
involved in decisions about their care.
• Privacy and confidentiality: Personal health information is kept
confidential.
• Emotional support: Women are provided continuous emotional and
psychological support.
• Autonomy: The woman’s voice is central in planning and decision-
making.
• Continuity of care: A single caregiver or team provides coordinated care
throughout pregnancy and childbirth.
• Compassionate communication: Caregivers communicate clearly,
kindly, and respectfully.
• Birth companionship: Encouraging a woman’s choice of companion
during labor and delivery
4. Key Components of Women-Centered Maternity Care
Component Description

Respectful Maternity Treating women with kindness and ensuring a

Care (RMC) violence-free environment

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Component Description

Informed Consent Explaining all procedures and seeking permission

Allowing women to choose their position during

Choice and Control
labor, birth plan, or pain relief method

Services must be available and reachable without

Accessibility
discrimination

Understanding and respecting traditional and cultural

Cultural Competency
practices (if safe)

Physical and Emotional Safe clinical care with attention to the woman’s
Safety mental and emotional state

5. Importance of Women-Centered Care

• Improves maternal and neonatal outcomes
• Reduces maternal mortality and morbidity
• Enhances woman’s satisfaction with the birth experience
• Encourages early initiation of breastfeeding
• Builds trust between women and healthcare providers
• Encourages utilization of health services
6. Role of Nurse/Midwife in Women-Centered Care
• Actively listen to the woman’s concerns and preferences
• Provide accurate information in a simple, understandable manner
• Support birth planning and companionship
• Ensure a safe, clean, and private environment
• Offer choices for labor and delivery positions
• Advocate for the woman’s rights and autonomy
• Ensure emotional support and pain relief options
• Maintain clear documentation of care and consent
7. Barriers to Women-Centered Care

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• Lack of training or awareness among health workers

• Overburdened or under-resourced facilities
• Gender bias and discriminatory practices
• Absence of privacy and poor infrastructure
• Poor communication skills or disrespectful behavior
8. Indian Initiatives Promoting Women-Centered Care
• LaQshya Program: To improve quality of care in labor rooms
• Respectful Maternity Care Guidelines (MoHFW)
• RMNCH+A strategy promoting integrated care for women
• Birth companion policy in government hospitals
Possible Outcome Questions
Two Marks
1. Define women-centered care.
2. List any two principles of women-centered care.
Five Marks
1. List five features of women-centered maternity care.
2. Explain the role of a nurse in providing respectful maternity care.
Ten Marks
1. What is women-centered care? Describe its components and the role of
the nurse.
2. Write in detail about respectful maternity care and its importance in
maternal health.
Respectful Care and Compassionate Communication
1. Introduction
Respectful care and compassionate communication are fundamental
components of quality maternal and newborn health care. They ensure that
women feel safe, respected, and supported throughout pregnancy, childbirth,
and postpartum periods.
2. Definition

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• Respectful Maternity Care (RMC) refers to care that maintains a

woman’s dignity, privacy, and confidentiality while ensuring freedom
from abuse and discrimination.
• Compassionate Communication is the use of kind, empathetic, and
clear communication by healthcare providers to build trust and support
with patients.
3. Principles of Respectful Maternity Care
• Dignity and respect: Every woman is a human being and must be treated
with honor.
• Privacy and confidentiality: Patient information and body privacy must
be protected.
• Freedom from harm and mistreatment: No verbal, physical, or
emotional abuse.
• Informed consent and autonomy: The woman has the right to
information and to make her own decisions.
• Non-discrimination: Care must be free of any bias related to caste,
religion, economic status, age, etc.
• Supportive care: Emotional, physical, and psychological support is
essential.
4. Key Aspects of Compassionate Communication
• Active listening: Giving full attention to the woman and acknowledging
her concerns.
• Empathy: Understanding the woman’s feelings and showing genuine
concern.
• Clear and simple language: Using local language or terms the woman
can understand.
• Non-verbal cues: Using eye contact, nodding, and open posture.
• Reassurance and encouragement: Motivating and reducing fear or
anxiety.
• Avoiding medical jargon: Ensuring everything is explained simply and
thoroughly.
5. Importance in Maternal and Newborn Care

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• Improves trust in the healthcare system

• Increases satisfaction with maternity services
• Reduces fear, stress, and anxiety during labor
• Promotes early reporting of danger signs
• Encourages institutional delivery and follow-up visits
• Strengthens mother-infant bonding and breastfeeding
6. Practices That Ensure Respectful and Compassionate Care
Practice Description

Use the woman’s name and introduce

Greet warmly
yourself

Before doing any assessment or

Explain procedures
intervention

Ask for consent For every examination or intervention

Maintain privacy Use screens, close doors, cover the body

Allow a birth companion Based on woman’s preference

Encourage questions Make the woman feel safe to ask

Respect cultural beliefs As long as they are not harmful

Provide continuous emotional

Especially during labor
support
7. Role of Nurse/Midwife
• Be an advocate for the woman’s rights
• Promote shared decision-making
• Address the woman’s physical and emotional needs
• Protect the woman from disrespect or abuse
• Maintain accurate documentation of care
• Provide culturally appropriate communication
• Ensure the woman is informed about her condition, care, and options

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8. National Guidelines and Initiatives

• LaQshya program – To improve quality and respectful care in labor
rooms
• Respectful Maternity Care Charter (White Ribbon Alliance)
• RMNCH+A strategy – For integrated and respectful care
• Birth Companion Policy – Encourages support persons during delivery
Possible Outcome Questions
Two Marks
1. Define Respectful Maternity Care (RMC).
2. Mention any two principles of compassionate communication.
Five Marks
1. List the components of respectful maternity care.
2. Explain the nurse’s role in promoting respectful and compassionate
maternity care.
Ten Marks
1. Define respectful maternity care. Describe its importance and the role of a
nurse.
2. Explain how compassionate communication improves maternal health
outcomes.
Health Education on IFA, Calcium & Vitamin D Supplementation, Glucose
Tolerance Test, etc.
1. Introduction
Health education during antenatal care includes guiding the mother about
nutritional supplementation and screening tests essential for a healthy
pregnancy. Proper counseling ensures compliance, early detection of risks,
and prevention of complications for both the mother and fetus.
2. Iron and Folic Acid (IFA) Supplementation
Purpose
• Prevent and treat iron deficiency anemia
• Support fetal neural development through folic acid

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Dosage (as per GoI guidelines)

• 60 mg elemental iron + 500 mcg folic acid tablet
• Start from 14 weeks of gestation or as early as possible
• 1 tablet daily for 180 days during pregnancy
• Continue for 180 days postpartum
Instructions for Education
• Take after meals to avoid gastric irritation
• Avoid taking with milk, tea, or coffee (decreases absorption)
• Expect black stools and mild constipation (normal)
• Report severe nausea, vomiting, or intolerance
3. Calcium and Vitamin D Supplementation
Purpose
• Prevent maternal bone loss, preeclampsia, low birth weight, and
rickets
• Support fetal skeletal development
Dosage
• 500 mg calcium tablet + 250 IU vitamin D
• Start from 14 weeks of gestation
• 2 tablets daily (one morning, one evening)
• Maintain 1–2 hours gap between iron and calcium tablets
Instructions for Education
• Take with meals
• Encourage sunlight exposure (20–30 mins daily) for natural vitamin D
• Include milk, curd, ragi, sesame seeds, green leafy vegetables in diet
4. Vitamin D (If Prescribed Separately)
Indications
• In women with low serum vitamin D levels or poor dietary intake
Dosage
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• 60,000 IU once weekly for 6–8 weeks (oral sachet) or as per prescription
Instructions for Education
• Take after a full meal
• Continue maintenance dose if advised
• Monitor for hypercalcemia symptoms if on prolonged therapy
5. Glucose Tolerance Test (GTT)
Purpose
• Screen for Gestational Diabetes Mellitus (GDM)
When to Perform
• Between 24–28 weeks gestation
• Earlier (12–16 weeks) in high-risk women (obese, family history of DM)
Procedure (DIPSI Test – Recommended in India)
• No fasting required
• Give 75 g oral glucose dissolved in water
• Check plasma glucose after 2 hours
Interpretation
• ≥140 mg/dL = Positive for GDM
Instructions for Education
• Explain the need and timing of the test
• Encourage light meal before test (if not fasting)
• Explain that a positive result does not mean lifelong diabetes
• Provide counseling on diet, exercise, and follow-up care if GDM is
detected
6. General Counseling Points for Compliance
• Importance of daily compliance with supplements
• Manage common side effects (nausea, constipation)
• Combine with nutritious diet and hydration
• Avoid self-medication or skipping doses
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• Keep follow-up visits for lab tests and monitoring

Role of Nurse in Health Education
• Explain dosage, timing, and benefits of supplements
• Address myths or misconceptions about iron, calcium, and vitamin D
• Demonstrate how to take tablets correctly
• Educate about GTT purpose, process, and results
• Encourage verbal confirmation from the mother for understanding
• Maintain documentation and counseling records
Possible Outcome Questions
Two Marks
1. What is the ideal timing for the Glucose Tolerance Test in pregnancy?
2. State the daily dose of IFA recommended during pregnancy.
Five Marks
1. Describe the role of calcium and vitamin D supplementation during
pregnancy.
2. Explain the DIPSI method for GDM screening.
Ten Marks
1. Write in detail about iron, folic acid, and calcium supplementation in
pregnancy.
2. Describe the glucose tolerance test and the nurse's role in educating
pregnant women about it.
Education and Management of Physiological Changes and Discomforts of 2nd
Trimester
1. Introduction
The second trimester (13 to 28 weeks) is often called the “honeymoon period”
of pregnancy because many early symptoms subside. However, new
physiological changes and discomforts emerge due to the growing fetus and
hormonal shifts. Health education and proper nursing care help in preparing
the woman and reducing discomfort.
2. Physiological Changes in 2nd Trimester

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System Changes

Uterus Enlarges and rises above pelvis, becomes abdominal organ

Breasts Continue enlarging, colostrum secretion may begin

Increased blood volume (30–50%), physiological anemia due

Cardiovascular
to hemodilution

Respiratory Mild dyspnea due to upward displacement of diaphragm

Gastrointestinal Decreased peristalsis, possible heartburn and constipation

Urinary Increased renal blood flow and glomerular filtration rate

Skin Stretch marks (striae gravidarum), linea nigra, chloasma

Musculoskeletal Lordosis, backache due to weight shift and softening of joints

Improved emotional state, fetal bonding begins with

Psychological
quickening
3. Common Discomforts and Their Management
Health Education and
Discomfort Cause
Management

- Encourage good posture

and pelvic tilt exercises
Uterine enlargement, posture
Backache - Use firm mattress and
change
lumbar support
- Avoid prolonged standing

- Elevate legs, stretch calf

muscles
Compression of pelvic
Leg cramps - Calcium supplements as
nerves, low calcium
prescribed
- Local warm compresses

- High-fiber diet (fruits,

Progesterone relaxes GI vegetables, whole grains)
Constipation
tract - Adequate fluid intake
- Moderate exercise

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Health Education and

Discomfort Cause
Management

- Avoid laxatives unless

prescribed

- Eat small, frequent meals

Relaxed cardiac sphincter, - Avoid spicy/fatty food
Heartburn
uterine pressure on stomach - Sit upright after meals
- Antacids if prescribed

- Elevate legs frequently

Pressure on pelvic veins and - Avoid standing/sitting long
Varicose veins
legs time
- Wear support stockings

- Use moisturizing creams

or oils
Stretch marks Skin stretching
- Educate that they may
fade postpartum

- Avoid direct sun exposure

Chloasma (mask of - Use sunscreen
Hormonal changes
pregnancy) - Reassure it fades post-
delivery

- Maintain perineal hygiene

Vaginal discharge Hormonal increase, cervical - Wear cotton underwear
(leukorrhea) stimulation - Report foul-smelling or
itchy discharge

- Reassure it's a normal sign

of fetal well-being
First fetal movements felt
Quickening - Encourage daily
around 18–20 weeks
monitoring of fetal
movements

- Practice good oral hygiene

Bleeding gums Hormonal effect on gums - Use soft toothbrush
- Visit dentist if needed
4. Education and Counseling Tips

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• Explain that most discomforts are temporary and manageable

• Reinforce importance of ANC visits to monitor fetal growth
• Discuss warning signs to report immediately (bleeding, severe pain, no
fetal movement)
• Promote emotional support, involve spouse/family in care
• Encourage nutritional supplementation (IFA, calcium, vitamin D)
• Promote physical activity and good sleep hygiene
• Educate on safe sexual activity if no contraindication
• Teach hygiene, hydration, and clothing comfort
5. Role of Nurse
• Assess discomforts and provide individualized advice
• Teach and demonstrate exercises (e.g., pelvic tilt, back stretches)
• Provide reassurance and emotional support
• Encourage participation in antenatal classes
• Monitor for any signs of high-risk conditions
• Maintain clear documentation of education provided
Possible Outcome Questions
Two Marks
1. What is quickening and when is it felt?
2. Mention two common discomforts during the second trimester.
Five Marks
1. List any five physiological changes in the second trimester.
2. Write short notes on backache and heartburn during pregnancy.
Ten Marks
1. Describe the physiological changes during the second trimester and the
nursing management of related discomforts.
2. Explain health education to be given to pregnant women in the second
trimester.

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Rh-Negative Pregnancy and Prophylactic Anti-D Administration

1. Introduction
Rh incompatibility is a significant cause of hemolytic disease of the newborn
(HDN). It occurs when an Rh-negative mother carries an Rh-positive fetus. To
prevent maternal sensitization and subsequent complications in future
pregnancies, Anti-D immunoglobulin (RhIg) is administered.
2. Basic Concept of Rh Factor
• Rh factor is a protein (D antigen) present on red blood cells.
• If a person has this protein, they are Rh-positive; if not, they are Rh-
negative.
• Rh incompatibility arises when:
o Mother is Rh-negative
o Fetus is Rh-positive (inherited from Rh-positive father)
3. Pathophysiology of Rh Incompatibility
• During pregnancy or delivery, fetal Rh-positive blood may enter the Rh-
negative mother's bloodstream.
• The mother’s immune system identifies the D antigen as foreign and
produces anti-D antibodies.
• These antibodies can cross the placenta in subsequent pregnancies and
attack fetal red blood cells → causing hemolytic disease of the fetus and
newborn (HDFN).
4. When Sensitization May Occur
Event Time

After delivery of Rh-positive

Childbirth (most common)
baby

Miscarriage or abortion Any gestation

Ectopic pregnancy Early gestation

Chorionic villus sampling (CVS) or

11–18 weeks or later
amniocentesis

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Event Time

Trauma or placental abruption Anytime

External cephalic version (ECV) During late pregnancy

Bleeding during pregnancy Any trimester

5. Role of Anti-D Immunoglobulin (RhIg)
• Prevents sensitization by destroying fetal Rh-positive RBCs before the
maternal immune system reacts.
• It is passive immunity, not active antibody production.
6. Indications for Anti-D Administration
Indication Dose Timing

Routine antenatal At 28 weeks

300 mcg
prophylaxis gestation

Post-delivery (if baby is Rh- Within 72 hours

300 mcg
positive) of delivery

Abortion, ectopic,
50–300 mcg (depending on
procedures (CVS, Within 72 hours
gestation)
amniocentesis)

Antepartum hemorrhage or
300 mcg or as needed Within 72 hours
trauma

Dose based on fetomaternal

Any sensitizing event hemorrhage (Kleihauer-Betke Within 72 hours
test)
7. Nurse's Role in Rh-Negative Pregnancy
• Identify Rh-negative mothers early in first antenatal visit
• Ensure blood grouping and Rh typing of mother and father
• Educate the woman about importance of anti-D injection
• Monitor for any sensitizing events during pregnancy
• Document administration of anti-D in the mother’s ANC card

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• Confirm baby's blood group at birth; if Rh-positive, administer

postpartum anti-D
• Provide emotional support and answer queries
8. Contraindications for Anti-D
• Already Rh-sensitized (positive indirect Coombs test)
• Rh-positive mother
• Rh-negative fetus/newbor
9. Side Effects of Anti-D
• Pain or redness at injection site
• Mild fever or allergic reaction (rare)
• Anaphylaxis (very rare)
10. Documentation and Record-Keeping
• Record date, time, dose, and batch number
• Obtain informed consent
• Update ANC and delivery records
• Inform woman about future pregnancy implications
Possible Outcome Questions
Two Marks
1. What is the ideal time for administering routine antenatal Anti-D
prophylaxis?
2. What is the dose of Anti-D immunoglobulin used after Rh-positive
delivery?
Five Marks
1. List any five indications for Anti-D prophylaxis in pregnancy.
2. Explain the nurse’s role in management of Rh-negative pregnancy.
Ten Marks
1. Describe Rh incompatibility. Explain the role of Anti-D immunoglobulin
and the nurse’s responsibilities in care of an Rh-negative pregnant
woman.

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Referral and Collaboration, Empowerment in Midwifery Practice

1. Introduction
Effective midwifery care includes recognizing when a woman requires services
beyond the scope of midwifery and ensuring timely referral and collaboration
with other healthcare professionals. At the same time, empowerment of women
and communities is a core principle in achieving positive maternal and newborn
outcomes.
2. Referral and Collaboration
Definition
• Referral is the process of directing a client to a more specialized facility
or healthcare provider when her needs exceed the resources or expertise
available at the current level of care.
• Collaboration refers to working in partnership with other healthcare
professionals to provide integrated, holistic care.
Purpose of Referral
• To ensure safe, timely, and appropriate care for high-risk cases
• To manage complications that cannot be addressed at primary/community
level
• To prevent maternal and neonatal morbidity and mortality
Common Conditions Requiring Referral
• Hypertensive disorders (pre-eclampsia, eclampsia)
• Antepartum or postpartum hemorrhage
• Preterm labor
• Breech or multiple pregnancy
• Obstructed labor or fetal distress
• Anemia (severe)
• Medical comorbidities (diabetes, cardiac disease)
Steps in Effective Referral
1. Early identification of danger signs and complications
2. Communication with referral center (verbal and written)

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3. Stabilization of the mother before referral (e.g., IV fluids, oxygen, vital

monitoring)
4. Proper documentation (referral slip, summary of care)
5. Transportation arrangement with safety measures
6. Feedback mechanism (if possible) from referral center
Role of Nurse/Midwife in Referral
• Monitor and assess for complications regularly
• Educate the woman and family about the need for referral
• Ensure safe transfer and accompaniment, if needed
• Coordinate with ambulance/transport services
• Follow-up and maintain records
3. Collaboration in Midwifery
Types of Collaboration
• With obstetricians for high-risk pregnancy and delivery
• With pediatricians for newborn care
• With anesthetists during operative deliveries
• With ASHAs, ANMs, and other community workers
• With NGOs and social workers for social issues
Benefits of Collaboration
• Promotes continuity of care
• Enhances patient safety
• Encourages multidisciplinary teamwork
• Reduces burden on any single provider
• Improves outcomes and satisfaction
4. Empowerment in Midwifery
Definition
Empowerment in midwifery means enabling women to take an active role in
their reproductive health by providing knowledge, support, and respect.

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Key Elements
• Informed decision-making
• Respect for autonomy and preferences
• Health education and counseling
• Emotional and psychological support
• Encouraging family involvement
Midwife’s Role in Empowerment
• Provide complete and understandable information to women
• Support birth preparedness and complication readiness
• Promote women-centered care
• Encourage questions, participation, and expression of preferences
• Foster confidence in a woman’s ability to give birth
• Advocate for rights of childbearing women
Empowerment in the Community
• Health education for adolescent girls and women
• Involving women in healthcare planning and feedback
• Training community health workers
• Promoting safe motherhood practices
Possible Outcome Questions
Two Marks
1. Define referral in midwifery practice.
2. Mention two roles of the midwife in empowering pregnant women.
Five Marks
1. List five conditions that require referral during pregnancy.
2. Explain the importance of collaboration in maternal health care.
Ten Marks
1. Describe the role of the nurse/midwife in the referral system and inter-
professional collaboration.
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2. Explain the concept of empowerment in maternal care and the midwife's

responsibility in facilitating it.
Ongoing Risk Assessment during Pregnancy
1. Introduction
Ongoing risk assessment is a continuous process during antenatal care (ANC)
to identify and manage actual or potential health risks in the mother or fetus
throughout pregnancy. This proactive approach helps in the early detection of
complications, timely referral, and appropriate interventions to improve
maternal and neonatal outcomes
2. Objectives of Ongoing Risk Assessment
• Ensure early identification of high-risk pregnancies
• Monitor maternal and fetal well-being
• Guide the frequency and level of care required
• Reduce maternal and neonatal morbidity and mortality
• Promote individualized, safe, and respectful care
3. Key Components of Ongoing Risk Assessment
A. Medical History
• Chronic diseases (hypertension, diabetes, epilepsy, asthma)
• Previous surgeries or blood transfusions
• Family history of genetic disorders
• Medication use or allergies
B. Obstetric History
• Parity and gravida status
• History of stillbirth, preterm birth, or neonatal death
• History of cesarean section
• Previous postpartum hemorrhage or eclampsia
C. Current Pregnancy Assessment
• Bleeding or spotting
• Hypertension or edema

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• Fetal growth and development (via USG, fundal height)

• Abnormal fetal presentation or movement
• Anemia or infections (UTI, HIV, Hepatitis B)
D. Psychosocial Factors
• Teenage or advanced maternal age
• Domestic violence or lack of social support
• Poor nutrition or housing conditions
• Substance abuse or mental health concerns
E. Laboratory and Diagnostic Tests
• Hemoglobin level, blood group & Rh typing
• Blood sugar screening
• Urinalysis (protein, sugar, infection)
• Ultrasound (anatomy scan, fetal growth)
• Non-stress test, Doppler, or biophysical profile if indicated
4. Risk Categories (Based on Assessment)
Category Description Example

No complications or Healthy mother with normal

Low Risk
comorbidities pregnancy

Any factor that may endanger

High Risk PIH, anemia, Rh incompatibility
mother or fetus

Very High Multiple or life-threatening Eclampsia, placenta previa, heart

Risk conditions disease in pregnancy
5. Frequency of Risk Reassessment
• At every ANC visit
• At key gestational milestones (e.g., 12, 20, 28, 36 weeks)
• If any symptom or abnormality develops
• Before and after any invasive procedure
6. Nurse’s Role in Ongoing Risk Assessment

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• Perform regular physical assessments: BP, weight, fundal height, fetal

HR
• Observe for danger signs: bleeding, decreased fetal movements,
convulsions, etc.
• Record and evaluate lab investigations
• Identify changes or emerging risks
• Provide health education and counseling
• Maintain accurate documentation
• Refer high-risk women to appropriate facilities
7. Tools and Records Used
• ANC card
• WHO Partograph (during labor)
• Maternal and fetal risk screening checklist
• Government of India’s MCP card (Mother and Child Protection Card)
8. Danger Signs to Monitor
• Vaginal bleeding
• Persistent headache or blurred vision
• Severe abdominal pain
• Convulsions
• Fever or foul-smelling vaginal discharge
• Severe breathlessness
• Absent or decreased fetal movements
Possible Outcome Questions
Two Marks
1. List two danger signs in pregnancy that require immediate attention.
2. What is the purpose of ongoing risk assessment?
Five Marks
1. Write five components of ongoing risk assessment during pregnancy.

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2. Describe the role of a nurse in identifying high-risk pregnancy.

Ten Marks
1. Define ongoing risk assessment. Discuss its components and the role of a
nurse in managing risks during pregnancy.
Maternal Mental Health
1. Introduction
Maternal mental health refers to a woman's emotional and psychological well-
being during pregnancy, childbirth, and the postpartum period. Good mental
health is essential for the health of both the mother and the child. Mental
disorders in this period can significantly impact pregnancy outcomes, child
development, and family relationships.
2. Importance of Maternal Mental Health
• Influences maternal behavior, bonding with the baby, and breastfeeding
• Affects fetal development (through maternal stress hormones)
• Impacts early childhood emotional and cognitive development
• Prevents long-term psychological issues in both mother and child
3. Common Maternal Mental Health Disorders
Disorder Description

Depression during pregnancy or within 1 year

Perinatal Depression
postpartum (antenatal/postnatal)

Mild emotional disturbance in 70–80% mothers within

Postpartum Blues
1st week postpartum; transient

Persistent low mood, fatigue, sleep disturbances, loss

Postpartum
of interest; begins within 4 weeks to 6 months
Depression (PPD)
postpartum

Rare, severe form of mental illness; may include

Postpartum Psychosis hallucinations, delusions, suicidal or infanticidal
thoughts

Includes panic attacks, obsessive-compulsive disorder

Anxiety Disorders
(OCD), generalized anxiety

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Disorder Description

Post-Traumatic Stress Due to traumatic birth, stillbirth, or obstetric

Disorder (PTSD) complications
4. Risk Factors
• History of mental illness (personal or family)
• Unplanned or high-risk pregnancy
• Poor social support or domestic violence
• Socioeconomic stressors (poverty, unemployment)
• Hormonal fluctuations
• Sleep deprivation
• Substance abuse
• Loss of child or previous traumatic birth
5. Signs and Symptoms to Assess
• Persistent sadness, hopelessness, or crying spells
• Lack of interest in the baby or self-care
• Anxiety, panic attacks, excessive worry
• Fatigue, sleep disturbances, appetite changes
• Thoughts of self-harm or harming the baby
• Feelings of guilt or worthlessness
• Difficulty bonding with the newborn
6. Screening Tools
Tool Use

Edinburgh Postnatal Depression Scale Widely used 10-question screening

(EPDS) tool

PHQ-9 (Patient Health Questionnaire) Assesses severity of depression

Screens for generalized anxiety

GAD-7
disorder

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7. Management
A. Mild to Moderate Cases
• Psychological support and counseling
• Health education and reassurance
• Support groups and peer support
• Relaxation techniques: deep breathing, yoga
• Family support and involvement
B. Moderate to Severe Cases
• Referral to mental health professionals
• Cognitive Behavioral Therapy (CBT) or Interpersonal therapy
• Medication (e.g., SSRIs — safe under supervision during pregnancy and
lactation)
• Hospitalization in case of psychosis or suicide risk
• Mother-baby psychiatric units (where available)
8. Role of the Nurse/Midwife
• Early identification of symptoms using screening tools
• Build trust and rapport with the woman
• Provide non-judgmental support and empathy
• Educate about normal emotional changes vs. abnormal signs
• Encourage family involvement and support
• Refer to specialists when needed
• Monitor for risk of harm to self or baby
• Promote self-care, rest, nutrition, and exercise
9. Preventive Strategies
• Antenatal education and mental health awareness
• Partner and family counseling
• Address domestic violence and abuse
• Adequate postnatal rest and support systems
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• Empowering women in decision-making regarding birth

Possible Outcome Questions
Two Marks
1. Name two screening tools used for postpartum depression.
2. Define postpartum blues.
Five Marks
1. List five risk factors for maternal mental health problems.
2. Write a short note on the role of a nurse in managing postpartum
depression.
Ten Marks
1. Describe common maternal mental health disorders and explain how a
nurse can assess and manage them during pregnancy and postpartum
III Trimester of Pregnancy
1. Introduction
The third trimester spans from 28 weeks to delivery (approximately 40
weeks). It is a crucial phase where fetal growth peaks, maternal body prepares
for labor, and regular monitoring ensures safe outcomes for both mother and
baby.
2. Objectives of Third Trimester Care
• Monitor fetal growth and well-being
• Detect and manage maternal or fetal complications
• Prepare the woman and family for childbirth
• Promote maternal comfort and psychological support
• Educate regarding birth preparedness and newborn care
3. Maternal Physiological Changes in III Trimester
• Increased uterine size: pressure on bladder, stomach, and lungs
• Weight gain continues (average 1–2 kg/month)
• Braxton Hicks contractions: irregular, mild uterine contractions
• Backache, leg cramps, and pelvic pressure

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• Shortness of breath due to upward displacement of diaphragm

• Breast enlargement and colostrum secretion
• Increased urinary frequency
• Mood swings and sleep disturbances
4. Fetal Development in III Trimester
Week Fetal Changes

28–32
Eyes open, lungs maturing, regular movement felt
weeks

32–36
Fat deposition, fetal position settles
weeks

36–40 Full-term fetus (~2.5–3.5 kg), mature organs, vertex presentation

weeks common
5. Antenatal Assessments in III Trimester
• Routine ANC visit every 2 weeks till 36 weeks, then weekly till
delivery
• Vital signs: BP, weight, temperature
• Abdominal palpation: fundal height, lie, presentation, fetal parts
• Auscultation of fetal heart rate (FHR) using Doppler or Pinard’s
stethoscope
• Fetal movement count (DFMC)
• Urine test: protein, glucose
• Laboratory tests: CBC, blood sugar, HIV, HBsAg, VDRL (if not done
earlier)
• Ultrasound: fetal growth, liquor volume, placenta position
• Pelvic exam (if required) after 36 weeks to assess cervix or presentation
6. Special Investigations (If Indicated)
• Non-Stress Test (NST)
• Biophysical Profile (BPP)
• Doppler Study

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• Kick chart monitorin

7. Common Conditions to Monitor in III Trimester
• Pre-eclampsia/Eclampsia
• Gestational diabetes
• Placenta previa
• Abruptio placentae
• Preterm labor
• Intrauterine growth restriction (IUGR)
• Oligohydramnios or polyhydramnios
8. Health Education and Counseling
• Importance of birth preparedness and complication readiness (BPCR)
• Signs of labor onset: show, contractions, rupture of membranes
• When to visit the hospital immediately
• Danger signs: vaginal bleeding, severe headache, blurred vision, absent
fetal movements
• Dietary advice: protein, calcium, iron, fluids
• Encourage rest and sleep, light exercise
• Hygiene and breast care
• Prepare for exclusive breastfeeding
• Educate about postnatal care and newborn care
9. Psychological and Social Support
• Address fear or anxiety about labor
• Encourage partner/family involvement
• Discuss delivery preferences (position, presence of birth companion)
• Ensure respectful and culturally sensitive care
10. Nurse's Role
• Perform regular maternal and fetal assessments
• Educate and counsel mother and family
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• Identify high-risk cases and refer appropriately

• Maintain accurate records (ANC card, fetal monitoring chart)
• Promote positive childbirth experience
• Prepare mother for labor and delivery
Possible Outcome Questions
Two Marks
1. What is the duration of the third trimester?
2. Mention any two physiological changes in the mother during the third
trimester.
Five Marks
1. Write five health teachings to be given to a pregnant woman in the third
trimester.
2. List and explain the components of antenatal assessment in the third
trimester.
Ten Marks
1. Describe the changes and antenatal care in the third trimester of
pregnancy. What is the role of a nurse in monitoring and educating a
pregnant woman during this period?
Antenatal Assessment – Abdominal Palpation, Fetal Assessment, Auscultation
of Fetal Heart Rate
1. Introduction
Antenatal assessment is a crucial component of prenatal care aimed at
evaluating the health status of the mother and fetus. Abdominal palpation and
fetal assessment are non-invasive clinical methods to monitor fetal growth,
position, and well-being. Auscultation of the fetal heart rate (FHR) using
Doppler or Pinard’s stethoscope is a routine procedure to assess fetal viability.
2. Purpose of Antenatal Assessment
• Monitor fetal growth and development
• Determine fetal position, lie, presentation
• Assess amniotic fluid and uterine size
• Detect any abnormalities in fetal well-being
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• Reassure the mother and prepare for delivery

• Facilitate early identification of complications
3. Abdominal Palpation (Leopold’s Maneuvers)
Performed after 28 weeks gestation with the woman in a semi-recumbent
position and an empty bladder.
A. First Maneuver – Fundal Grip
• To identify which fetal pole (head or buttocks) is in the fundus
• Determines the presentation (cephalic or breech)
B. Second Maneuver – Lateral Grip
• To locate the fetal back and small parts
• Helps identify lie of the fetus (longitudinal, oblique, transverse)
C. Third Maneuver – Pawlik’s Grip
• To determine the presenting part above the pelvic inlet
• Assesses engagement (if the presenting part is still movable or fixed)
D. Fourth Maneuver – Pelvic Grip
• Confirms engagement of the presenting part into the pelvis
• Helps in identifying attitude (flexed or extended)
4. Fetal Assessment
Parameter Assessment Focus

Relationship of fetal spine to maternal spine (longitudinal,

Lie
transverse)

Presentation Part of fetus over pelvic inlet (cephalic, breech, shoulder)

Position Fetal back location (LOA, ROA, etc.)

Engagement Degree to which presenting part has entered pelvis

Amniotic Fluid Assessed by uterine size, consistency

Fetal
Inquired subjectively (kick count), felt on palpation
Movements

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5. Auscultation of Fetal Heart Rate (FHR)

Auscultation helps in monitoring fetal well-being and viability. FHR is
assessed in the lower abdomen, depending on fetal position.
A. Normal FHR Range:
• 110–160 beats per minute (bpm)
B. Methods of Auscultation:
Method Description

Electronic, detects FHR with ultrasound waves; can be used

Doppler Device
early in pregnancy

Pinard’s Traditional instrument; used after 20 weeks; requires skill

Fetoscope and quiet environment
C. Procedure for FHR Auscultation
• Woman in semi-recumbent or lateral position
• Palpate to determine fetal back
• Place Doppler or Pinard over fetal back near head
• Count FHR for 1 full minute
• Note rate, rhythm, and variability
• Compare with maternal pulse to avoid confusion
D. Abnormal Findings
• Tachycardia (>160 bpm)
• Bradycardia (<110 bpm)
• Irregular rhythms
• Absence of FHR – may indicate fetal demise
6. Nurse’s Role in Antenatal Assessment
• Ensure privacy and explanation before procedure
• Use gentle technique and ensure maternal comfort
• Perform accurate abdominal palpation
• Document findings (lie, presentation, FHR)

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• Identify abnormal findings and report promptly

• Educate the mother on fetal movements and signs of concer
7. Documentation
• Gestational age
• Fundal height in cm
• Lie, presentation, position
• FHR (beats per minute and location)
• Engagement status
• Amniotic fluid adequacy
• Maternal response and understanding
Possible Outcome Questions
Two Marks
1. Define fetal presentation.
2. What is the normal range of fetal heart rate?
Five Marks
1. Explain the steps of Leopold’s maneuvers.
2. Describe the method of fetal heart rate auscultation using Pinard’s
stethoscope.
Ten Marks
1. Discuss the procedure of abdominal palpation and auscultation of fetal
heart rate during antenatal assessment. What abnormalities should the
nurse look for?
Education and Management of Physiological Changes and Discomforts of 3rd
Trimester
1. Introduction
The third trimester of pregnancy (28–40 weeks) brings significant
physiological changes and discomforts due to the growing fetus, hormonal
shifts, and body’s preparation for labor. Educating pregnant women on these
changes and effective self-care helps in ensuring maternal comfort, preventing
complications, and promoting positive pregnancy outcomes.

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2. Common Physiological Changes and Nursing Management

Change Cause Management/Education

- Use proper posture

Increased lumbar
- Avoid standing for long
Backache curvature, weight of
- Apply warm compress
uterus
- Light massage or yoga

- Sleep propped with

Enlarged uterus
pillows
Breathlessness pressing against
- Avoid tight clothing
diaphragm
- Practice deep breathing

Pressure on nerves & - Gentle stretching

Leg cramps blood vessels; low - Calcium supplementation
calcium - Adequate hydration

- Encourage bladder
Pressure of uterus on emptying
Frequent urination
bladder - Limit fluids before bed
- Maintain perineal hygiene

Progesterone-induced - High-fiber diet

Constipation slow bowel - Increased fluid intake
movement - Mild exercise like walking

Relaxed esophageal - Small frequent meals

Heartburn/Acidity sphincter due to - Avoid spicy/fried food
progesterone - Sit upright after meals

- Encourage rest during day

Physical strain,
- Balanced diet and iron
Fatigue anemia, disturbed
supplements
sleep
- Avoid stress

- Use of safe moisturizers

Skin stretching over
Stretch marks - Gentle massage
abdomen, thighs
- Adequate hydration

Increased blood
Swelling of feet/ankles
volume and pressure - Elevate legs while resting
(physiological edema) - Avoid prolonged standing
on veins

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Change Cause Management/Education

- Wear comfortable
footwear

- Avoid crossing legs

Pressure on pelvic
Varicose veins - Wear support stockings
veins and legs
- Elevate legs when sitting

- Relaxation techniques
Anxiety, discomfort,
Insomnia - Warm milk before sleep
fetal movements
- Light reading/music

- Reassure mother (painless,

Irregular uterine irregular)
Braxton Hicks
contractions - Rest or change in position
contractions
preparing for labor - Educate difference from
true labor

Breast Hormonal changes

- Wear supportive bra
enlargement/leaking preparing for
- Maintain breast hygiene
colostrum lactation
3. Education to be Provided by Nurse
• Explain that these discomforts are normal physiological responses
• Reassure that they usually resolve after delivery
• Emphasize importance of balanced diet, iron, calcium, hydration
• Educate about warning signs that need immediate medical attention
(bleeding, blurred vision, severe headache, etc.)
• Teach daily fetal movement count (DFMC) and when to seek help
• Promote antenatal exercises and relaxation practices
• Encourage partner/family support for emotional well-being
• Counsel regarding birth preparedness and complication readiness
4. Nurse’s Role
• Monitor for normal vs abnormal symptoms
• Provide individualized education and support

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• Refer to physician if symptoms are severe or abnormal

• Maintain regular assessment and documentation
• Encourage positive body image and mental healt
Possible Outcome Questions
Two Marks
1. Name two common discomforts of 3rd trimester.
2. What is the cause of Braxton Hicks contractions?
Five Marks
1. List five physiological discomforts of 3rd trimester with their
management.
2. Write a short note on the role of a nurse in managing pregnancy
discomforts.
Ten Marks
1. Describe the physiological changes in the third trimester of pregnancy
and explain the nursing interventions to manage associated discomforts.
Third Trimester Tests and Screening
1. Introduction
The third trimester (weeks 28–40) is critical for monitoring fetal growth,
detecting complications, and ensuring both maternal and fetal well-being.
Regular antenatal screening and diagnostic tests are essential for early
identification of risks and timely intervention.
2. Common Third Trimester Tests and Screenings
Test/Screening Purpose Timing Nurse's Role

Detect anemia, Collect sample,

Complete Blood Around 28–32
infection, platelet monitor results,
Count (CBC) weeks
count educate

Blood Grouping & Once, ideally Administer Anti-D if

Detect Rh
Rh typing (if not before 28 Rh– mother with
incompatibility
done earlier) weeks Rh+ baby

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Test/Screening Purpose Timing Nurse's Role

24–28 weeks Explain fasting,

Glucose Tolerance Screen for
or up to 32 monitor for
Test (GTT) gestational diabetes
weeks hypoglycemia

Monthly till 36 Collect sample,

Urine Routine & Detect proteinuria,
weeks, weekly advise hydration,
Microscopy UTI, sugar
after report signs

Check fetal growth,

Ultrasound Scan Between 32– Assist during scan,
position, placenta,
(Growth Scan) 36 weeks educate mother
liquor volume

Doppler Assess placental

As advised in Schedule and prepare
Ultrasound (if blood flow and fetal
high-risk cases for scan
indicated) circulation

Monitor fetal heart After 32 weeks Position mother,

Non-Stress Test
rate response to or high-risk attach monitor,
(NST)
movement pregnancy observe

Kick Count (Daily Teach mother how to

Assess fetal well- From 28
Fetal Movement count and report
being weeks onward
Count - DFMC) changes

Preferably
HIV, HBsAg,
early, repeat in Counsel and follow
VDRL (if not done Screen for infections
3rd trimester if universal precautions
earlier)
high-risk

Educate about risk to

Group B Screen for
newborn, prepare for
Streptococcus vaginal/rectal 35–37 weeks
antibiotics during
(GBS) Culture colonization
labor if positive

Amniotic Fluid Assess fluid around Through Monitor trends,

Index (AFI) fetus ultrasound report abnormalities

Evaluate fetal
If NST Coordinate with
Biophysical Profile breathing, tone,
abnormal or in sonographer, record
(BPP) movement, amniotic
high-risk findings
fluid, FHR

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3. Risk-Based/Additional Tests
Condition Additional Screening/Test

Rh-negative mother Indirect Coombs test, Anti-D prophylaxis at 28 weeks

Blood pressure, urine protein, liver & kidney function

Hypertension
tests

IUGR or twin
Serial ultrasounds, NST, Doppler
pregnancy

Preterm labor risk Cervical length on ultrasound, fetal fibronectin test

4. Nurse’s Responsibilities
• Educate the mother about the purpose of each test
• Ensure proper sample collection and handling
• Prepare mother physically and emotionally
• Encourage compliance with scheduled checkups
• Observe and report any abnormal findings
• Maintain accurate documentation
• Provide follow-up care based on test results
5. Health Education for Mother
• Drink water before ultrasound for better imaging
• Fast for 8–12 hours if required for GTT or fasting sugar
• Report symptoms like decreased fetal movement, bleeding, or
headache
• Be aware of danger signs and birth preparedness
Possible Outcome Questions
Two Marks
1. Mention any two third trimester tests.
2. What is the purpose of NST?
Five Marks
1. List and explain the importance of four third trimester screenings.
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2. Write a short note on the nurse’s role in managing tests during the third
trimester.
Ten Marks
1. Describe the various third trimester tests and screenings, their purpose,
and the nursing responsibilities in ensuring maternal and fetal well-being.
Fetal Engagement in Late Pregnancy
1. Introduction
Fetal engagement is an important event in late pregnancy, usually occurring in
the last few weeks of gestation. It signifies that the presenting part of the
fetus (usually the head) has descended into the maternal pelvic inlet,
preparing for labor and delivery.
2. Definition of Engagement
Fetal engagement is defined as the descent of the widest (biparietal) diameter
of the fetal presenting part into the pelvic inlet, such that it remains fixed and
does not return to the abdomen when pushed.
3. Timing of Engagement
• Primigravida: Usually by 36–38 weeks
• Multigravida: May occur just before or during labo
4. Criteria for Engagement
• Clinically: The presenting part is at or below the level of the ischial
spines (0 station)
• Abdominal palpation: Only 2/5 or less of the fetal head is palpable
above the pelvic brim
• Pelvic examination: Presenting part is engaged or fixed, not ballotable
5. Assessment Methods
A. Abdominal Palpation – Fifths Rule
Head Palpable Engagement Status

5/5 Free and floating

4/5 to 3/5 Entering pelvis

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Head Palpable Engagement Status

2/5 or less Engaged

B. Pelvic Examination
• Station 0 = Engagement
• Negative stations = Above ischial spines (unengaged)
• Positive stations = Below ischial spines (engaged and descending)
C. Ultrasound (if required)
• Can confirm head position and descent
6. Signs of Engagement (Lightening)
• Dropping of the abdomen
• Easier breathing (relief of pressure on diaphragm)
• Increased pelvic pressure
• More frequent urination
• Change in gait ("waddling walk")
• Sense of lightness
7. Clinical Significance
• Indicates favorable pelvis and fetal size
• Suggests that labor may begin soon, especially in primigravida
• Helps determine mode of delivery (normal vs. operative)
• Assists in birth preparedness
8. Nursing Responsibilities
• Observe and document signs of engagement and fetal descent
• Educate the mother about lightening and its implications
• Instruct mother to report signs of labor
• Monitor for onset of labor in engaged head
• Provide emotional support and answer questions about fetal position
• Prepare for labor and delivery if engagement occurs late in pregnancy

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9. Abnormalities Related to Engagement

Condition Description

Non-engagement in May indicate CPD (Cephalopelvic

primigravida Disproportion)

Floating head at term Suggests malposition or large baby

Deep transverse arrest Head enters pelvis but does not rotate

Possible Outcome Questions

Two Marks
1. Define fetal engagement.
2. Mention one sign of fetal engagement.
Five Marks
1. Describe the methods used to assess fetal engagement.
2. Explain the nurse's role in monitoring engagement during late pregnancy.
Ten Marks
1. Discuss the clinical significance, assessment, and nursing management of
fetal engagement in late pregnancy.
Childbirth Preparation Classes
1. Introduction
Childbirth preparation classes are educational sessions designed for pregnant
women and their families to prepare them physically, emotionally, and
mentally for labor, delivery, and postpartum care. These sessions are usually
conducted during the third trimester by trained professionals such as
midwives, nurses, or childbirth educators.
2. Objectives of Childbirth Preparation Classes
• To educate mothers and partners about labor and childbirth
• To reduce fear, stress, and anxiety through information and reassurance
• To enhance coping skills and promote positive birth experiences
• To prepare for birth preparedness and complication readiness (BPCR)

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• To teach comfort techniques for pain relief

• To promote partner involvement and support
3. Timing and Duration
• Usually begins in the third trimester (around 28–30 weeks)
• Sessions may be weekly or biweekly, lasting 1–2 hours per session
• Conducted over 4–8 weeks
4. Key Topics Covered
Topic Details

Anatomy & Physiology of Understanding body changes, fetal

Pregnancy and Labor development

True vs false labor, when to go to the

Signs of Labor
hospital

Stages of Labor First, second, third stages explained

Breathing exercises, massage,

Pain Management Techniques
relaxation, positioning

Role of Birth Partner Supportive presence, comfort measures

Induction, augmentation, cesarean,

Medical Interventions
episiotomy

Discussing preferences with healthcare

Birth Plans
team

Maternal recovery, breastfeeding,

Postpartum Care
emotional changes

Feeding, bathing, immunization, danger

Newborn Care
signs

Techniques, latching, frequency,

Breastfeeding Education
advantages
5. Benefits of Childbirth Classes
• Improved maternal confidence and reduced fear
• Enhanced ability to manage labor pain and cope with contractions
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• Stronger bonding between partners

• Better informed decision-making during labor
• Increased likelihood of normal vaginal delivery
• Improved postnatal adaptation and breastfeeding success
6. Methods Used in Classes
• Audio-visual aids (videos, models, posters)
• Demonstrations (positioning, breathing)
• Group discussions and Q&A
• Role-plays and simulated labor situations
• Distribution of reading materials/handouts
7. Nurse/Midwife’s Role
• Plan and organize sessions with clear objectives
• Ensure culturally sensitive and evidence-based content
• Use simple language and provide individual attention
• Encourage questions and participation
• Teach and supervise practical techniques (e.g., breathing)
• Provide emotional support and motivation
• Evaluate understanding through feedback and interactive exercises
8. Components of BPCR Included in Sessions
• Choosing birth companion
• Identifying transport
• Saving money for emergencies
• Recognizing danger signs
• Arranging for blood donors
9. Challenges and Considerations
• Language barriers
• Cultural taboos about discussing childbirth

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• Limited access in rural areas

• Need for trained childbirth educators
Possible Outcome Questions
Two Marks
1. What is the main goal of childbirth preparation classes?
2. Name one breathing technique used during labor.
Five Marks
1. List the key contents covered in childbirth preparation classes.
2. What is the role of the nurse in organizing childbirth education?
Ten Marks
1. Explain childbirth preparation classes in detail and discuss their
importance in improving maternal and newborn outcomes.
Birth Preparedness and Complication Readiness (BPCR) including Micro Birth
Planning
1. Introduction
Birth Preparedness and Complication Readiness (BPCR) is a key
component of antenatal care that aims to prepare the woman, her family, and the
healthcare system for a safe birth and timely management of complications. It
ensures that pregnant women and their families are well-informed, well-
equipped, and ready to respond effectively to any situation that may arise
during pregnancy, childbirth, and the postpartum period.
2. Objectives of BPCR
• Promote safe delivery through timely access to care
• Minimize delays in seeking, reaching, and receiving care
• Reduce maternal and neonatal morbidity and mortality
• Empower women and families with knowledge and preparedness
• Encourage early recognition of danger signs and prompt referral
3. Components of Birth Preparedness

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Component Details

Identify a skilled birth Preferably institutional delivery under trained

attendant personnel

Choose a birth companion Husband, mother, or trusted family member

Select place of delivery Plan for nearby health center/hospital

Plan transportation Arrange for vehicle to reach facility at any time

For delivery cost, medicines, transport,

Save money
emergencies

In case of hemorrhage or anemia-related

Identify blood donor(s)
emergencies

Clothes, baby blanket, sanitary pads, ID,

Pack essential items
medical records

Educate mother/family about complications

Know danger signs
requiring referral

Plan for household Child care, food, home duties during hospital
responsibilities stay
4. Danger Signs to Watch For (Mother and Baby)
During Pregnancy:
• Severe headache, blurred vision
• Swelling of face/hands, excessive vomiting
• Vaginal bleeding, reduced fetal movement
• High fever, convulsions
During Labor/Postpartum:
• Excessive bleeding, prolonged labor
• Retained placenta, foul-smelling discharge
• Breast pain with fever, difficulty breastfeeding
Newborn:
• Difficulty breathing

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• Fever/hypothermia
• Poor feeding, lethargy
• Yellowing of skin (jaundice)
5. Micro Birth Planning (Individualized BPCR Plan)
A micro birth plan is a personalized birth preparedness plan created during
antenatal visits for each pregnant woman, often documented in the Mother and
Child Protection (MCP) card.
Key Elements of a Micro Birth Plan:
• Personal and obstetric details of the woman
• Expected date of delivery
• Preferred place of delivery and service provider
• Contact details of family members and birth companion
• Emergency contacts: ASHA, ANM, ambulance number
• Transportation arrangements
• Financial savings or insurance coverage
• Potential blood donors
• History of previous obstetric complications
• Plan for accompanying person during labor
• Follow-up visit schedules
6. Nurse’s Role in BPCR and Micro Birth Planning
• Educate the woman and family about importance of planning
• Use MCP card to document birth plan and review at each visit
• Identify risk factors and refer if needed
• Conduct home visits and involve ASHA/ANM
• Reinforce the availability of government services (Janani Suraksha
Yojana, ambulance, referral units)
• Ensure compliance with ANC visits and institutional delivery
• Promote male involvement in birth planning

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7. Government Support Schemes Supporting BPCR

Scheme Key Support

Janani Suraksha Yojana (JSY) Cash assistance for institutional delivery

Janani Shishu Suraksha Free transport, drugs, diet, and

Karyakram (JSSK) diagnostics

Free emergency transportation for

104/102 Ambulance Services
pregnant women
8. Benefits of BPCR and Micro Birth Planning
• Reduces delays at all three levels: decision, transport, treatment
• Improves maternal and newborn outcomes
• Increases rate of institutional deliveries
• Empowers women and families with health knowledge
• Enhances community participation and male involvement
Possible Outcome Questions
Two Marks
1. Define birth preparedness and complication readiness.
2. Mention two components of a micro birth plan.
Five Marks
1. List the major components of BPCR.
2. Write a short note on the nurse’s role in birth preparedness.
Ten Marks
1. Describe birth preparedness and complication readiness. Explain the
concept of micro birth planning and the nurse’s responsibilities.
Danger Signs of Pregnancy – Recognition of Ruptured Membranes
1. Introduction
Rupture of membranes (ROM) refers to the breaking of the amniotic sac,
commonly known as the "water bag." While it is a normal event during labor,

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premature rupture of membranes (PROM) or preterm PROM can pose

risks and is considered a danger sign if it occurs before the onset of labor or
before term.
2. Types of Rupture of Membranes
Type Definition Timing

Spontaneous ROM Natural rupture during active

At or after 37 weeks
(SROM) labor

Premature ROM
ROM before onset of labor At or after 37 weeks
(PROM)

Preterm PROM ROM before 37 weeks and

Preterm, risky
(PPROM) before labor

Artificial ROM Done intentionally by health During labor

(AROM) provider (amniotomy)
3. Signs of Ruptured Membranes
• Sudden gush or constant trickle of fluid from the vagina
• Wetness in undergarments or bed
• Clear, pale, and odorless fluid (may be greenish/yellow if infected or
with meconium)
• Feeling of leaking fluid without control (unlike urine)
• Fluid continues even when bladder is emptied
4. Confirmation of ROM
Method Explanation

Speculum
Pooling of fluid in vaginal vault
examination

Nitrazine test Turns blue in alkaline amniotic fluid

Dried sample shows fern-like crystals under

Fern test
microscope

Ultrasound Reduced amniotic fluid index (AFI)

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Method Explanation

AmniSure/ROM Plus Advanced test for amniotic fluid markers

5. Dangers of Ruptured Membranes
• Infection (chorioamnionitis)
• Preterm labor (if before term)
• Cord prolapse
• Oligohydramnios (low amniotic fluid)
• Fetal distress
• Stillbirth or neonatal complications
6. Nursing Responsibilities
• Recognize and assess for ROM signs
• Instruct woman to note the color, amount, and smell of fluid
• Advise her to lie on left side and not insert anything vaginally
• Monitor maternal temperature and fetal heart rate for infection
• Prepare for hospital referral immediately
• Maintain strict aseptic precautions
• Educate on importance of reporting ROM immediately
7. Health Education to Mother
• Seek care immediately if membranes rupture, even if labor hasn’t
started
• Avoid intercourse, douching, or using tampons after ROM
• Keep undergarments dry and clean
• Drink fluids to prevent dehydration
• Be alert for fever, foul-smelling discharge, decreased fetal movement
Possible Outcome Questions
Two Marks
1. What is PROM?

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2. Name one sign of ruptured membranes.

Five Marks
1. List the signs and complications of premature rupture of membranes.
2. Explain the nursing interventions in case of suspected ROM.
Ten Marks
1. Discuss the recognition, risks, and nursing management of ruptured
membranes during pregnancy.
Education on Alternative Birthing Positions – Women’s Preferred Choices &
Role of Birth Companion
1. Introduction
Birthing positions refer to the various physical positions a woman may adopt
during labor and delivery. Allowing women to choose their preferred
birthing position enhances comfort, autonomy, and labor outcomes.
Education about these positions helps women make informed decisions and
promotes respectful, women-centered care.
2. Objectives of Education on Alternative Birthing Positions
• Promote comfort and empowerment in labor
• Improve physiological effectiveness of contractions
• Facilitate fetal descent and proper positioning
• Reduce need for interventions (episiotomy, instrumental delivery)
• Involve birth companions in supportive roles
• Ensure evidence-based and respectful maternity care
3. Common Alternative Birthing Positions
Position Description Advantages

Upright Woman remains Uses gravity, promotes

(Standing/Walking) vertical descent, reduces pain

Sitting (on birthing Supported sitting Opens pelvis, encourages

stool/ball/chair) posture engagement

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Position Description Advantages

Maximizes pelvic opening,

Squatting Deep knee bend
faster descent

Knees on bed/floor, Relieves back pain, good

Kneeling (with or without
torso upright or for OP (occipito-posterior)
support)
supported position

Hands and Knees (All Helps rotate baby, reduces

On hands and knees
Fours) backache

Side-lying (Lateral Lying on side, legs Conserves energy, suitable

position) flexed for women with high BP

Water Birth (in birthing Labor and/or birth in Pain relief, comfort,
pool) water relaxation

Common in medical
Lithotomy (traditional Supine with legs in
settings but less
hospital position) stirrups
physiological
4. Education Points for Pregnant Women
• Learn and practice different positions during antenatal classes
• Choose a position based on comfort and labor progress
• Movement during labor is encouraged unless contraindicated
• Practice breathing, relaxation, and partner-assisted support in
preferred positions
• Avoid prolonged supine (flat on back) due to risk of vena cava
compression
• Keep hydrated and nourished to maintain energy during labor

5. Birth Companion’s Role

Function Activities

Physical Support Assist woman in changing or maintaining position

Emotional Support Encourage, reassure, provide calming presence

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Function Activities

Practical Help Hold the woman, offer water, massage back

Advocacy Communicate her preferences to the care team

Examples of companions: Husband, mother, sister, friend, trained doul
6. Nurse’s Role in Promoting Alternative Birthing Positions
• Educate women and partners during antenatal visits
• Provide demonstration using models, charts, or videos
• Encourage free movement and position changes during labor
• Assess fetal heart rate and labor progress in all positions
• Ensure safety, privacy, and dignity
• Respect the woman’s choices and informed consent
7. Benefits of Encouraging Alternative Positions
• Shorter first and second stages of labor
• Less need for analgesia and medical intervention
• Better maternal satisfaction and experience
• Enhanced uteroplacental blood flow and fetal oxygenation
• Improved pelvic alignment and fetal positioning
Possible Outcome Questions
Two Marks
1. Name two alternative birthing positions.
2. Who can act as a birth companion?
Five Marks
1. Write a short note on the importance of educating pregnant women about
birthing positions.
2. Explain the role of a birth companion during labor.
Ten Marks
1. Discuss various birthing positions and their advantages. What is the
nurse's role in supporting a woman's preferred birthing position?
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Ongoing Risk Assessment during Pregnancy

1. Introduction
Ongoing risk assessment during pregnancy is a continuous process of
identifying any potential or emerging maternal or fetal risks that can affect
the health outcomes of pregnancy, labor, and postpartum period. It helps ensure
timely intervention, referral, and safe delivery.
2. Objectives of Ongoing Risk Assessment
• Detect high-risk pregnancies early
• Prevent maternal and neonatal complications
• Provide individualized care based on risk profile
• Guide appropriate referral and management decisions
• Promote safe and respectful maternity care
3. When Is Risk Assessment Done?
• First Antenatal Visit (baseline risk identification)
• Each Subsequent ANC Visit
• During Labor and Delivery
• Postpartum Period (early detection of postnatal complications)
4. Risk Factors Monitored Continuously
A. Maternal Risk Factors
• Age (<18 or >35 years)
• Height <145 cm (risk of CPD)
• Anemia (Hb <11 g/dL)
• Hypertension / Preeclampsia
• Gestational Diabetes Mellitus (GDM)
• Obesity or underweight (BMI extremes)
• Previous obstetric complications (e.g., stillbirth, C-section, PPH)
• Bleeding during pregnancy
• Multiple pregnancies

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• Malpresentations (breech, transverse)

• Medical conditions (cardiac, thyroid, renal, epilepsy)
B. Fetal Risk Factors
• Intrauterine Growth Restriction (IUGR)
• Macrosomia (Large for Gestational Age)
• Reduced fetal movements
• Abnormal fetal heart rate patterns
• Amniotic fluid abnormalities (oligo-/polyhydramnios)
• Congenital anomalies
5. Tools and Methods for Risk Assessment
Tool/Assessment Purpose

To identify risk factors (age, previous

History taking
complications)

Physical examination BP, pallor, edema, fundal height

Weight & BMI

Detect undernutrition/obesity
monitoring

Lab investigations Hb, blood sugar, urine albumin/sugar, HIV, HBsAg

Ultrasound Fetal growth, AFI, anomalies

Kick Count (DFMC) Assess fetal well-being

BPCR Plan review To ensure preparedness

6. Nurse’s Role in Ongoing Risk Assessment
• Conduct thorough history and physical assessment at every visit
• Monitor vital signs, fetal heart rate, fetal movements
• Perform weight, BP, fundal height measurements
• Review lab reports and refer for abnormal findings
• Reinforce Birth Preparedness and Complication Readiness (BPCR)
• Identify danger signs and initiate immediate referral if needed

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• Document findings clearly in MCP card or antenatal record

• Educate the woman on self-monitoring and danger signs
7. Referral Criteria
• Severe anemia (Hb <7 g/dL)
• Uncontrolled hypertension or eclampsia
• Bleeding per vagina
• Malpresentation beyond 36 weeks
• Suspected fetal distress or IUGR
• GDM not controlled with diet
8. Benefits of Ongoing Risk Assessment
• Early identification of complications
• Timely intervention and management
• Improved maternal and neonatal survival
• Strengthens continuity of care
• Promotes informed decision-making by mother and family
Possible Outcome Questions
Two Marks
1. Name two risk factors that are assessed during ANC.
2. What is the normal value of hemoglobin in pregnancy?
Five Marks
1. List common maternal and fetal risk factors identified during pregnancy.
2. What is the nurse’s role in ongoing antenatal risk assessment?
Ten Marks
1. Discuss the importance, tools, and nursing responsibilities in ongoing risk
assessment during pregnancy.
Cultural Needs During Pregnancy and Childbirth
1. Introduction

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Understanding and addressing cultural needs is essential in providing

respectful, woman-centered, and holistic care during pregnancy and
childbirth. Culture influences how women perceive pregnancy, labor, delivery,
pain, nutrition, hygiene, and postnatal practices.
2. Importance of Cultural Consideration in Midwifery
• Promotes trust and cooperation between mother and care provider
• Enhances compliance with antenatal and postnatal care
• Prevents miscommunication or misunderstanding
• Ensures respectful maternity care
• Improves maternal satisfaction and outcomes
3. Aspects of Culture Affecting Maternity Care
Cultural Aspect Examples of Beliefs/Practices

Wearing specific items, food restrictions, avoidance of

Pregnancy rituals
certain places

Restriction of "hot" or "cold" foods, special herbal drinks,

Nutrition
fasting

Preference for home birth, presence of specific attendants

Labor and delivery
(e.g., only female relatives), prayer rituals

Some women may suppress expression; others may be

Pain expression
vocal

Modesty and
Preference for female care providers, covering body parts
privacy

Confinement for 40 days, traditional massages, dietary

Postnatal care
restrictions

Naming and Religious or cultural ceremonies (e.g., naming after 7

newborn rituals days, shaving head, applying kohl)

Burial or ceremonial handling of the placenta in some

Placenta rituals
cultures
4. Nurse’s Role in Addressing Cultural Needs
• Conduct cultural assessment as part of antenatal history

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• Respect religious and cultural preferences during care

• Provide privacy and dignity, especially for modest women
• Allow family participation if preferred by the woman
• Incorporate safe traditional practices into care plan
• Provide education to correct harmful myths gently and respectfully
• Collaborate with ASHA, family, and community health workers
• Use interpreters or visual tools if language barriers exist
• Empower women while preserving their cultural identity
5. Cultural Competency in Care
• Be non-judgmental and open-minded
• Recognize individual variations within cultures
• Understand that no single approach fits all women
• Provide individualized care that meets both clinical and cultural needs
• Document and follow cultural preferences wherever possible
6. Benefits of Culturally Sensitive Maternity Care
• Builds trust and cooperation between woman and care team
• Reduces fear and anxiety in the mother
• Improves adherence to health advice and facility-based delivery
• Enhances maternal and neonatal outcomes
• Promotes equity and human rights in healthcare
Possible Outcome Questions
Two Marks
1. Give two examples of cultural practices during postpartum period.
2. Why is cultural assessment important in maternity care?
Five Marks
1. Describe how culture affects maternity care.
2. What is the nurse’s role in managing cultural needs of pregnant women?

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Ten Marks
1. Discuss the cultural needs of women during pregnancy and childbirth and
the nursing responsibilities in addressing them.
Women-Centered Care
1. Introduction
Women-centered care is an approach to maternity services that respects and
responds to the unique needs, preferences, rights, and values of each woman.
It ensures that women are active participants in decision-making and that care
is individualized, respectful, and empowering.
2. Key Principles of Women-Centered Care
• Respect and dignity: Treating women with courtesy, maintaining privacy
and confidentiality
• Informed decision-making: Women are given evidence-based
information to make choices
• Holistic care: Addresses physical, emotional, social, cultural, and
spiritual needs
• Individualized care: Care is tailored to the woman's situation, beliefs,
and expectations
• Continuity of care: Ensures consistent caregivers and communication
throughout the maternity cycle
• Empowerment: Builds confidence and autonomy in the mother
• Non-discrimination: Inclusive care regardless of age, caste, religion,
socio-economic status, or disability
• Safe and respectful maternity care (RMC): Upholds the woman’s
rights and safety in all settings
3. Components of Women-Centered Care
Component Details

Communication Open, empathetic, and in the woman’s preferred language

Antenatal classes, birth preparedness, nutrition,

Education
breastfeeding

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Component Details

Support Systems Involvement of family, birth companion, ASHA workers

Choice and
Choice in birthing position, pain relief, place of birth
Control

Continuum of
Preconception → Antenatal → Intranatal → Postnatal
Care

Clean, private, culturally sensitive, woman-friendly

Safe Environment
facilities
4. Benefits of Women-Centered Care
• Increases maternal satisfaction and trust
• Encourages early antenatal registration and regular check-ups
• Promotes safe institutional deliveries
• Reduces fear, anxiety, and stress during childbirth
• Enhances positive birth outcomes and newborn bonding
• Supports exclusive breastfeeding and postpartum well-being
5. Nurse’s Role in Providing Women-Centered Care
• Establish a trusting relationship with the woman
• Provide comprehensive education throughout the maternity cycle
• Maintain non-judgmental, respectful communication
• Encourage the woman to express her preferences and concerns
• Ensure privacy, comfort, and informed consent before procedures
• Involve the woman in care decisions
• Support the presence of a birth companion
• Monitor the woman’s emotional well-being along with physical health
• Facilitate referral and follow-up if complications arise
• Advocate for the woman’s rights and dignity in all settings
6. Examples of Women-Centered Practices
• Offering the choice to walk or change positions during labor
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• Allowing the woman to have her mother or partner present during

delivery
• Using simple and culturally appropriate language for instructions
• Respecting a woman’s decision to refuse a procedure
• Ensuring skin-to-skin contact and early initiation of breastfeeding
Possible Outcome Questions
Two Marks
1. Define women-centered care.
2. Give one benefit of women-centered care.
Five Marks
1. List the principles of women-centered care.
2. Write a short note on the role of a nurse in providing women-centered
care.
Ten Marks
1. Discuss the concept, principles, and benefits of women-centered care.
Explain the role of the nurse in promoting it.
Respectful and Compassionate Communication
1. Introduction
Respectful and compassionate communication is a key element of Respectful
Maternity Care (RMC). It ensures that all interactions with pregnant women
are rooted in empathy, dignity, trust, active listening, and cultural sensitivity.
This communication style enhances a woman’s experience throughout the
antenatal, intranatal, and postnatal periods.
2. Importance of Respectful and Compassionate Communication
• Builds trust between the woman and care provider
• Reduces anxiety, fear, and stress during pregnancy and childbirth
• Promotes informed decision-making
• Enhances compliance with health advice
• Encourages facility-based delivery
• Improves maternal satisfaction and health outcomes
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3. Core Elements of Respectful and Compassionate Communication

Component Explanation

Understanding the woman's feelings and perspectives

Empathy
without judgment

Giving full attention, maintaining eye contact, nodding,

Active Listening
asking relevant questions

Using the woman’s name, maintaining privacy, avoiding

Respect
harsh words

Clear
Providing information in simple, understandable language
Explanation

Non-verbal Cues Gentle tone, kind facial expressions, calm body language

Cultural Respecting cultural beliefs, practices, and language

Sensitivity preferences

Informed Consent Asking permission before any examination or procedure

Encouragement Motivating and reassuring during labor and discomfort

Ensuring personal health information is not shared without

Confidentiality
consent
4. Nurse’s Role in Practicing Respectful Communication
• Address the woman by her name, not by bed or case number
• Use language she understands, preferably in her local dialect
• Provide complete, unbiased information about her condition and
choices
• Allow her to express concerns, fears, or discomfort freely
• Avoid using judgmental, rude, or dismissive language
• Always obtain consent before any procedure
• Maintain eye contact and sit at eye level when speaking
• Encourage the presence of a birth companion or family member
• Provide updates on labor progress or baby's condition

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• Educate with patience and kindness, especially during pain or anxiety

5. Examples of Respectful and Compassionate Communication
• “I understand this is difficult. I am here with you.”
• “Would you like me to explain what we’re doing now?”
• “Is there anything you need or are worried about?”
• “You are doing a great job. Keep breathing slowly.”
• “Do you want someone from your family to stay with you?”
• “Thank you for trusting us. We will take care of you.”
6. Outcomes of Good Communication in Maternity Care
• Increased maternal confidence in the care team
• Reduced refusal of hospital services
• Better pain coping and shorter labor
• Increased uptake of postnatal care and family planning
• Reduced incidents of violence, disrespect, or mistreatment
Possible Outcome Questions
Two Marks
1. Mention one component of respectful communication.
2. What is the benefit of active listening during labor?
Five Marks
1. Write a short note on the importance of respectful and compassionate
communication in maternity care.
2. Describe the role of a nurse in respectful communication with pregnant
women.
Ten Marks
1. Explain the core components and importance of respectful and
compassionate communication. Discuss the nurse’s role with examples.
Health Education on Exclusive Breastfeeding
1. Introduction

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Exclusive breastfeeding (EBF) means feeding the baby only breast milk (no
other food or drink, not even water) for the first six months of life, except for
prescribed medicines or vitamins. It is a crucial component of newborn care
and supports the child's growth, immunity, and development.
2. Objectives of Health Education on Exclusive Breastfeeding
• Promote awareness about the importance of breastfeeding
• Encourage initiation of breastfeeding within the first hour of birth
• Support mothers in sustaining EBF for 6 months
• Educate on correct positioning, latching, and frequency
• Prevent common problems such as engorgement, cracked nipples,
mastitis
• Reduce infant morbidity and mortality
3. Importance of Exclusive Breastfeeding
Benefit Explanation

Provides all nutrients in proper quantity and quality for

Nutritional
6 months

Rich in antibodies (especially colostrum), protects

Immunological
against infections

Digestive Health Easily digestible, prevents constipation and diarrhea

Cognitive
Enhances brain development and IQ
Development

Reduces postpartum bleeding, aids weight loss, delays

Mother’s Health
next pregnancy

Economic Free, always available, no risk of contamination

4. Key Messages in Health Education
• Start breastfeeding within 1 hour after birth (early initiation)
• Give colostrum, the first milk – rich in antibodies and nutrients
• Do not give honey, sugar water, ghutti, or cow’s milk
• Breastfeed on demand (at least 8–12 times a day)

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• Avoid using bottles and pacifiers

• Watch for baby’s hunger cues (sucking fingers, restlessness)
• Ensure correct latching and positioning
• Encourage rooming-in and mother–baby bonding
• Continue EBF even if the mother has mild illness
• Counsel for breast care and expressing milk if needed
5. Techniques for Educating Mothers
• One-on-one or group sessions during antenatal visits and postnatal
wards
• Use of posters, flipcharts, models, and videos
• Involve birth companions or husbands in the session
• Demonstrate correct techniques using dolls or visual aids
• Encourage mothers to ask questions and share their concerns
• Reinforce key messages during immunization visits
6. Common Barriers to EBF and How to Address Them
Barrier Educational Strategy

Explain its benefits for immunity and

Belief that colostrum is dirty
digestion

Educate on demand-feeding and signs of

Fear of insufficient milk
adequate milk

Working mothers Teach milk expression and safe storage

Involve family members and community

Social stigma
health workers

Breast problems (cracked nipples, Demonstrate care techniques and latching

engorgement) correction
7. Role of Nurse in Promoting EBF
• Educate during ANC and PNC visits
• Assist mother in initiating breastfeeding in labor room

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• Demonstrate positioning and attachment techniques

• Monitor and counsel on feeding difficulties
• Refer mothers to lactation consultants if needed
• Record breastfeeding status in mother-child protection (MCP) card
8. Signs That the Baby Is Exclusively Breastfed Properly
• Baby passes urine at least 6–8 times/day
• Gains weight adequately (minimum 500–700 gm/month)
• Sleeps well between feeds
• Suckles effectively and is satisfied after feeding
Possible Outcome Questions
Two Marks
1. Define exclusive breastfeeding.
2. How many times should a baby be breastfed in 24 hours?
Five Marks
1. List five benefits of exclusive breastfeeding for the infant and mother.
2. Write short notes on the nurse’s role in promoting exclusive
breastfeeding.
Ten Marks
1. Explain exclusive breastfeeding. Discuss the role of the nurse in
promoting and educating mothers about EBF.
Role of Doula / ASHA during Pregnancy, Labor, and Postpartum
1. Introduction
Doulas and ASHA (Accredited Social Health Activist) workers play a
significant role in providing physical, emotional, and informational support
to women during pregnancy, childbirth, and the postpartum period. Their
presence enhances the quality of maternity care and promotes positive health
outcomes through community-based and personalized support.
2. Role of a Doula
A Doula is a trained, non-medical birth companion who supports a woman
before, during, and shortly after childbirth.
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A. Antenatal Period
• Educates the woman and family about birth planning, nutrition, and
preparation
• Helps reduce anxiety and fear about labor and delivery
• Provides emotional support and comfort techniques
• Encourages partner/family involvement
• Supports informed decision-making
B. Intranatal Period (During Labor)
• Stays continuously with the woman
• Provides emotional reassurance and physical comfort (massage,
breathing techniques)
• Supports the woman in choosing birthing positions
• Advocates for the woman’s preferences and consent
• Encourages communication with healthcare providers
C. Postpartum Period
• Assists with breastfeeding initiation and newborn care
• Monitors the mother’s emotional well-being (screening for postpartum
depression)
• Provides support for rest, hygiene, and self-care
• Facilitates bonding between mother and baby
• Provides referral if complications are suspected
3. Role of ASHA Worker
An ASHA is a community-based voluntary health worker appointed under
the National Health Mission (NHM) to act as a bridge between the healthcare
system and community.
A. During Pregnancy
• Identifies pregnant women and registers them for ANC
• Facilitates antenatal check-ups, immunization, and supplements (IFA,
calcium)

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• Educates on danger signs in pregnancy

• Promotes institutional delivery
• Ensures Birth Preparedness and Complication Readiness (BPCR)
• Coordinates for transport (Janani Shishu Suraksha Karyakram –
JSSK)
B. During Labor and Delivery
• Accompanies the woman to healthcare facility
• Stays with the woman and provides psychological support
• Helps with documentation and admission process
• Coordinates with staff nurses and birth companions
C. Postpartum and Newborn Care
• Ensures postnatal visits at home
• Educates on exclusive breastfeeding, warmth, cord care, hygiene
• Promotes immunization and family planning
• Monitors for postpartum complications
• Acts as a link to referral centers in emergencies
• Maintains records and reports under government schemes
4. Importance of Doula and ASHA in Maternal Health
Doula ASHA

Community-based government health

Non-medical, continuous presence
worker

Focuses on emotional and physical Acts as a bridge between home and

support facility

Promotes institutional delivery and

Promotes woman-centered birthing
follow-up

Enhances maternal satisfaction and Ensures access to free maternal health

confidence services
5. Nurse’s Role in Supporting Doula and ASHA

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• Collaborate with doula/ASHA to provide holistic care

• Respect and acknowledge their supportive role
• Share updates on care plans for continuity
• Train ASHAs in basic maternity and newborn care protocols
• Involve them in health education sessions and referrals
Possible Outcome Questions
Two Marks
1. Mention one role of a doula during labor.
2. Who appoints ASHA workers?
Five Marks
1. Write the role of ASHA workers during pregnancy and postpartum.
2. Explain the contributions of a doula during labor.
Ten Marks
1. Discuss the roles of ASHA and doula in maternal health and how they
contribute to improving maternal and neonatal outcomes.

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Unit -04
Physiology, Management and Care During Labour

Physiology, Management and Care During Labour

1. Definition of Labour
Labour is the process by which the fetus, placenta, and membranes are
expelled through the birth canal from the uterus to the outside world. It usually
occurs between 37 to 42 weeks of gestation in a term pregnancy.
2. Onset of True Labour
• Regular uterine contractions with increasing frequency and intensity
• Cervical effacement and dilatation
• Show (blood-tinged mucus)
• Rupture of membranes may occur
• Descent of fetal head
3. Physiology of Labour
A. Uterine Contractions
• Coordinated and rhythmic contractions begin from the fundus and move
downward
• Contractions cause cervical effacement (thinning) and dilatation
(opening)
B. Hormonal Regulation
• Oxytocin: Stimulates uterine contractions
• Prostaglandins: Promote cervical ripening
• Estrogen: Increases uterine sensitivity
• Relaxin: Softens the cervix and pelvic ligaments
C. Cervical Changes
• Effacement: Cervix becomes thin (0–100%)
• Dilatation: Cervical opening widens (0–10 cm)

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D. Fetal Adaptation
• Fetal head molds to pass through the birth canal
• Rotations and flexion allow descent
4. Stages of Labour
Stage Duration Physiological Events

First Onset of true labor to full Regular contractions, cervical

Stage cervical dilatation (10 cm) effacement and dilatation

Second Full dilatation to delivery of

Expulsion of fetus
Stage baby

Third Delivery of baby to expulsion

Placental separation and expulsion
Stage of placenta

Fourth Observation for maternal

First hour postpartum
Stage stabilization
5. Nursing Management and Care During Labour
A. First Stage
• Monitor vital signs, contractions, fetal heart rate (FHR)
• Provide emotional support and privacy
• Encourage voiding every 2 hours
• Maintain hydration and nutrition (if allowed)
• Perform per vaginal examinations (as per policy)
• Maintain partograph to monitor progress
• Educate about breathing and relaxation techniques
B. Second Stage
• Encourage bearing down with contractions
• Ensure bladder is empty
• Prepare delivery tray and neonatal resuscitation kit
• Monitor FHR every 5 minutes
• Assist with safe delivery

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• Support episiotomy if indicated

• Receive and place baby on mother’s abdomen (skin-to-skin)
• Clamp and cut the cord safely
C. Third Stage
• Watch for signs of placental separation
• Assist in delivery of placenta using controlled cord traction
• Administer uterotonics (e.g., oxytocin 10 IU IM)
• Examine placenta and membranes for completeness
• Monitor for PPH (Postpartum Hemorrhage)
• Check vital signs and uterine tone
• Repair episiotomy/lacerations under aseptic precautions
D. Fourth Stage
• Monitor maternal vital signs every 15 mins for 1 hour
• Observe for bleeding, uterine firmness, bladder status
• Support bonding and early breastfeeding initiation
• Ensure mother’s comfort and hygiene
• Record all observations and events
6. Use of the Partograph
• Graphical tool used to monitor progress of labor
• Tracks cervical dilatation, fetal heart rate, contractions, maternal
vitals
• Early detection of prolonged or obstructed labour
7. Non-Pharmacological Pain Relief
• Breathing and relaxation techniques
• Massage and back rubbing
• Change in positions
• Warm bath or compress
• Support from birth companion/doula
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8. Danger Signs During Labour

• Prolonged labour (>12 hrs)
• Meconium-stained liquor
• Excessive vaginal bleeding
• Absent fetal heart sounds
• Cord prolapse
• Retained placenta (>30 mins)
Possible Outcome Questions
Two Marks
1. Define labour.
2. Mention two signs of onset of true labour.
Five Marks
1. Write the nursing care during the first stage of labour.
2. List the stages of labour and events occurring in each.
Ten Marks
1. Explain the physiology of labour and describe the nursing management
across all four stages.
2. Describe the role of the nurse in the safe and effective management of
labour using the partograph.
Normal Labour and Birth
1. Definition
Normal labour and birth is a spontaneous onset of labour at term (37–42
weeks), with progression of uterine contractions, cervical dilatation and
effacement, and delivery of the fetus and placenta without complications,
using no or minimal medical intervention, and resulting in the birth of a
healthy baby and healthy mother.
2. Characteristics of Normal Labour
• Spontaneous onset at term
• Vertex presentation (cephalic, head-first)

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• No use of instrumental delivery (forceps/vacuum)

• Single fetus
• Labour progresses within expected timeframes
• No maternal or fetal distress
• Natural expulsion of the placenta within 30 minutes
• Minimal or no complications during labour
3. Stages of Normal Labour
Stage Duration Physiological Events

First 8–12 hours in primigravida, 6–8 From onset of true labour to full
Stage hours in multigravida cervical dilatation (10 cm)

Second From full dilatation to delivery of

30–90 minutes
Stage baby

Third Delivery of placenta and

5–30 minutes
Stage membranes

Fourth Observation for maternal

First 1–2 hours after placenta
Stage stabilization and bleeding control

4. Mechanism of Labour (Cardinal Movements)

1. Engagement – Fetal head enters pelvic brim
2. Descent – Downward movement through pelvis
3. Flexion – Chin to chest, smallest diameter presents
4. Internal rotation – Head rotates to align with pelvis
5. Extension – Head extends as it emerges
6. Restitution and External rotation – Realignment of the head
7. Expulsion – Entire body is born
5. Management and Care During Normal Labour and Birth
A. First Stage
• Monitor contractions, fetal heart rate, vitals, and progress (Partograph)

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• Encourage voiding, light eating, and walking

• Provide emotional support and pain relief (non-pharmacologic or
analgesia)
• Maintain hygiene and privacy
• Monitor for rupture of membranes and signs of distress
B. Second Stage
• Position woman comfortably (lithotomy/squatting/semi-recumbent)
• Guide mother to bear down effectively during contractions
• Monitor fetal descent, heart rate, and perineum
• Prepare sterile delivery setup
• Support perineum to prevent tears
• Suction baby’s airway if needed after birth
• Dry and stimulate baby; initiate skin-to-skin contact and breastfeeding
C. Third Stage
• Watch for signs of placental separation
• Controlled cord traction (if active management)
• Administer uterotonic drug (e.g., oxytocin)
• Check for completeness of placenta and membranes
• Inspect for vaginal/cervical tears and manage accordingly
D. Fourth Stage
• Monitor mother’s vitals, uterine contraction, vaginal bleeding
• Promote bonding and breastfeeding
• Ensure mother comfort and rest
• Document labour events and newborn details
6. Role of Nurse During Normal Labour
• Observe and record labour progress on Partograph
• Provide emotional support and coaching
• Encourage hydration, breathing techniques, and movement
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• Promote respectful maternity care (RMC)

• Ensure infection prevention practices
• Assist with neonatal resuscitation if needed
• Maintain records and documentation
7. Signs of Normal Birth Outcomes
• Baby cries spontaneously and breathes well
• APGAR score is ≥ 7 at 1 and 5 minutes
• Placenta delivered within 30 minutes
• No excessive maternal bleeding
• Mother is alert, oriented, and stable
Possible Outcome Questions
Two Marks
1. Define normal labour.
2. Name the four stages of labour.
Five Marks
1. Write the characteristics of normal labour.
2. Describe the role of a nurse during the second stage of labour.
Ten Marks
1. Explain the mechanism of labour and nursing management during each
stage.
2. Describe the stages of labour with the physiological changes and the
nurse’s responsibilities
Onset of Birth / Labour
1. Definition
Labour is the physiological process by which the fetus, placenta, and
membranes are expelled from the uterus through the birth canal.
The onset of labour refers to the beginning of true labour, marked by regular
uterine contractions that lead to progressive cervical effacement and
dilatation.

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2. Features of Onset of True Labour

• Regular and rhythmic uterine contractions
o Start mildly and gradually become stronger, longer, and more
frequent (every 3–5 minutes)
• Pain starts in the back and radiates to the lower abdomen
• Progressive cervical effacement (thinning) and dilatation (opening)
• Show: Passage of blood-tinged mucus plug due to cervical changes
• Rupture of membranes (may or may not occur at onset)
• Descent of fetal head into the pelvis (engagement)
3. False Labour vs True Labour
Feature False Labour True Labour

Contractions Irregular, short-lived Regular, progressive

Intensity Does not increase Increases with time

Duration No pattern Lasts longer with time

Location Abdomen only Starts in back, radiates to abdomen

Effect of rest Contractions stop No relief with rest

Cervical change No effacement/dilatation Progressive changes present

Show Absent May be present

4. Hormonal Changes Leading to Onset of Labour
• Increased estrogen: Stimulates uterine sensitivity to oxytocin
• Decreased progesterone: Reduces uterine quiescence
• Oxytocin: Released from posterior pituitary, increases uterine
contractions
• Prostaglandins: Produced by decidua and fetal membranes, soften cervix
and enhance contractions
• Fetal cortisol: Helps in placental aging and prostaglandin release
5. Signs Preceding Labour (Pre-labour Signs)

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These may occur days to weeks before actual labour begins:

• Lightening: Descent of fetal head into the pelvis (more common in
primigravida)
• Increased vaginal discharge
• Backache and pelvic pressure
• Braxton Hicks contractions become more noticeable
• Bloody show: Mucous plug discharge
• Sudden burst of energy ("nesting instinct")
6. Factors Influencing Onset of Labour
• Maturity of fetal hypothalamic-pituitary-adrenal axis
• Uterine distension and stretch receptors
• Aging of the placenta
• Maternal stress or activity level
Nurse’s Role at Onset of Labour
• Assess frequency, duration, and intensity of contractions
• Monitor fetal heart rate
• Evaluate cervical status (effacement/dilatation)
• Check for rupture of membranes (fluid color, amount, odor)
• Provide emotional reassurance and information to the mother
• Start partograph to monitor labour progress
• Encourage mother to stay calm and practice relaxation technique
Possible Outcome Questions
Two Marks
1. Define true labour.
2. Mention two signs of the onset of true labour.
Five Marks
1. Differentiate between false and true labour.
2. List the premonitory signs of labour and explain their significance.
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Ten Marks
1. Describe the hormonal and physiological changes that lead to the onset of
labour.
2. Explain the features of true labour and the nursing management at its
onset.
Per Vaginal Examination (If Necessary)
1. Definition
Per Vaginal Examination (P/V Examination) is a manual examination of
the vaginal canal and cervix using sterile gloved fingers to assess the
progress of labour and the status of the cervix, membranes, and fetal presenting
part.
2. Purpose of P/V Examination
• To assess cervical effacement and dilatation
• To determine the position and station of the fetal presenting part
• To evaluate the status of membranes (intact or ruptured)
• To assess pelvic adequacy (if required)
• To confirm progress of labour
• To rule out cord prolapse or complications after rupture of membranes
3. Indications for P/V Examination
• At onset of labour for initial assessment
• When there is a change in contraction pattern or maternal symptoms
• To assess labour progress (usually every 4 hours unless otherwise
indicated)
• Prior to administering analgesics/anesthesia
• When patient feels urge to bear down (to confirm full dilatation)
• After rupture of membranes, to rule out cord prolapse (if not already
dilated)
4. Contraindications
• Placenta previa (unless placenta location is confirmed)
• Active vaginal bleeding of unknown origin
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• Premature rupture of membranes in preterm labor (to minimize

infection risk)
• Frequent repetition in short intervals (increases infection risk)
5. Preparation for P/V Examination
• Explain the procedure and gain informed verbal consent
• Ensure privacy and dignity (use screen or curtain)
• Prepare sterile gloves, lubricant, and light source
• Maintain aseptic technique
• Position woman in dorsal or lithotomy position with knees flexed
• Ask the woman to empty bladder before examination
• Wash and dry hands before and after the procedure
6. Procedure Steps
• Wear sterile gloves
• Lubricate index and middle finger
• Gently insert two fingers into the vaginal canal
• Assess the following:
1. Cervical effacement (measured in %)
2. Cervical dilatation (in cm, from 0–10 cm)
3. Station (fetal presenting part in relation to ischial spines)
4. Presentation (e.g., vertex, breech)
5. Position of the presenting part (LOA, ROA, etc.)
6. Status of membranes (intact, bulging, ruptured)
7. Presence of caput/moulding
8. Any abnormal findings (e.g., cord prolapse, bleeding)
• Gently withdraw fingers and dispose of gloves safely
• Document all findings accurately in the labour record or partograph
7. Frequency of P/V Examination in Labour

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Labour Stage Recommended Interval

Latent phase Every 4–6 hours or as needed

Active phase Every 4 hours or if indicated

Second stage Only when urge to push is present or on maternal request

8. Complications/Risks (if not done correctly)
• Introduction of infection
• Discomfort or trauma to cervix or vaginal wall
• Accidental rupture of membranes
• Misinterpretation of findings if performed improperly
9. Nurse’s Responsibilities
• Explain and prepare the woman physically and emotionally
• Maintain strict asepsis
• Provide emotional support and reassurance
• Avoid unnecessary repetition of examination
• Record time, findings, and signature in documentation
• Monitor for any adverse reactions
Possible Outcome Questions
Two Marks
1. What is the purpose of per vaginal examination during labour?
2. Mention one contraindication of per vaginal examination.
Five Marks
1. List the steps and assessments done during per vaginal examination.
2. What are the nursing responsibilities during per vaginal examination?
Ten Marks
1. Explain in detail the purpose, indications, contraindications, and
procedure of per vaginal examination during labour.
Stages of Labour

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1. Definition of Labour
Labour is the physiological process by which the fetus, placenta, and
membranes are expelled from the uterus through the birth canal, typically
between 37 and 42 weeks of gestation.
2. Stages of Labour
Labour is divided into four stages, each with distinct events and management.
I. First Stage of Labour
Duration:
• Primigravida: ~8–12 hours
• Multigravida: ~6–8 hours
Begins: With onset of regular uterine contractions
Ends: With full cervical dilatation (10 cm)
A. Phases of First Stage:
1. Latent Phase:
o Cervical dilatation: 0–3 cm
o Contractions: mild, irregular
o Duration: ~6–8 hours
2. Active Phase:
o Cervical dilatation: 4–7 cm
o Contractions: stronger, more regular (every 3–5 mins)
o Duration: ~3–6 hours
3. Transition Phase:
o Cervical dilatation: 8–10 cm
o Contractions: very strong, every 2–3 mins
o Shortest but most intense phase
Nursing Management:
• Monitor contractions, FHR, vitals
• Encourage urination every 2 hrs

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• Emotional support and breathing techniques

• Start partograph to monitor labour progress
• Ensure adequate hydration and comfort
II. Second Stage of Labour
Duration:
• Primigravida: ~30–90 minutes
• Multigravida: ~15–45 minutes
Begins: With full cervical dilatation (10 cm)
Ends: With delivery of the baby
Physiological Events:
• Mother has an urge to bear down
• Fetal descent through the birth canal
• Crowning and delivery of the baby
Nursing Management:
• Encourage effective pushing with contractions
• Monitor FHR every 5 minutes
• Assist in safe delivery
• Suction baby’s mouth and nose if needed
• Dry and place baby on mother's chest
• Initiate skin-to-skin contact and breastfeeding
• Maintain a sterile field
• Support perineum to reduce tears
III. Third Stage of Labour
Duration: 5–30 minutes
Begins: After birth of the baby
Ends: With expulsion of placenta and membranes
Physiological Events:
• Uterine contractions resume

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• Placental separation signs: gush of blood, lengthening of cord

• Placenta expelled with membranes
Nursing Management:
• Administer uterotonics (e.g., oxytocin 10 IU IM)
• Perform controlled cord traction (CCT)
• Inspect placenta for completeness
• Monitor for postpartum hemorrhage (PPH)
• Check and repair perineal tears or episiotomy
IV. Fourth Stage of Labour
Duration: 1–2 hours after placenta delivery
Begins: With placenta expulsion
Ends: With maternal stabilization
Physiological Events:
• Uterus contracts and remains firm
• Hemostasis achieved
Nursing Management:
• Monitor vital signs every 15 mins
• Palpate uterine fundus for firmness
• Observe vaginal bleeding
• Promote bonding and breastfeeding
• Provide warmth, hygiene, and comfort
• Record all events
Summary Table: Stages of Labour
Stage Start – End Key Events Nurse’s Role

Onset of labour – Full

I Cervical changes Monitor, support, document
dilatation

Full dilatation – Baby

II Baby expelled Assist delivery, monitor FHR
birth

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Stage Start – End Key Events Nurse’s Role

Placenta Administer oxytocin, inspect

III Birth – Placenta expelled
separation placenta

Monitor vitals, fundus,

IV After placenta – 1–2 hrs Stabilization
bleeding
Possible Outcome Questions
Two Marks
1. How many stages are there in labour?
2. What is the duration of the second stage in a primigravida?
Five Marks
1. Describe the events of the third stage of labour.
2. Write short notes on nursing care in the first stage of labour.
Ten Marks
1. Explain all the stages of labour with nursing responsibilities.
2. Discuss the physiological changes and management in each stage of
labour.
Organization of Labour Room – Triage and Preparation for Birth
1. Definition
Labour room organization refers to the systematic arrangement of space,
staff, and equipment to ensure safe, efficient, respectful, and timely care to
the mother and newborn throughout the intrapartum period.
2. Labour Room Zones and Areas
A well-organized labour room is divided into functional zones for smooth
workflow:
1. Triage Area
o First point of contact
o Assessment of labour status and maternal-fetal condition
o Decision-making for admission/referral
2. Admission Area

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o Registration, initial observation, documentation

3. First Stage Room / Early Labour Bay
o Monitoring of latent and active labour
o Comfortable and private environment
4. Second Stage (Delivery) Room
o For active labour and delivery
o Equipped with delivery table, radiant warmer
5. Third and Fourth Stage Recovery Area
o Observation for immediate postpartum period (1–2 hrs)
o Monitoring of maternal vitals, bleeding, bonding
6. Newborn Care Corner (NBCC)
o For immediate assessment, resuscitation, and warmth
o Located within 2 meters of delivery area
7. Septic Room
o For delivery of high-risk or infected mothers (e.g., HIV, hepatitis)
3. Labour Triage System
Triage helps prioritize care based on maternal and fetal condition.
Colour
Triage Category Action
Code

Category 1 – Immediate intervention (e.g., eclampsia,

Red
Emergency abruption, fetal distress)

Category 2 – Evaluation within 30 minutes (e.g., PROM,

Yellow
Urgent mild preeclampsia)

Category 3 – Non-
Green Routine care (e.g., early labour)
urgent
Components of Triage Assessment:
• Chief complaint and history
• Gestational age

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• Fetal movements
• Vital signs
• Uterine contractions
• Fetal heart rate
• Vaginal discharge/bleeding
• Cervical dilatation (if needed)
4. Preparation for Birth
A. Staff Preparedness
• Trained obstetric nurse/midwife available 24x7
• Emergency protocols known to all staff
• Availability of backup obstetrician, anesthetist, pediatrician
B. Physical Setup
• Clean, well-ventilated, and well-lit rooms
• Privacy screens or curtains
• Emergency exits clearly marked
• Birth companion allowed as per policy
C. Equipment and Supplies Checklist
Maternal Equipment Newborn Equipment

Delivery set (sterile) Radiant warmer

Episiotomy set Suction device

Suturing materials Bag and mask (neonatal size)

Oxytocin injection Sterile cord clamp

IV fluids and cannulas Weighing scale

Emergency drugs (MgSO4, antihypertensives) APGAR chart

Gloves, gowns, pads Newborn identification tags

D. Infection Prevention and Control

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• Availability of handwashing station

• PPE (gloves, masks, aprons)
• Biomedical waste disposal bins (color coded)
• Disinfection of surfaces and instruments
E. Documentation
• Labour and delivery register
• Partograph
• Case records
• Consent forms
• NBCC documentation
5. Essential Policies to be Displayed
• Labour triage flowchart
• Emergency referral numbers
• AMTSL protocol
• Essential newborn care guidelines
• Rights of women in labour
6. Nurse's Responsibilities in Labour Room
• Perform initial triage and assessment
• Maintain clean and ready environment
• Prepare equipment and arrange delivery sets
• Explain procedures to the woman and gain consent
• Ensure availability of skilled birth attendant
• Prepare birth companion and encourage emotional support
• Monitor mother and fetus per protocol
• Keep emergency drugs and neonatal resuscitation kit ready
Possible Outcome Questions
Two Marks

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1. What is triage in the labour room?

2. Name two zones in a well-organized labour room.
Five Marks
1. Describe the organization of a labour room and the purpose of triage.
2. List the essential equipment required in the delivery room.
Ten Marks
1. Explain the triage process and organization of a modern labour room with
nursing responsibilities.
2. Discuss the preparation needed for birth and immediate newborn care.
Positive Birth Environment
1. Definition
A positive birth environment refers to a supportive, respectful, safe, clean,
and emotionally empowering space that enhances a woman’s physical,
emotional, and psychological well-being during childbirth, promoting positive
birth experiences and better outcomes for both mother and baby.
2. Key Components of a Positive Birth Environment
• Respect and Dignity
o Respect for woman’s rights, choices, privacy, and culture
o Non-discriminatory, compassionate care
o Informed decision-making encouraged
• Clean, Comfortable, and Safe Physical Setting
o Adequate ventilation and lighting
o Cleanliness and infection control maintained
o Access to water, sanitation, and hand hygiene facilities
o Comfortable birthing beds, clean linen
• Emotional Support and Birth Companionship
o Presence of birth companion of woman’s choice
o Continuous support and reassurance
o Caring and non-judgmental communication
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• Privacy and Confidentiality

o Use of curtains, partitions, or private rooms
o Minimal exposure during examinations
o Respect for confidentiality of patient information
• Freedom of Movement and Position
o Woman encouraged to walk, sit, squat, or lie in preferred positions
o Support for upright birthing positions when possible
• Pain Relief Options
o Non-pharmacological: breathing techniques, massage, warm
compresses
o Pharmacological: analgesics, epidural (if available and appropriate)
• Effective Communication
o Clear explanations in local language
o Involving the woman in all decisions
o Listening to her concerns and preferences
• Positive and Responsive Health Care Providers
o Skilled, compassionate, and respectful staff
o Timely and evidence-based interventions
o Support for delayed cord clamping, skin-to-skin contact, and early
breastfeeding
3. Importance of a Positive Birth Environment
• Reduces labour complications and intervention rates
• Promotes maternal satisfaction and emotional well-being
• Encourages natural progression of labour
• Improves bonding and breastfeeding outcomes
• Builds trust between woman and healthcare system
4. Role of the Nurse/Midwife
• Establish trust and rapport with the woman

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• Advocate for her needs and preferences

• Provide emotional encouragement and continuous presence
• Maintain cleanliness, safety, and privacy in the labour area
• Respect cultural practices (as long as they are safe)
• Facilitate the presence of a birth companion
• Support and encourage woman-centered car
5. WHO Recommendations for Positive Childbirth Experience
• Respectful maternity care
• Emotional support
• Effective pain relief
• Freedom of movement
• Evidence-based interventions
• Involvement in decision-making
Possible Outcome Questions
Two Marks
1. What is a positive birth environment?
2. Mention two characteristics of a positive labour room environment.
Five Marks
1. List the key components of a positive birth environment.
2. What is the nurse's role in creating a positive birth environment?
Ten Marks
1. Explain the importance and components of a positive birth environment
in maternity care.
2. Describe how a midwife can support a woman in labour through a
positive childbirth experience.
Respectful Care and Compassionate Communication in Maternity Services
1. Definition

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• Respectful Maternity Care (RMC) is a universal human right that

recognizes a woman’s right to dignity, privacy, confidentiality,
informed choice, and continuous support during labour and childbirth.
• Compassionate Communication involves empathetic listening, non-
verbal support, kindness, and clear, honest interaction with women
and families during the perinatal period.
2. Key Principles of Respectful Maternity Care
1. Dignity and Respect
o Treating every woman with courtesy and non-judgment
o Avoiding shouting, scolding, or verbal abuse
2. Privacy and Confidentiality
o Using curtains or screens
o Limiting exposure during examinations
o Keeping patient information confidential
3. Informed Consent and Autonomy
o Explaining all procedures and obtaining consent
o Encouraging decision-making by the woman
4. Freedom from Harm and Ill Treatment
o No physical or verbal abuse
o Avoiding unnecessary interventions
5. Equality and Non-Discrimination
o Providing care irrespective of age, caste, religion, economic status
6. Enabling Supportive Care
o Allowing birth companion
o Providing comfort measures during labour
7. Continuity of Care
o Ensuring uninterrupted support throughout the childbirth process
3. Key Elements of Compassionate Communication
• Use of clear, simple, and culturally appropriate language
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• Active listening without interruption

• Non-verbal cues: eye contact, nodding, gentle tone
• Acknowledge emotions: fear, anxiety, pain
• Provide honest, timely information
• Offer emotional encouragement: “You’re doing well”, “We are here for
you”
4. Strategies to Ensure Respectful and Compassionate Care
• Educate staff on human rights-based care
• Regular monitoring of patient feedback
• Encourage presence of birth companion
• Display RMC charters and maternal rights posters in labour room
• Promote woman-centered care plans
• Maintain a clean, safe, and private birthing space
5. Nurse’s Role in Promoting RMC and Compassionate Communication
• Greet women warmly, introduce self
• Explain each step/procedure before performing
• Address concerns, anxieties, and cultural beliefs
• Avoid harsh language or negative attitude
• Encourage the woman to express her needs
• Support decision-making (position in labour, pain relief, etc.)
• Educate family about respectful care practices
• Advocate for zero tolerance of abuse in healthcare settings
6. Benefits of Respectful and Compassionate Care
• Enhances positive birth experience
• Reduces labour stress and anxiety
• Promotes maternal satisfaction and cooperation
• Encourages institutional delivery
• Improves mother-baby bonding and breastfeeding
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Possible Outcome Questions

Two Marks
1. What is respectful maternity care?
2. Mention one principle of compassionate communication.
Five Marks
1. Write five principles of respectful maternity care.
2. Describe the role of a nurse in ensuring compassionate care during labour.
Ten Marks
1. Discuss the key principles and importance of respectful maternity care.
2. Explain how a midwife ensures respectful and compassionate
communication in labour and delivery settings.
Drugs Used in Labour (As per GoI Guidelines)
1. Introduction
During labour, specific drugs are used to initiate, augment, monitor, and
manage various stages of labour and delivery to ensure the safety of both
mother and baby. The Ministry of Health and Family Welfare (MoHFW),
Government of India (GoI) recommends a list of essential drugs in labour
based on evidence-based practices and aligned with WHO standards.
2. Categories of Drugs Used in Labour
Category Purpose Common Drugs

To induce or augment labour, Oxytocin, Misoprostol,

Uterotonics
and prevent/manage PPH Methylergometrine

To delay preterm labour (in

Tocolytics Nifedipine
selected cases)

Pain relief and anxiety

Analgesics/Sedatives Tramadol, Diazepam
reduction

Management of Labetalol, Nifedipine,

Antihypertensives
preeclampsia/eclampsia Methyldopa

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Category Purpose Common Drugs

Prevent/treat seizures in
Anticonvulsants Magnesium sulfate
eclampsia

Antiemetics Manage nausea/vomiting Ondansetron

Infections, PROM, or
Antimicrobials Ampicillin, Ceftriaxone
prophylaxis

Anesthetics For episiotomy or cesarean Lignocaine

3. Essential Drugs Used – Detailed Description
A. Oxytocin
• Use: Induction, augmentation of labour, active management of third stage
of labour (AMTSL), prevention and treatment of PPH
• Dose:
o Labour induction: 5 IU in 500 ml DNS/NS
o AMTSL: 10 IU IM after delivery of anterior shoulder or baby
• Route: IV infusion or IM
• Storage: Cold chain (2–8°C)
B. Misoprostol
• Use: Cervical ripening, labour induction, PPH prevention and treatment
• Dose:
o Induction: 25 mcg vaginally every 6 hours (max 200 mcg)
o PPH: 600 mcg orally or 800 mcg sublingually
• Route: Oral, vaginal, or sublingual
• Storage: Room temperature, dry place
C. Methylergometrine (Methergine)
• Use: Prevention and treatment of PPH
• Dose: 0.2 mg IM/IV
• Contraindication: Hypertension, preeclampsia
D. Magnesium Sulfate (MgSO₄)
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• Use: Eclampsia/severe preeclampsia seizure prophylaxis

• Dose:
o Loading: 4 g IV + 5 g IM in each buttock
o Maintenance: 5 g IM 4-hourly
• Monitoring: Patellar reflex, urine output, respiratory rate
E. Nifedipine
• Use: Antihypertensive (preeclampsia), tocolysis (off-label)
• Dose: 10 mg oral every 6–8 hrs
• Route: Oral
F. Labetalol
• Use: Antihypertensive in pregnancy
• Dose: 20–40 mg IV bolus, then maintenance as per BP
• Route: IV/Oral
G. Tramadol
• Use: Moderate pain relief
• Dose: 50–100 mg IM or IV
• Note: Caution in labour due to neonatal respiratory depression
H. Diazepam
• Use: Sedation, management of eclampsia
• Dose: 10 mg IV slowly
• Note: Not preferred over MgSO₄
I. Lignocaine 1%
• Use: Local anesthesia for episiotomy/laceration repair
• Dose: 5–10 ml infiltration
• Route: Local infiltration
4. Protocol-Based Drug Use: AMTSL (GoI Recommended)
Drugs used:

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• Oxytocin 10 IU IM – preferred
• Misoprostol 600 mcg orally – where oxytocin is not available
• Methylergometrine 0.2 mg IM – if no hypertensio
5. Essential PPH Management Kit (as per GoI)
• Oxytocin
• Misoprostol
• Methergine
• IV set with fluids
• Magnesium sulfate
• Tranexamic acid (in some protocols)
6. Storage and Inventory Practices (GoI Norms)
• Maintain cold chain for oxytocin
• Stock misoprostol in original blister packs
• Keep emergency drug tray ready
• Regularly check expiry dates and replenish stock
7. Nurse’s Responsibilities
• Verify correct drug, dose, route, time
• Monitor maternal vitals and fetal heart rate
• Document administration and response
• Educate woman/family on reason for drug use
• Ensure safe storage and availability of emergency drugs
Possible Outcome Questions
Two Marks
1. Name two uterotonic drugs used in AMTSL.
2. What is the storage requirement for oxytocin?
Five Marks
1. List the commonly used drugs in labour as per GoI.

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2. Write short notes on misoprostol and its role in labour.

Ten Marks
1. Describe the drugs used during labour, their indications, and nursing
responsibilities.
2. Discuss the active management of third stage of labour and drugs used in
it.
First Stage of Labour – Physiology of Normal Labour
1. Definition of First Stage of Labour
The first stage of labour begins with the onset of true regular uterine
contractions and ends with full cervical dilatation (10 cm).
It is the longest stage of labour, especially for primigravida women.
2. Phases of First Stage
Cervical
Phase Key Characteristics
Dilatation

Mild, infrequent contractions; cervix softens

Latent Phase 0–3 cm
and effaces

Stronger, more regular contractions; rapid

Active Phase 4–7 cm
cervical dilatation

Transition Intense contractions; maximal discomfort;

8–10 cm
Phase rapid final dilatation
3. Physiological Changes in First Stage of Labour
A. Uterine Contractions
• Begin from the fundus (upper segment) and spread downward
• Cause cervical effacement (thinning) and dilatation (opening)
• Help descend the fetus into the pelvis
• Become more frequent, intense, and regular as labour progresses
B. Cervical Effacement and Dilatation
• Effacement: Shortening and thinning of the cervix (from 2–3 cm to paper
thin)
• Dilatation: Opening of the cervix from 0 to 10 cm
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• Occurs due to uterine contractions and fetal head pressure

C. Formation of the Bag of Waters (Amniotic Sac)
• Lower uterine segment stretches, forming a fluid-filled pouch
• Acts as a hydrostatic wedge to assist in dilatation
• May rupture spontaneously (SROM) or be artificially broken (ARM)
D. Fetal Descent and Engagement
• Fetus starts to descend into the maternal pelvis
• Engagement: BPD of fetal head passes pelvic inlet
• Helps apply pressure on the cervix for faster dilatation
E. Bloody Show
• Mucus plug dislodges from cervix
• Mixed with blood from ruptured capillaries due to cervical changes
• Indicates that labour is progressing
F. Maternal Systemic Responses
• Increased heart rate and blood pressure
• Hyperventilation due to pain and anxiety
• Increased white blood cells as stress response
• Frequent urination or defecation due to pelvic pressure
4. Hormonal Influence in First Stage of Labour
Hormone Role

Oxytocin Stimulates uterine contractions

Prostaglandins (PGF2α, PGE2) Cervical ripening and contractions

Estrogen Enhances oxytocin receptor sensitivity

Relaxin Softens cervix and ligaments

Endorphins Natural pain relief during contractions

5. Nursing Responsibilities in First Stage of Labour
• Monitor uterine contractions (frequency, duration, intensity)
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• Assess fetal heart rate using Doppler or CTG

• Check cervical dilatation and effacement through per vaginal exam (as
indicated)
• Support the woman with breathing techniques, positioning, hydration
• Maintain privacy, calm environment, and encourage birth companion
• Observe for rupture of membranes, colour of amniotic fluid
• Monitor maternal vital signs and emotional state
• Record findings on partograph
6. Signs of Progress in First Stage
• Increasing frequency and strength of contractions
• Gradual cervical effacement and dilatation
• Bloody show and descent of presenting part
• Maternal urge to bear down (towards second stage)
Possible Outcome Questions
Two Marks
1. Define first stage of labour.
2. What are the phases of the first stage of labour?
Five Marks
1. List the physiological changes in the first stage of labour.
2. Describe the role of oxytocin and prostaglandins during labour.
Ten Marks
1. Describe the physiology of the first stage of labour with hormonal
influence.
2. Explain the phases of the first stage and nursing care during this stage.
Monitoring Progress of Labour Using Partograph / Labour Care Guide
1. Introduction
• Partograph is a simple, evidence-based tool used for the systematic
monitoring of progress of labour and early detection of complications.

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• The Labour Care Guide (LCG) is the updated WHO tool replacing the
traditional partograph, promoting woman-centered care, decision-
making, and quality intrapartum care.
2. Purpose of the Partograph / Labour Care Guide
• Monitor maternal and fetal well-being
• Track progress of labour (especially cervical dilatation)
• Detect and prevent prolonged/obstructed labour
• Guide timely interventions and referral
• Promote evidence-based decision making
3. Traditional WHO Partograph – Key Components
A. Fetal Monitoring
• Fetal heart rate (every 30 min)
• Amniotic fluid (color, amount)
• Molding of fetal skull bones
B. Labour Progress
• Cervical dilatation (plotted on graph, hourly)
• Descent of the fetal head
• Uterine contractions (frequency, duration, intensity)
C. Maternal Monitoring
• Pulse (every 30 min), BP (4-hourly), temperature (4-hourly)
• Urine output (for volume, protein, acetone)
• Drugs/IV fluids given
4. Interpretation of the Graph: Alert and Action Lines
Line Meaning

Alert Line Indicates expected rate of cervical dilatation (1 cm/hour)

Action 4 hours to the right of alert line; action required if labour crosses
Line this line

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5. WHO Labour Care Guide (LCG) – Modern Replacement

Structure of LCG (2020 WHO):
1. Supportive Care: Birth companion, mobility, oral fluids
2. Monitoring:
o Fetal well-being: FHR, amniotic fluid, position
o Labour progress: Cervical dilatation, contraction details
o Maternal well-being: Vitals, pain, urine, medications
3. Decision-making: Space for documentation of clinical findings,
interventions, rationale
Features of LCG:
• Starts at ≥5 cm cervical dilatation
• Includes woman’s preferences and rights
• More holistic approach than traditional partograph
• Emphasizes clinical judgment and respectful care
6. Cervical Dilatation vs. Time (Graph Sample)
Time (Hours) 0123456

Cervical Dilatation (cm) 4 5 6 7 8 9 10

Note: Plot on graph paper against Alert and Action lines for interpretation.
7. Nursing Responsibilities in Using Partograph / LCG
• Initiate charting at active labour (≥4 cm for partograph; ≥5 cm for LCG)
• Assess and record FHR, contractions, BP, pulse, urine, etc. timely
• Identify delayed progress or distress
• Communicate findings to senior staff
• Ensure documentation and safe referral if required
• Provide respectful, supportive care throughout
8. Benefits of Using Partograph / LCG
• Reduces maternal and neonatal morbidity/mortality

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• Helps identify deviations early

• Guides appropriate interventions
• Ensures standardized, quality care
Possible Outcome Questions
Two Marks
1. What is the alert line in the partograph?
2. At what cervical dilatation is LCG initiated?
Five Marks
1. Write the advantages of using a partograph.
2. What are the components recorded in the WHO Labour Care Guide?
Ten Marks
1. Describe the structure and interpretation of the partograph and its use in
monitoring labour.
2. Explain the Labour Care Guide and how it improves quality intrapartum
care.
Assessing and Monitoring Fetal Well-Being
1. Introduction
• Assessing fetal well-being during pregnancy and labour is crucial to
ensure that the fetus is developing normally, receiving adequate
oxygen, and is not in distress.
• Regular monitoring helps in early detection of complications and
planning timely interventions to ensure a safe birth outcome.
2. Objectives of Fetal Well-Being Monitoring
• Ensure adequate oxygenation and placental function
• Detect signs of fetal hypoxia or distress
• Guide clinical decisions in high-risk and normal pregnancies
• Reduce perinatal morbidity and mortality
3. Methods of Assessing Fetal Well-Being
A. Clinical Methods

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1. Fetal Movement Count (FMC/DFMC – Daily Fetal Movement

Count)
o Perceived by the mother
o Normal: ≥10 movements in 12 hours
o Fewer than 3 movements in 1 hour = further evaluation required
2. Symphysis Fundal Height (SFH)
o Assesses uterine growth and fetal size
o Measured from 20 weeks onward
o Correlates in cm with gestational age (from 24–36 weeks)
3. Abdominal Palpation (Leopold’s Maneuvers)
o Determines fetal lie, presentation, position, and engagement
o Helps detect multiple gestation or IUGR
4. Auscultation of Fetal Heart Rate (FHR)
o Normal rate: 110–160 bpm
o Tools used: Pinnard’s stethoscope, Doppler, CTG
o Performed every 30 minutes in active labour; every 5 minutes in
second stage
B. Electronic and Imaging Methods
Method Purpose Interpretation

Visualizes fetal
Detects anomalies, IUGR,
Ultrasonography (USG) anatomy, growth, AFI,
multiple pregnancy
placenta

Cardiotocography
Records FHR with Reactive (normal): 2
(CTG/Non-Stress Test -
uterine contractions accelerations in 20 mins
NST)

Score out of 10: includes

Combines NST with
Biophysical Profile (BPP) FHR, tone, movement,
USG
breathing, AFI

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Method Purpose Interpretation

Measures blood flow

Abnormal flow = placental
Doppler Flow Studies in umbilical and
insufficiency
cerebral arteries
C. Biochemical Methods
1. Maternal Serum Screening (Quadruple Test) – detects fetal anomalies
2. Amniocentesis – genetic and chromosomal evaluation
3. Lecithin-Sphingomyelin Ratio (L:S Ratio) – assesses fetal lung maturity
4. Fetal Heart Rate Monitoring: Interpretation Guide
Parameter Normal Abnormal

Baseline FHR 110–160 bpm <110 or >160 bpm

Variability 6–25 bpm <5 or marked variability

Accelerations Present Absent

Decelerations None or early Late or variable

5. Amniotic Fluid Index (AFI)
• Normal AFI: 8–18 cm
• Oligohydramnios: <5 cm
• Polyhydramnios: >24 cm
• Assessed by ultrasound, important for fetal movement and lung
development
6. Nursing Responsibilities in Fetal Monitoring
• Educate mother on kick count technique
• Monitor and document FHR pattern, maternal vitals
• Prepare and assist with CTG, USG, NST, BPP
• Report abnormal findings immediately
• Provide psychological support and ensure privacy
• Maintain accurate documentation

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7. Signs of Fetal Distress

• FHR <110 or >160 bpm
• Persistent late decelerations
• Meconium-stained amniotic fluid
• Decreased fetal movements
• Abnormal BPP or Doppler flow studies
Possible Outcome Questions
Two Marks
1. What is the normal fetal heart rate range?
2. Define Daily Fetal Movement Count (DFMC).
Five Marks
1. List five methods of fetal well-being assessment.
2. What is a biophysical profile and how is it scored?
Ten Marks
1. Describe the clinical and electronic methods used to assess fetal well-
being.
2. Explain the interpretation of fetal heart rate patterns and their significance
in labour.
Evidence-Based Care During First Stage of Labour
1. Introduction
Evidence-based care during the first stage of labour aims to ensure safe,
respectful, and supportive childbirth experiences based on scientific research,
clinical expertise, and women's preferences.
It includes continuous monitoring, non-pharmacological support, and
interventions only when necessary, in line with WHO and GoI guidelines
2. Goals of Evidence-Based Care in First Stage
• Promote normal physiological birth
• Avoid unnecessary interventions
• Ensure maternal and fetal safety

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• Provide respectful maternity care (RMC)

• Improve maternal satisfaction and birth outcomes
3. Key Evidence-Based Interventions
A. Supportive Care and Environment
• Birth companion of choice should be allowed (improves outcomes)
• Ensure privacy, emotional support, and calm environment
• Encourage mobility, upright posture if no contraindications
• Provide clear information and informed consent
B. Monitoring Labour Progress
• Use Labour Care Guide (LCG) or WHO Partograph starting at ≥5 cm
dilatation
• Monitor contractions, FHR, maternal vitals, and cervical dilatation at
regular intervals
• Observe for signs of obstructed labour, fetal distress, or prolonged
labour
C. Non-Pharmacological Comfort Measures
• Encourage breathing exercises, massage, warm showers
• Use of birthing ball, music, relaxation techniques
• Avoid routine IV fluids or fasting unless indicated
• Allow oral fluids and light food in low-risk cases
D. Avoid Routine Interventions
• No routine amniotomy (artificial rupture of membranes) unless
indicated
• Avoid frequent vaginal examinations; perform only when necessary
(every 4 hours)
• Do not administer oxytocin for augmentation unless labour is prolonged
and monitored
• Avoid episiotomy in first stage; not relevant until second stage
E. Respectful Maternity Care (RMC)

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• Treat the woman with dignity, respect, and compassion

• Provide informed decision-making support
• Protect privacy and ensure confidentiality
• Avoid verbal or physical abuse
F. Pain Relief Options
• Offer non-pharmacologic methods first
• Use analgesics or epidural only with consent and clinical indication
• Explain risks and benefits of each method clearly
4. WHO Recommendations for First Stage (2020)
Area Recommendations

Duration Active phase may last up to 12 hours in nulliparous women

Vaginal Exams Every 4 hours; avoid excessive exams

Amniotomy Not routinely recommended

Oxytocin Only if progress is unsatisfactory

Mobility Encourage walking and upright positions

Food/Fluids Oral intake encouraged in low-risk women

5. Role of Nurse/Midwife in Evidence-Based Labour Care
• Educate and support the woman throughout labour
• Monitor and document labour parameters accurately using LCG or
Partograph
• Encourage birth companion and woman’s participation in decisions
• Provide emotional reassurance and manage pain effectively
• Ensure timely referral if labour deviates from normal
• Advocate for respectful and non-discriminatory care
6. Signs to Report Immediately
• Abnormal fetal heart rate (<110 or >160 bpm)
• Meconium-stained amniotic fluid

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• Prolonged labour or no progress

• Severe pain not relieved by rest/support
• Bleeding or signs of rupture uterus
Possible Outcome Questions
Two Marks
1. What is the purpose of evidence-based care during labour?
2. Mention two non-pharmacological comfort measures during labour.
Five Marks
1. List five evidence-based practices during the first stage of labour.
2. Describe the role of the nurse in supporting a woman during the first
stage.
Ten Marks
1. Explain the key components of evidence-based care during the first stage
of labour.
2. Discuss WHO recommendations for intrapartum care during the first
stage of labour.
Pain Management in Labour – Non-Pharmacological Methods
1. Introduction
• Labour pain is a natural physiological experience, but its intensity and
perception vary among women.
• Non-pharmacological methods offer safe, cost-effective, and
supportive approaches to help women cope with pain during labour.
• These methods do not interfere with the normal labour process and
help promote positive birth experiences
2. Objectives of Non-Pharmacological Pain Relief
• Enhance maternal comfort and relaxation
• Reduce anxiety, fear, and tension
• Promote normal labour progress
• Avoid unnecessary pharmacological interventions

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• Encourage active participation of the woman in childbirth

3. Common Non-Pharmacological Pain Relief Methods
A. Psychological Support
• Continuous support from nurse, birth companion, or doula
• Encouragement, reassurance, and positive reinforcement
• Maintain calm environment with minimal disturbance
• Address emotional needs and fear of labour
B. Breathing and Relaxation Techniques
• Controlled and rhythmic deep breathing
• Reduces anxiety and helps focus energy
• Helps with muscle relaxation and oxygenation
C. Positioning and Movement
• Encourage frequent position changes (upright, squatting, kneeling)
• Walking or rocking using a birthing ball or chair
• Hands-and-knees or side-lying positions reduce back pain
• Upright positions help in fetal descent and shorten labour
D. Touch and Massage
• Back massage (especially over the sacrum) during contractions
• Gentle stroking or effleurage
• Increases endorphin release and provides distraction from pain
E. Hydrotherapy
• Use of warm showers or water immersion (birthing pools)
• Promotes muscle relaxation and eases back and pelvic pain
F. Heat and Cold Application
• Warm compress on lower back, abdomen, or perineum
• Cold packs for localized pain or inflammation
G. Acupressure and Reflexology

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• Pressure on specific body points (e.g., LI-4, BL-32) to relieve pain

• Helps stimulate natural pain-relieving hormones
H. Distraction and Visualization
• Use of music therapy, guided imagery, or focus objects
• Visualization of calm scenes or happy memories to reduce perception of
pain
I. Aromatherapy
• Use of essential oils (e.g., lavender, peppermint) to soothe and relax
• Must ensure the woman has no allergy to fragrances
4. Benefits of Non-Pharmacological Methods
• No adverse effects on mother or baby
• Can be used in all stages of labour
• Encourages active participation of woman and companion
• Supports physiological birth process
• Promotes faster recovery and positive birth memorie
5. Role of the Nurse in Non-Pharmacological Pain Relief
• Educate and prepare the woman antenatally or on admission
• Encourage and assist in choosing comfortable positions
• Provide emotional support and encouragement
• Create a calm, private, and respectful birthing environment
• Monitor progress of labour while supporting comfort
• Involve birth companion to provide support and comfort
Possible Outcome Questions
Two Marks
1. List any two non-pharmacological methods of pain relief during labour.
2. What is the benefit of breathing techniques in labour?
Five Marks

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1. Describe any five non-pharmacological methods used for pain relief in

labour.
2. Write the nurse’s role in implementing non-pharmacological pain relief
during labour.
Ten Marks
1. Explain the various non-pharmacological techniques used for pain
management during labour and their advantages.
2. Discuss in detail the importance and application of psychological and
physical support methods during labour.
Psychological Support – Managing Fear During Labour
1. Introduction
• Labour is a physiological process, but it often triggers emotional
responses such as fear, anxiety, and uncertainty.
• Psychological support plays a key role in reducing fear, promoting
relaxation, and enhancing the woman’s ability to cope with labour.
• Unmanaged fear may lead to prolonged labour, increased pain, and
negative birth experience
2. Causes of Fear During Labour
• Fear of pain and physical discomfort
• Worry about complications or harm to self or baby
• Lack of knowledge or preparation
• Previous traumatic birth experience
• Loss of control or feeling isolated
• Fear of episiotomy, instrumental delivery, or C-section
3. Effects of Fear in Labour
• Increases catecholamine (stress hormones) release
• Decreases oxytocin production, leading to weak contractions
• May cause uterine dysfunction and prolonged labour
• Increases perception of labour pain
• May lead to emergency interventions
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4. Psychological Support Strategies

A. Emotional Reassurance
• Provide compassionate communication
• Use calm, encouraging words
• Offer genuine presence and attention
B. Continuous Support
• Presence of a birth companion (partner, doula, family member)
• Continuous presence of a nurse or midwife
• Studies show continuous support shortens labour and reduces fear
C. Education and Information
• Provide accurate explanations about labour process
• Discuss what to expect next and options available
• Clarify any misconceptions or myths
D. Involvement in Decision Making
• Respect the woman’s choices and preferences
• Involve her in care planning and informed consent
• Promotes sense of control and confidence
E. Relaxation Techniques
• Breathing exercises, guided imagery, progressive muscle relaxation
• Soothing music, dim lighting, and a calm environment
• Encourages release of endorphins (natural pain relievers)
F. Cultural Sensitivity
• Respect woman’s cultural beliefs and practices
• Use language she understands and avoid medical jargon
• Support birth rituals that are safe and meaningful for her
5. Role of the Nurse in Managing Fear
• Establish trust and rapport

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• Perform frequent psychological assessment of the woman

• Offer constant support, especially to first-time mothers
• Encourage positive thinking and confidence
• Avoid scolding or neglecting emotional needs
• Create an atmosphere of safety, privacy, and dignity
6. Importance of Psychological Support
• Improves labour outcomes and birth satisfaction
• Reduces need for pain medication and interventions
• Enhances maternal-infant bonding
• Promotes mental health and reduces postpartum depression
Possible Outcome Questions
Two Marks
1. Mention any two causes of fear during labour.
2. Define psychological support in the context of labour.
Five Marks
1. Write any five strategies to manage fear during labour.
2. Describe the nurse’s role in providing psychological support during
labour.
Ten Marks
1. Explain the importance of psychological support in labour and how it
helps manage fear.
2. Describe the effects of fear on labour progress and the interventions used
to overcome it.
Activity and Ambulation During First Stage of Labour
1. Introduction
• Activity and ambulation refer to encouraging the woman in labour to
stay mobile, walk, or change positions during the first stage of labour.

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• Supported by WHO and GoI guidelines, ambulation promotes

physiological labour, reduces complications, and enhances maternal
satisfaction.
2. Importance of Activity and Movement
• Utilizes gravity to aid fetal descent
• Promotes effective uterine contractions
• Reduces labour duration
• Enhances maternal comfort and sense of control
• Decreases need for pharmacological interventions
• Improves fetal alignment and rotation
3. Recommended Activities During Labour
• Walking around the labour room or corridor
• Sitting on a birthing ball or upright chair
• Rocking or swaying while standing or sitting
• Leaning forward on a table or wall during contractions
• Kneeling, squatting, or hands-and-knees position
• Using support from a birth companion for balance
4. Appropriate Positions to Encourage
Position Benefit

Upright sitting or standing Promotes descent and stronger contractions

Walking Uses gravity, increases pelvic mobility

Side-lying Conserves energy, promotes comfort

Squatting Opens pelvis, promotes fetal engagement

Kneeling/hands and knees Relieves back pain, helps with malpresentation

5. When Ambulation is Beneficial
• Labour progressing normally without complications
• No contraindications like preterm labour, vaginal bleeding, or
ruptured membranes without engagement
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• Woman is comfortable, alert, and able to walk with/without assistance

• Continuous fetal and maternal monitoring indicates stable condition
6. Contraindications to Ambulation
• High-risk pregnancy or complicated labour
• Need for continuous electronic fetal monitoring (EFM)
• Presence of epidural anesthesia (unless protocol permits movement)
• Maternal hypotension or exhaustion
7. Role of the Nurse/Midwife
• Encourage the woman to remain active and change positions
• Provide safety support during ambulation
• Monitor fetal heart rate and uterine contractions regularly
• Ensure hydration and rest breaks
• Educate woman and companion about benefits of movement
• Document activity and maternal response
8. Benefits for the Fetus
• Enhances placental perfusion
• Facilitates fetal rotation and descent
• May reduce risk of fetal distress or prolonged labour
Possible Outcome Questions
Two Marks
1. Define ambulation in the context of labour.
2. Mention any two benefits of walking during the first stage of labour.
Five Marks
1. List five recommended positions during the first stage of labour.
2. Write the nurse’s role in encouraging activity during the first stage of
labour.
Ten Marks

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1. Explain the importance of activity and ambulation during the first stage
of labour and the precautions to be taken.
2. Describe how maternal movement supports physiological labour and
improves outcomes.
Nutrition During Labour
1. Introduction
• Nutrition during labour is essential to maintain the mother's energy
levels, prevent dehydration, and support the physiological process of
childbirth.
• WHO and various national guidelines support allowing light food and
oral fluids during early and active labour, especially in low-risk women.
2. Importance of Nutrition During Labour
• Provides energy for uterine contractions
• Prevents maternal fatigue and exhaustion
• Maintains glucose levels and electrolyte balance
• Reduces the risk of ketosis and acidosis
• Promotes positive labour outcomes
3. Nutritional Needs in Labour
• Carbohydrates: Primary energy source (e.g., glucose, fruits)
• Fluids: Maintain hydration (e.g., water, coconut water, clear juices)
• Electrolytes: Support neuromuscular function (e.g., ORS, soups)
• Avoid heavy meals that are rich in fat or protein which are slow to
digest
4. Recommended Foods During Labour (Low-risk, Unmedicated Labour)
Type Examples

Light carbohydrates Biscuits, toast, rice flakes, bananas

Clear fluids Water, fruit juice, coconut water, ORS

Easily digestible Boiled potatoes, khichdi, curd rice

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Type Examples

Electrolytes Salted lemon water, vegetable soup

• Intake should be in small frequent amounts
5. Food and Fluid Restrictions (When Applicable)
• In high-risk pregnancies, or when C-section or general anesthesia is
anticipated, food intake may be restricted to clear fluids only
• NPO (nil per oral) status is required if:
o Emergency surgery is expected
o Labour is complicated
o Woman is under general or regional anesthesia (as per protocol)
6. Precautions
• Avoid carbonated drinks or caffeinated beverages
• Avoid spicy, greasy, or heavy meals
• Monitor for vomiting or gastric discomfort
• Keep woman upright during and after eating
7. Nurse's Role in Supporting Nutrition During Labour
• Assess the maternal condition and risk status
• Encourage light oral intake in low-risk women
• Ensure hydration by offering fluids frequently
• Educate the woman and family on what to eat or avoid
• Monitor for nausea, vomiting, or aspiration risk
• Document all intake and maternal tolerance
8. Hydration Importance
• Dehydration can lead to:
o Weak uterine contractions
o Reduced placental perfusion
o Maternal fatigue and longer labour

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Possible Outcome Questions

Two Marks
1. Mention two foods recommended during early labour.
2. Why is hydration important during labour?
Five Marks
1. Write any five reasons why nutrition is important during labour.
2. List the nurse's responsibilities in maintaining nutrition during labour.
Ten Marks
1. Discuss the importance, recommended intake, and nursing role in
nutrition during labour.
2. Explain the dietary considerations during labour and indications for food
restrictions.
Promoting Positive Childbirth Experience for Women
1. Introduction
• A positive childbirth experience is safe, empowering, respectful, and
emotionally satisfying for the woman.
• The WHO emphasizes that care during labour should uphold the
woman’s dignity, choices, and comfort, and not just focus on clinical
outcomes.
2. Key Elements of a Positive Childbirth Experience
1. Respectful Maternity Care (RMC)
2. Informed decision-making and consent
3. Emotional and psychological support
4. Continuous support from skilled providers
5. Birth companionship
6. Freedom of movement and preferred birth position
7. Effective pain management (non-pharmacological and
pharmacological)
8. Privacy and confidentiality

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9. Clear and compassionate communication

[Link] and reassurance throughout labour
3. WHO Recommendations (2018) for Positive Birth Experience
Area Recommendation

Individualized expectations – active phase may last up to

Labour duration
12 hours

Birth position Should be the woman’s choice

Episiotomy Not routine; only when medically necessary

Amniotomy/Oxytocin Avoid routine use; only if clinically indicated

Birth companionship Strongly recommended for continuous support

Interventions Minimal, evidence-based, and with informed consent

4. Strategies to Promote Positive Childbirth Experience
A. Provide Respectful Maternity Care
• Treat every woman with dignity, empathy, and non-discrimination
• Ensure confidentiality and privacy
• Protect her right to information and participation
B. Ensure Birth Companion Support
• Allow a companion of the woman’s choice during labour and birth
• Companions provide emotional comfort, advocacy, and motivation
C. Maintain Clear and Compassionate Communication
• Use simple language and explain each procedure
• Encourage the woman to express her needs, fears, and preferences
D. Promote Comfort Measures
• Encourage mobility, change of position, warm baths, massages
• Offer non-pharmacological pain relief early
• Use pharmacological options only when chosen and needed
E. Encourage Informed Decision Making

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• Involve the woman in all decisions regarding her care

• Discuss risks, benefits, and alternatives for any intervention
• Respect cultural preferences and birth plans
F. Support Autonomy and Control
• Encourage the woman to take an active role in labour
• Avoid routine restrictions (e.g., on movement, fluids, food) unless
necessary
• Respect her chosen birth position and coping methods
G. Ensure Safe, Clean and Conducive Environment
• Labour room must be calm, clean, well-ventilated, and private
• Avoid overcrowding and unnecessary personnel
5. Nurse's Role in Promoting Positive Birth Experience
• Build trust and rapport with the woman
• Monitor labour while supporting emotional well-being
• Advocate for the woman’s preferences and rights
• Provide continuous presence and reassurance
• Coordinate with doctors and birth team to ensure woman-centred care
• Educate the woman antenatally about what to expect during labour
6. Outcomes of a Positive Birth Experience
• Higher maternal satisfaction
• Reduced risk of postpartum depression or trauma
• Improved bonding with newborn
• Greater breastfeeding success
• Encourages positive attitudes toward future pregnancies
Possible Outcome Questions
Two Marks
1. Mention any two factors that promote a positive childbirth experience.
2. What is meant by respectful maternity care?
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Five Marks
1. List five WHO recommendations for promoting a positive childbirth
experience.
2. Write the nurse's role in promoting positive childbirth experiences.
Ten Marks
1. Describe in detail how a nurse can promote a positive childbirth
experience for a woman during labour.
2. Explain the importance, strategies, and outcomes of providing woman-
centered care during labour.
Birth Companion
1. Introduction
• A birth companion is a person chosen by the woman to provide her with
continuous emotional, physical, and psychological support during
labour and childbirth.
• Recommended by WHO and supported under Government of India
(GoI) guidelines for promoting Respectful Maternity Care (RMC).
2. Definition
• A birth companion is a non-medical support person, such as the
husband, mother, sister, friend, or trained doula, who stays with the
woman throughout labour and delivery.
3. Objectives of Birth Companionship
• Provide emotional support and reassurance
• Help the woman feel safe, respected, and cared for
• Encourage active participation in the birth process
• Improve the labour experience and outcome
4. Benefits of Birth Companionship
For the Mother:
• Reduces fear, anxiety, and stress
• Increases sense of control and confidence
• Promotes shorter labour duration

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• Reduces need for analgesia and interventions

• Enhances maternal satisfaction and positive birth experience
For the Baby:
• Improves fetal outcomes due to better maternal cooperation
• Reduces risk of birth complications
For Health System:
• Promotes positive image of healthcare facility
• Encourages institutional deliveries and community trust
• Reduces workload by providing non-clinical suppor
5. WHO and GoI Recommendations
• WHO recommends continuous companionship for every woman in
labour.
• Ministry of Health and Family Welfare (MoHFW), GoI promotes birth
companionship under LaQshya initiative for quality intrapartum care in
public health facilities.
6. Selection of Birth Companion
Criteria Details

Chosen by the woman Preferably a close family member

Female companion preferred in many setups As per cultural acceptability

Should be healthy and emotionally stable Able to stay throughout labour

Should respect privacy and hospital rules Trained if necessary by staff

7. Responsibilities of the Birth Companion
• Provide emotional reassurance
• Offer physical comfort (massage, cold compress, support in walking)
• Assist in breathing techniques and position changes
• Advocate for the woman’s preferences and needs
• Communicate with staff on the woman's behalf if needed
• Maintain calm and comforting presence
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8. Nurse's Role in Supporting Birth Companionship

• Educate the woman antenatally about the benefits of a birth companion
• Orient the companion to the labour environment and basic dos and
don’ts
• Ensure privacy and space for the companion to be present
• Encourage the companion to actively support the woman
• Supervise and guide the companion as needed
• Promote teamwork between staff and the birth companio
9. Limitations or Challenges
• Space constraints in crowded labour rooms
• Lack of awareness among women and families
• Resistance from staff or hospital policy
• Need for proper orientation and boundarie
10. Strategies to Promote Birth Companionship
• Include topic in antenatal education classes
• Create hospital policies supporting companionship
• Train staff to accept and facilitate companions
• Provide curtains or partitions for privacy
• Engage ASHAs and community workers to spread awarenes
Possible Outcome Questions
Two Marks
1. Who is a birth companion?
2. Mention any two roles of a birth companion during labour.
Five Marks
1. Write any five benefits of a birth companion for a labouring woman.
2. Describe the nurse's role in facilitating birth companionship.
Ten Marks

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1. Explain the concept of a birth companion, its importance, and the

responsibilities of both the nurse and the companion.
2. Discuss WHO and GoI recommendations on birth companionship and
how it can be effectively implemented in labour rooms.
Role of Doula / ASHAs (Accredited Social Health Activists)
1. Introduction
• A Doula is a trained, non-medical support person who provides
continuous physical, emotional, and informational support to a
woman before, during, and shortly after childbirth.
• ASHA (Accredited Social Health Activist) is a community-level
female health worker appointed under the National Rural Health
Mission (NRHM) to promote maternal and child health services in rural
areas of India.
2. Role of a Doula
A. During Pregnancy
• Provide emotional support, listen to fears and concerns
• Educate about labour, birth, and postpartum period
• Help in creating a birth plan based on the woman’s values
• Teach relaxation, breathing, and comfort measures
• Encourage communication with healthcare providers
B. During Labour and Birth
• Offer continuous presence and encouragement
• Help with position changes, massages, and breathing techniques
• Provide comfort measures (heat/cold, support pillows, etc.)
• Support birth partner and promote a calm environment
• Ensure woman feels respected, heard, and empowered
C. Postpartum Support
• Assist in establishing breastfeeding
• Monitor for emotional well-being (postpartum blues)
• Provide information on newborn care and maternal recovery
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• Refer to professionals if medical or psychological needs arise

D. Limitations
• Doulas do not perform clinical tasks (e.g., fetal monitoring, medication,
delivery)
• Work alongside nurses and midwives, not replacing the
3. Role of ASHA Workers
A. Antenatal Care
• Identify and register all pregnancies in the community
• Promote early ANC registration and minimum 4 check-ups
• Motivate for TT injections, IFA tablets, and nutrition counseling
• Counsel about birth preparedness, danger signs, and hygiene
• Encourage institutional delivery at PHC or government facility
B. Intranatal Support
• Escort pregnant woman to health facility for delivery
• Support during labour and birth by providing psychological comfort
• Facilitate access to Janani Suraksha Yojana (JSY) benefits
C. Postnatal Care
• Conduct home visits within 48 hours and during 1st week
• Educate about exclusive breastfeeding, newborn care
• Identify high-risk neonates and mothers and refer early
• Promote postnatal checkups, immunization, and family planning
D. Health Education and Community Link
• Act as a bridge between community and health services
• Mobilize women for health days, vaccination camps
• Maintain health records and ensure referral services
• Work with Anganwadi workers (AWWs) and ANMs
4. Difference Between Doula and ASHA

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Aspect Doula ASHA

Trained birth companion Community health worker under

Type of Worker
(non-clinical) NRHM

Emotional and physical Health promotion and service

Main Role
support linkage

Location Urban/private settings Rural/community-based

Labour, birth, early Antenatal, delivery escort,

Involvement
postpartum postnatal

Clinical Limited (referral and basic

None
Procedures health support)
5. Nurse’s Role in Collaboration
• Guide and train Doulas/ASHAs in maternal health protocols
• Include them in birth preparedness and complication readiness
• Encourage coordination for ANC checkups, delivery plans
• Foster respectful, integrated care between nurses and birth support staff
Possible Outcome Questions
Two Marks
1. Mention one role of a Doula and one role of an ASHA during childbirth.
2. What is the primary focus of ASHA workers under NRHM?
Five Marks
1. Write the role of ASHA workers in maternal and child health.
2. Mention any five responsibilities of a Doula during labour.
Ten Marks
1. Compare and contrast the roles of Doula and ASHA in maternal care.
2. Describe in detail the contribution of ASHA workers in improving
reproductive and child health outcomes in India.
Second Stage of Labour – Physiology (Mechanism of Labour)
1. Introduction

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• The second stage of labour begins from full cervical dilatation (10 cm)
and ends with the expulsion of the fetus.
• This stage typically lasts:
o 30 minutes to 2 hours in primigravida
o 15 minutes to 1 hour in multigravida
• This is the pushing stage involving strong maternal effort and uterine
contractions.
• Mechanism of labour refers to the passive movements that the fetus
undergoes to navigate through the birth canal
2. Uterine and Maternal Physiology
• Contractions become more frequent, strong, and expulsive
• The presenting part (usually head) descends with each contraction
• Voluntary bearing down by the mother aids fetal expulsion
• Pelvic floor muscles stretch and rotate the fetal head
• Perineum bulges and thins out before delivery
3. Cardinal Movements (Mechanism of Labour)
These are the 7 passive movements of the fetal head to accommodate the
maternal pelvis:
Step Description

Biparietal diameter of fetal head passes through

1. Engagement
pelvic inlet

Downward movement of the head through the pelvis

2. Descent
(continuous throughout labour)

Chin moves to chest to present smallest diameter

3. Flexion
(suboccipitobregmatic)

4. Internal Rotation Occiput rotates anteriorly toward the symphysis pubis

Head extends to pass through the vulva after reaching

5. Extension
perineum

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Step Description

6. External Rotation
Head realigns with shoulders after delivery
(Restitution)

7. Expulsion Shoulders and the rest of the body are delivered

4. Hormonal Changes and Reflexes
• Oxytocin levels increase – intensifying contractions
• Ferguson reflex – stimulation of stretch receptors in the cervix and
vagina triggers oxytocin release
• Enhanced endorphins reduce perception of pain
5. Signs Indicating Onset of Second Stage
• Sudden appearance of bearing-down efforts
• Anal dilation and bulging perineum
• Show of presenting part at vulva
• Urgent desire to defecate or push
• Spontaneous rupture of membranes, if not already ruptured
6. Maternal and Fetal Responses
A. Maternal:
• Increase in respiratory rate and cardiac output
• Exhaustion and emotional changes (fear, excitement)
• Urge to push with each contraction
B. Fetal:
• Head undergoes moulding to adapt to maternal pelvis
• Heart rate should be monitored to detect distress
7. Nurse's Role During the Second Stage
• Encourage and guide the woman on effective pushing techniques
• Monitor fetal heart rate every 5 minutes or after each contraction
• Maintain aseptic technique
• Observe for crowning and perineal bulging
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• Prepare for immediate newborn care

• Provide emotional support and encouragement
• Protect the perineum using techniques like perineal support or
episiotomy if needed
8. Summary of Second Stage Mechanism
Movement Purpose

Engagement Entry of head into pelvis

Descent Movement down the birth canal

Flexion Optimal head positioning for narrowest diameter

Internal Rotation Aligns head with pelvic outlet

Extension Allows passage through the perineum

External Rotation Aligns shoulders with anteroposterior diameter

Expulsion Final exit of body

Possible Outcome Questions
Two Marks
1. Define the second stage of labour.
2. Mention any two cardinal movements of labour.
Five Marks
1. Write the mechanism of labour during the second stage.
2. Mention the nurse’s responsibilities during the second stage of labour.
Ten Marks
1. Describe in detail the physiology and mechanism of labour during the
second stage.
2. Explain the cardinal movements of labour and maternal-fetal adaptations
during the second stage.
Signs of Imminent Labour
1. Introduction

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• Imminent labour refers to the time shortly before the onset of true
labour when physiological and observable signs indicate that childbirth
is approaching.
• Recognizing these signs helps prepare the mother, arrange hospital
admission, and initiate labour monitoring.
2. Major Signs of Imminent Labour
A. Lightening (Dropping)
• Descent of the fetal head into the pelvic cavity
• Occurs 2–3 weeks before labour in primigravida; during labour in
multigravida
• Mother feels easier breathing but increased pressure on the bladder
B. Increased Braxton Hicks Contractions
• Irregular, mild uterine contractions become more frequent and stronger
• Often mistaken for true labour, but do not cause cervical dilation
C. Bloody Show
• Passage of blood-tinged mucus from the vagina due to cervical
effacement and dilation
• Indicates labour is near or has started
D. Rupture of Membranes (ROM)
• Spontaneous rupture of amniotic sac, commonly known as water
breaking
• Clear or slightly pink fluid leaks or gushes from vagina
• Signifies that labour may begin soon or has already started
• Should prompt immediate hospital admission
E. Cervical Changes
• Cervix becomes soft, effaced (thinned), and dilated
• Confirmed on per vaginal (PV) examination
F. Change in Energy Levels (Nesting Instinct)
• Sudden burst of energy and urge to clean or prepare for baby

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• Can occur 24–48 hours before labour

G. Lower Backache and Abdominal Cramps
• Due to increased pelvic pressure and fetal descent
• Constant dull back pain often reported
H. Diarrhea or Loose Stools
• Body’s natural way of clearing the bowels in preparation for birth
• Caused by hormonal changes
3. Distinguishing True vs False Labour
False Labour (Braxton
Features True Labour
Hicks)

Contraction
Regular, increasing in intensity Irregular and mild
pattern

Starts from back and radiates

Location of pain Localized in abdomen
to abdomen

Cervical Progressive effacement and

No cervical change
changes dilation

Effect of Continues or worsens with Disappears with rest or

activity activity position change
4. Nurse's Role in Identifying Imminent Labour
• Educate the woman on early signs of labour
• Perform abdominal and vaginal assessment if needed
• Monitor for contraction pattern, rupture of membranes, and fetal
descent
• Prepare labour room and inform the care team
• Provide psychological support and admission guidance
Possible Outcome Questions
Two Marks
1. Define 'lightening' in the context of imminent labour.
2. What is meant by 'bloody show'?
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Five Marks
1. List and explain five signs of imminent labour.
2. Differentiate between true and false labour.
Ten Marks
1. Describe in detail the signs of imminent labour and the nurse's role in
managing them.
2. Explain the physiological basis of each sign that occurs before the onset
of true labour.
Intrapartum Monitoring
1. Introduction
• Intrapartum monitoring refers to the systematic observation,
assessment, and documentation of the maternal and fetal well-being
during labour and childbirth.
• The main goal is to ensure the safe progress of labour, early detection of
complications, and timely interventions to prevent morbidity or
mortality.
2. Objectives of Intrapartum Monitoring
• Monitor maternal and fetal well-being
• Assess progress of labour
• Identify signs of fetal or maternal distress
• Guide decisions regarding intervention (e.g., augmentation, cesarean)
• Ensure safe and timely delivery
3. Components of Intrapartum Monitoring
A. Maternal Monitoring
1. Vital Signs
o Blood pressure, pulse, respiratory rate – every 4 hours
o Temperature – every 4 hours (or more if membranes are ruptured)
o Oxygen saturation if at risk
2. Uterine Contractions

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o Frequency (every x minutes)

o Duration (in seconds)
o Strength (mild, moderate, strong)
o Resting tone between contractions
3. Pain Level
o Assess pain using a pain scale
o Provide non-pharmacological or pharmacological relief
4. Bladder
o Ensure regular bladder emptying – every 2 hours
o Full bladder can impede fetal descent
5. Hydration and Nutrition
o Monitor oral fluid intake or IV fluids
6. Emotional Status and Coping
o Assess anxiety, fear, and provide support and reassurance
B. Fetal Monitoring
1. Fetal Heart Rate (FHR)
o Intermittent auscultation using Doppler or Pinnard stethoscope
o Every 30 mins in 1st stage and every 5–15 mins in 2nd stage
o After each contraction in active pushing phase
2. Fetal Movement
o Encourage mother to report fetal movement pattern
3. Amniotic Fluid
o Assess for rupture of membranes
o Note color, odor, amount
▪ Clear: Normal
▪ Greenish: Meconium-stained (fetal distress)
▪ Bloody: May indicate abruption

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▪ Foul-smelling: Infection
4. Presentation and Descent
o Palpate fetal position, lie, attitude
o Monitor descent of head through abdominal palpation or vaginal
examination
C. Assessment of Labour Progress – Partograph
• Use of Partograph is WHO recommended for monitoring active labour
• Graphical record of:
o Cervical dilation
o Fetal descent
o Contractions
o FHR
o Maternal vitals
o Amniotic fluid status
• Alert line and action line help in early detection of slow progress
4. Tools Used for Monitoring
Tool Purpose

Partograph Monitor progress of labour

Doppler/Fetoscope Assess fetal heart rate

Blood pressure cuff Monitor maternal BP

Thermometer Check for infection or fever

Urine dipstick Check protein, glucose, ketones

Vaginal examination gloves Assess cervical changes

5. Nurse’s Responsibilities in Intrapartum Monitoring
• Accurately observe and document all parameters
• Communicate promptly any abnormal findings to the doctor
• Maintain privacy, dignity, and comfort

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• Use aseptic techniques during all procedures

• Encourage mobility, position changes, and adequate hydration
• Provide emotional and physical support
6. Danger Signs to Watch For
• FHR <110 bpm or >160 bpm
• Meconium-stained liquor
• Absent fetal movement
• Severe headache, high BP in mother
• Prolonged labour or arrested descent
• Vaginal bleeding
• Foul-smelling discharge or fever
Possible Outcome Questions
Two Marks
1. Define intrapartum monitoring.
2. What is a partograph used for?
Five Marks
1. List the components of fetal monitoring during labour.
2. Explain the nurse’s role in intrapartum monitoring.
Ten Marks
1. Describe the components of intrapartum monitoring and the role of the
nurse.
2. Discuss the use and interpretation of the partograph during labour
Birth position Of Choice
1. Introduction
• Birth position refers to the physical posture adopted by a woman during
labor and delivery.
• Allowing the woman to choose her preferred position is part of
respectful maternity care, promotes comfort, and can enhance labor
efficiency.
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2. Importance of Birth Position Choice

• Enhances maternal comfort and control
• Promotes gravity-assisted labor
• Reduces duration of second stage of labor
• Lowers the need for instrumental delivery
• Decreases the risk of perineal trauma (in some positions)
• Supports physiological and psychological well-being
3. Types of Birth Positions
Position Description Advantages Disadvantages

Common in
Lying on back Less gravity,
hospitals, easy
Lithotomy with legs in increased risk of
access for care
stirrups perineal tear
providers

Uses gravity,
Mother stands
Upright widens pelvic Needs support,
or squats during
(Standing/Squatting) outlet, may shorten may be tiring
pushing phase
labor

Requires
Sitting (Birthing Sitting on chair Uses gravity, more supervision to
chair) with support control for mother prevent sudden
delivery

Reduces perineal
Mother lies on
pressure, good for Less effective
Lateral (Side-lying) her side with
hypertensive gravity
one leg raised
mothers

Helps in occipito-
All-fours (Hands & On hands and posterior position, May be physically
knees) knees reduces back pain, tiring
promotes rotation

May be less
Semi- Leaning back Combines comfort
effective than fully
sitting/Reclining supported by and gravity
upright positions

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Position Description Advantages Disadvantages

pillows or
backrest

Needs special
Delivered in Comfort, reduced
Water birth position facilities and
warm water tub perineal trauma
trained staff

4. WHO Recommendations
• Women should be encouraged to adopt positions of their choice during
labor and delivery.
• Health care providers should avoid routine lithotomy unless clinically
required.
• Women must be informed about options and supported in their decision.
5. Nurse/Midwife’s Role
• Educate the woman antenatally about various birthing positions.
• Assist and support the woman’s choice during labor.
• Ensure safe environment and equipment for chosen position.
• Monitor maternal and fetal well-being continuously.
• Adapt care based on changes in condition or need for interventions.
6. Diagram Suggestions
• Diagrams showing common birth positions: lithotomy, squatting, side-
lying, all-fours, etc.
7. Possible Outcome Questions
Two Marks
1. Mention any two positions used during childbirth.
2. What is the benefit of the squatting position during labor?
Five Marks
1. Explain the advantages and disadvantages of any two birth positions.

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2. Describe the nurse’s role in supporting a woman’s birth position of

choice.
Ten Marks
1. Discuss the importance of allowing women to choose their birthing
position. Include types, advantages, and nursing responsibilities.
Vaginal Examination (VE)
1. Introduction
• Vaginal Examination (VE) is a clinical procedure used during
pregnancy and labour to assess the progress of labour, fetal position,
presentation, and status of the cervix.
• It must be conducted gently, aseptically, and only when necessary to
minimize risk of infection, especially after rupture of membranes
2. Purposes of Vaginal Examination
• Confirm cervical effacement and dilation
• Assess fetal presenting part, position, and station
• Identify membrane status (intact or ruptured)
• Monitor labour progress
• Rule out cord prolapse or abnormal presentation
• Check pelvic adequacy
• Detect vaginal bleeding or abnormalities
3. Timing of Vaginal Examination
• On admission in labour
• Every 4 hours during active labour (unless otherwise indicated)
• Before administering medications (e.g., oxytocin or analgesia)
• When the woman feels the urge to push
• After rupture of membranes, if indicated
• If there is bleeding, only performed with extreme caution and indication
4. Procedure of Vaginal Examination
A. Preparation

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• Explain the procedure to the woman

• Ensure privacy and obtain informed consent
• Wash hands and wear sterile gloves
• Place the woman in a dorsal position with knees flexed
• Drape appropriately
B. Steps of Examination
1. Inspect vulva for swelling, discharge, bleeding
2. Gently insert two fingers into the vagina
3. Assess the following:
Assessment Description

Cervical Dilatation Measured in cm (0–10 cm)

Cervical Effacement Thickness of cervix (in %)

Station of Presenting
Relation of fetal head to ischial spines (-3 to +3)
Part

Presentation Cephalic (vertex, brow, face), breech, shoulder

Position Occiput anterior/posterior, sacrum position

Intact, bulging, ruptured; note color and smell of

Membrane Status
amniotic fluid

Pelvis Assessment Evaluate bony pelvis for shape and adequacy

Moulding Degree of overlapping of fetal skull bones (0 to +3)

Caput Succedaneum Swelling of fetal scalp (assess presence and degree)

4. Withdraw fingers carefully
5. Clean perineum if needed
6. Record findings immediately on partograph or case sheet
5. Interpretation of Findings
• Dilatation: Progressive opening of cervix – 1 cm/hour in active labour
• Effacement: 0% (thick) to 100% (fully thinned)

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• Station:
o 0: Level of ischial spines
o +1 to +3: Below spines (closer to delivery)
o -1 to -3: Above spines
• Presentation:
o Vertex (ideal), Brow, Face, Breech
• Membranes: Bulging/intact vs ruptured (check for meconium/foul smell)
6. Precautions
• Avoid frequent VEs, especially after rupture of membranes, to reduce
infection risk
• Never perform VE when unexplained vaginal bleeding is present – rule
out placenta previa
• Maintain strict aseptic technique
• Always provide emotional support and reassurance
7. Documentation (Sample Format)
Tim Dilatati Effaceme Statio Presentati Positio Membran Caput/Mouldi
e on nt n on n es ng

10:0
0 4 cm 50% -1 Vertex LOA Intact None/+1
AM
Possible Outcome Questions
Two Marks
1. Mention two purposes of vaginal examination.
2. What is cervical effacement?
Five Marks
1. Write the procedure and indications of vaginal examination during labour.
2. List the components assessed during a vaginal examination.
Ten Marks

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1. Describe the technique, findings, and nursing responsibilities of vaginal

examination.
2. Explain the precautions and interpretation of findings in a labouring
woman undergoing vaginal examination.
Psychological Support During Labour and Childbirth
1. Introduction
• Psychological support refers to emotional, mental, and social care
provided to women during labour to reduce fear, anxiety, pain
perception, and to enhance confidence and satisfaction.
• Labour is not only a physical process but also a deeply emotional
experience, and psychological care is essential for positive birth
outcomes
2. Objectives of Psychological Support
• Build trust and rapport with the labouring woman
• Reduce stress, fear, and anxiety
• Promote relaxation and cooperation
• Provide emotional security and strength
• Encourage positive coping strategies
• Prevent birth trauma or negative psychological impact
3. Components of Psychological Support
A. Communication
• Use clear, honest, and simple language
• Explain each procedure before performing
• Maintain a calm tone and non-threatening posture
• Offer continuous reassurance
B. Empathy and Presence
• Stay physically present to provide emotional strength
• Use touch, eye contact, and gentle encouragement
• Respect and validate her feelings and expressions

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C. Privacy and Dignity

• Maintain privacy during examinations and delivery
• Provide clean and comfortable environment
• Respect cultural and personal preferences
D. Encouraging Participation
• Encourage the woman to express her needs and preferences
• Involve her in decision-making
• Support birth plan if available
E. Support Persons
• Allow presence of partner, doula, or family member if culturally and
medically appropriate
• Support person helps reduce labour pain, anxiety, and gives emotional
comfort
4. Strategies to Provide Psychological Support
• Breathing exercises and relaxation techniques
• Encourage upright positions, walking, and movement
• Use verbal encouragement: “You are doing well,” “You’re strong,”
“Almost there”
• Offer comfort measures like massage, cold/warm compress
• Play soothing music (if preferred)
• Avoid harsh commands, criticism, or fear-inducing statements
5. Nurse's Role
• Assess the woman’s emotional and psychological status regularly
• Establish rapport and a supportive relationship
• Act as a birth companion when no support person is available
• Promote positive birth experience
• Provide counseling if needed
• Watch for signs of emotional distress or trauma

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6. Benefits of Psychological Support

Benefits for Mother Benefits for Baby

Reduced perception of pain Better fetal oxygenation

Shorter duration of labour Reduced risk of fetal distress

Lower rate of interventions Increased Apgar scores

Increased satisfaction and confidence Better bonding after birth

Possible Outcome Questions
Two Marks
1. Define psychological support during labour.
2. Mention one objective of emotional care during childbirth.
Five Marks
1. Write the nurse’s role in providing psychological support during labour.
2. List five components of emotional and psychological support during
childbirth.
Ten Marks
1. Explain in detail the strategies and importance of psychological support
during labour.
2. Describe the nurse's role in ensuring emotional well-being of the woman
during intrapartum care.
Non-Directive Coaching
1. Introduction
• Non-directive coaching is a supportive communication approach where
the nurse or midwife facilitates self-exploration, decision-making, and
problem-solving in the pregnant or labouring woman without giving
direct instructions.
• It is based on the principle of respecting the woman’s autonomy,
preferences, and inner strength to make informed decisions during
pregnancy and childbirth.
2. Definitions

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• Non-directive coaching: A method of guidance where the coach

(nurse/midwife) asks open-ended questions, listens actively, and
encourages reflection, helping the client to arrive at their own decisions.
• It contrasts with directive coaching, where advice or orders are given
directly.
3. Objectives of Non-Directive Coaching
• Empower women to trust their body and instincts during labour
• Promote autonomy and decision-making
• Support self-awareness and confidence
• Reduce fear and build psychological strength
• Encourage active participation in maternity care
4. Key Principles of Non-Directive Coaching
• Listening actively without judgment
• Asking open-ended, non-leading questions
• Avoiding advice unless specifically asked
• Encouraging the woman to explore her own feelings, beliefs, and
options
• Promoting respectful, client-centered communication
5. Techniques Used
Technique Example

Open-ended
"How are you feeling about the labour today?"
questions

"It sounds like you’re worried about the pain. Can you tell
Reflective listening
me more?"

"When you say you’re unsure, what do you mean by

Clarification
that?"

"You’re doing a great job handling this, and your instincts

Affirmation
are strong."

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Technique Example

"So, you’re hoping to avoid medication and try natural

Summarizing
techniques first?"
6. Nurse/Midwife’s Role in Non-Directive Coaching
• Create a safe, non-judgmental environment
• Recognize verbal and non-verbal cues from the woman
• Respect the woman’s values, beliefs, and cultural background
• Promote informed choices through reflective dialogue
• Reassure and validate the woman’s emotions
• Use coaching as part of birth preparation, labour support, or
counseling sessions
7. Benefits of Non-Directive Coaching
For the Woman For the Midwife/Nurse

Greater sense of control Builds trusting relationship

Increased self-confidence Enhances communication effectiveness

Better emotional readiness Encourages shared decision-making

Less anxiety and fear Reduces resistance and promotes cooperation

8. Application in Midwifery Practice
• During antenatal counseling
• When helping a woman create a birth plan
• In labour room, when discussing comfort measures
• While guiding postpartum self-care or breastfeeding
• For discussing family planning or parenting concerns
Possible Outcome Questions
Two Marks
1. Define non-directive coaching.
2. Mention one technique used in non-directive coaching.

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Five Marks
1. List the principles and benefits of non-directive coaching.
2. Explain the role of a nurse in using non-directive coaching during labour.
Ten Marks
1. Describe in detail the concept, principles, and nursing application of non-
directive coaching in maternal care.
2. How does non-directive coaching differ from directive coaching?
Illustrate with examples.
Evidence-Based Management of Physiological Birth / Conduction of Normal
Childbirth
1. Introduction
• Physiological (normal) birth is a natural, spontaneous, and low-
intervention process that allows labour and delivery to progress without
unnecessary medical procedures.
• Evidence-based practice in childbirth means using the best available
scientific evidence, combined with clinical expertise and women’s
preferences, to support safe and respectful birth.
2. Definition of Normal Labour and Childbirth
• Normal Labour: Spontaneous onset of labour at term (37–42 weeks),
progressing without complications, with the baby born vertex vaginally,
and both mother and baby in good condition.
• Evidence-Based Care: Clinical decisions made using the best available,
current, valid, and relevant evidence.
3. Goals of Evidence-Based Management
• Promote safe, positive birth experiences
• Reduce unnecessary interventions
• Respect the physiological process
• Support informed decision-making
• Improve maternal and neonatal outcomes
4. Key Principles of Evidence-Based Physiological Birth
• Birth is a natural process, not a medical event
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• The woman is an active participant, not a passive patient

• Continuous support and comfort measures are essential
• Interventions should only be used when medically necessary
• Respectful maternity care (RMC) must be central
5. Stages of Labour and Evidence-Based Management
A. First Stage (Onset of regular contractions to full cervical dilatation)
• Supportive environment: quiet, private, low lighting
• Ambulation and upright positions to enhance labour progress
• Encourage hydration and light food
• Intermittent fetal monitoring (not continuous unless indicated)
• Avoid routine amniotomy or early rupture of membranes
• Use non-pharmacological pain relief (breathing, massage,
hydrotherapy)
• Emotional support from nurse, doula, or birth partner
B. Second Stage (Full dilatation to birth of baby)
• Allow spontaneous bearing down – no forced pushing
• Use upright or lateral positions for effective pushing
• Avoid episiotomy unless medically indicated
• Support perineum to minimize tears
• Gentle, controlled birth of the head – “hands-on” or “hands-poised”
technique
C. Third Stage (Birth of baby to expulsion of placenta)
• Use Active Management of Third Stage of Labour (AMTSL):
o Administer oxytocin within 1 minute of birth
o Controlled cord traction (CCT)
o Uterine massage after placenta delivery
• Delayed cord clamping (after 1–3 minutes) unless contraindicated
• Check for placenta completeness

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• Monitor bleeding and uterine tone

6. Nurse/Midwife's Role in Physiological Birth
• Create a calm, supportive atmosphere
• Provide continuous labour support
• Offer comfort measures and positioning
• Monitor labour using partograph
• Ensure informed choices and consent
• Recognize deviations from normal and refer promptly
• Support early skin-to-skin contact and breastfeeding initiation
7. Practices to Encourage (WHO Recommendations)
Recommended Discouraged

Allow freedom of movement Routine enema or perineal shaving

Support person of choice Routine IV fluids

Oral intake of fluids and light

Restrictive positions (supine)
food

Continuous electronic fetal monitoring

Intermittent auscultation
(CTG)

Delayed cord clamping Routine amniotomy or augmentation

8. Benefits of Evidence-Based Normal Birth
• Reduced risk of cesarean and instrumental delivery
• Improved maternal satisfaction
• Better neonatal outcomes
• Enhanced bonding and breastfeeding
• Lower risk of postpartum hemorrhage and infection
9. Documentation in Normal Childbirth
• Labour progress chart (partograph)
• Vital signs

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• Fetal heart rate

• Time of rupture of membranes
• Time of full dilatation and delivery
• Drug administration
• Placenta and membrane status
• Estimated blood loss
• Apgar score of newborn
• Immediate postpartum condition of mother and baby
Possible Outcome Questions
Two Marks
1. Define physiological birth.
2. Mention any two evidence-based practices during first stage of labour.
Five Marks
1. Explain the principles of evidence-based normal childbirth.
2. Describe the nurse's role during physiological labour.
Ten Marks
1. Describe the evidence-based management of all three stages of labour.
2. Write in detail about evidence-based practices that promote safe and
normal childbirth.
Essential Newborn Care (ENBC)
1. Introduction
• Essential Newborn Care (ENBC) is a set of simple, evidence-based
practices provided to all newborns immediately after birth to ensure
their survival, health, and development.
• These practices are especially important during the first 60 minutes
(golden hour) after birth, which is critical for newborn survival and
adaptation.
2. Objectives of ENBC
• Ensure smooth transition from intrauterine to extrauterine life

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• Maintain body temperature

• Initiate and establish breastfeeding
• Prevent infections
• Early identification and management of danger signs
• Promote bonding between mother and baby
3. Components of Essential Newborn Care (As per WHO & GoI guidelines)
A. Immediate Care at Birth
1. Prepare a clean, warm area for delivery
2. Dry the baby thoroughly with a warm towel to prevent heat loss
3. Assess breathing: Crying or not
o If crying: Continue routine care
o If not crying: Start neonatal resuscitation immediately
4. Skin-to-skin contact (Kangaroo care): Place baby on the mother’s chest
5. Delayed cord clamping (1–3 minutes after birth or until pulsation stops)
6. Cut cord with sterile blade and tie with sterile ties
7. Do not suction the mouth or nose unless necessary (only if secretions are
obstructing breathing)
B. Thermal Protection (Prevent Hypothermia)
• Ensure delivery room is warm (≥25°C)
• Immediate drying and wrapping
• Use skin-to-skin contact (especially for LBW infants)
• Delay baby’s first bath by at least 24 hours
• Use cap and socks to cover head and feet
C. Early and Exclusive Breastfeeding
• Initiate breastfeeding within 1 hour of birth
• Encourage exclusive breastfeeding for 6 months
• No prelacteal feeds (no honey, sugar water, etc.)
• Support proper latching and positioning
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D. Cleanliness and Infection Prevention

• Hand hygiene before handling the newborn
• Keep cord stump dry and exposed
• Avoid applying any substances to the stump
• Use clean, sterilized instruments for cord cutting
• No unnecessary separation from mother
E. Eye and Umbilical Cord Care
• Eye care: Wipe eyes with clean, damp cloth (if policy permits, antibiotic
eye ointment may be used to prevent ophthalmia neonatorum)
• Cord care: Keep clean and dry; monitor for redness or discharge
F. Immunization at Birth
Vaccine When Where

BCG At birth Left upper arm

OPV-0 At birth Oral (2 drops)

Hepatitis B (birth dose) At birth within 24 hours Intramuscular

G. Assessment of the Newborn
• APGAR score at 1 and 5 minutes
• Birth weight (within first hour)
• Length, head circumference
• Look for birth injuries, congenital anomalies, danger signs
H. Identification and Registration
• Tag with baby’s ID band (name, gender, birth time)
• Register birth with hospital authorities
• Take footprint if required for record keeping
I. Parental Education and Bonding
• Teach mother how to breastfeed and care for the baby
• Educate parents on danger signs

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• Encourage rooming-in (keeping mother and baby together)

• Promote early bonding and attachment
4. Danger Signs in a Newborn (Refer for Medical Care Immediately)
• Difficulty in breathing or fast breathing
• Lethargy or not feeding
• Convulsions
• Hypothermia or fever
• Jaundice in first 24 hours
• Bleeding from any site
• Umbilical redness/swelling/discharge
• Vomiting or abdominal distention
5. Role of the Nurse
• Prepare for birth with all ENBC equipment
• Perform immediate care using clean and safe practices
• Monitor temperature, feeding, breathing
• Educate mother and family
• Maintain records and documentation
• Initiate referral if needed
Possible Outcome Questions
Two Marks
1. Mention two components of essential newborn care.
2. What is the ideal time to initiate breastfeeding?
3. Name any two vaccines given at birth.
Five Marks
1. Write the immediate care of a newborn at birth.
2. Describe the role of a nurse in essential newborn care.
Ten Marks

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1. Explain in detail the components of essential newborn care as per

Government of India guidelines.
2. Describe thermal protection, breastfeeding, and infection prevention in
newborn care.
Immediate Assessment and Care of the Newborn
1. Introduction
• The immediate assessment and care of the newborn is performed
within the first few minutes after birth, often called the golden minute,
to ensure the newborn’s safe transition from intrauterine to extrauterine
life.
• Proper care in this period is crucial to reduce neonatal morbidity and
mortality, and improve long-term health outcomes.
2. Objectives of Immediate Newborn Care
• Establish breathing and ensure effective oxygenation
• Maintain body temperature to prevent hypothermia
• Prevent infection
• Promote mother-child bonding and early breastfeeding
• Detect and manage life-threatening conditions immediately
3. Immediate Newborn Assessment
A. Initial Observations Immediately After Birth
Parameter Normal Finding

Breathing Spontaneous cry or breathing within 30 sec

Tone Good tone (active movements, flexed limbs)

Heart rate >100 beats per minute

Color Pink centrally and peripherally

• APGAR Score (done at 1 and 5 minutes):
Component 0 1 2

Appearance Blue or pale Body pink, extremities blue Completely pink

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Component 0 1 2

Pulse Absent <100 bpm ≥100 bpm

Grimace (Reflex) No response Grimace Cough/sneeze/cry

Activity (Tone) Limp Some flexion Active movement

Respiration Absent Slow, irregular Good crying

• Total Score Interpretation:
o 7–10: Normal
o 4–6: Moderate difficulty (need monitoring/support)
o 0–3: Severe distress (resuscitation required)
4. Immediate Care of the Newborn (Within First 1 Hour)
A. Warmth and Thermal Protection
• Immediately dry the baby with a warm towel
• Remove wet linen and cover with dry one
• Skin-to-skin contact (kangaroo care) with mother
• Cover head with a cap and body with clean cloth
• Delay first bath for at least 24 hours
B. Clear the Airway
• Routine suctioning is not recommended
• If needed, gently suction mouth before nose with sterile bulb syringe
• If baby is not breathing, begin neonatal resuscitation immediately
C. Cord Care
• Wait for 1–3 minutes before clamping (delayed cord clamping)
• Use sterile blade and ties/clamps
• Keep cord stump dry and clean
• Do not apply anything to the stump
D. Eye Care
• Gently clean eyes with sterile gauze or clean cloth

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• Prophylactic antibiotic eye drops may be used if per hospital protocol

E. Breastfeeding
• Encourage exclusive breastfeeding
• Initiate within 1 hour of birth
• Position baby properly for latching
• Avoid prelacteal feeds (like honey, water, etc.)
F. Identification and Documentation
• Label the newborn (name, sex, mother’s name, hospital ID)
• Record time of birth, APGAR score, weight
• Complete registration and documentation in delivery register
5. Immunization at Birth
Vaccine Timing Route & Site

BCG At birth Intradermal – left upper arm

OPV-0 At birth Oral (2 drops)

Hepatitis B Within 24 hrs Intramuscular – thigh

6. Role of the Nurse
• Prepare for clean, safe, and warm delivery area
• Perform rapid assessment and record APGAR score
• Provide thermal protection and hygiene
• Assist in early initiation of breastfeeding
• Educate mother on cord care, feeding, danger signs
• Maintain infection control practices
• Observe for any abnormalities or danger signs
• Initiate referral if complications arise
7. Danger Signs to Watch in Newborn
• Not breathing or poor cry
• Poor tone or not moving

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• Bluish color (cyanosis)

• Low temperature (<36.5°C) or fever
• Bleeding, especially from cord
• Seizures or jerky movements
• Poor feeding or vomiting
Possible Outcome Questions
Two Marks
1. What is the ideal time to clamp the cord in a normal newborn?
2. Mention any two components of the APGAR score.
3. Name one thermal protection method for a newborn.
Five Marks
1. Write the immediate care of a normal newborn at birth.
2. Describe the assessment of a newborn immediately after birth.
Ten Marks
1. Explain the immediate assessment and care of a newborn baby.
2. Describe the nurse’s responsibilities during the first hour after delivery.
Role of Doula / ASHAs (Accredited Social Health Activists)
1. Introduction
• Doula and ASHA (Accredited Social Health Activist) play an essential
role in maternal and newborn care by providing support, health
education, and facilitating access to healthcare services during
pregnancy, childbirth, and the postnatal period.
• Their contribution enhances safe motherhood, promotes respectful
maternity care, and improves maternal and neonatal outcomes
especially in rural and underserved communities
2. Who is a Doula?
• A doula is a trained, non-medical companion who provides continuous
physical, emotional, and informational support to a woman before,
during, and shortly after childbirth.

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• Doulas are not part of the clinical team but work in collaboration with
midwives and nurses to ensure the mother feels empowered and cared
for.
3. Roles and Responsibilities of a Doula
• Provide emotional support (reassurance, encouragement, presence)
during labour
• Assist with breathing techniques, comfort measures, and positioning
• Facilitate communication between the woman and healthcare
providers
• Promote informed decision-making and advocacy
• Support partner and family involvement
• Offer postpartum support (breastfeeding help, newborn care education)
• Respect cultural and individual preferences
4. Who is an ASHA?
• An ASHA is a female community health worker instituted by the
Government of India under the National Rural Health Mission
(NRHM).
• She acts as a link between the community and public health system
and is chosen from the same village she serves.
5. Qualifications of an ASHA
• Female resident of the village
• Preferably married/widow/divorced woman (25–45 years)
• Minimum educational qualification – Class 8th pass
6. Roles and Responsibilities of ASHA in Maternal and Child Health
A. During Pregnancy
• Identify pregnant women in the community
• Ensure early registration of pregnancy and ANC visits
• Motivate women for institutional delivery
• Counsel on nutrition, rest, and danger signs in pregnancy
• Accompany the mother for checkups and delivery
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B. During Labour and Childbirth

• Provide birth preparedness counseling
• Arrange for transportation to health facility
• Stay with the woman at the health facility during childbirth
• Ensure respectful care and support
C. Postnatal Period and Newborn Care
• Visit mother and baby at home on Day 1, 3, 7, 14, 21, 28, and 42
• Promote early breastfeeding and exclusive breastfeeding
• Monitor baby for weight gain and danger signs
• Counsel on postpartum family planning
• Ensure immunization as per schedule
D. General Health Promotion
• Conduct home visits and community meetings
• Promote sanitation, nutrition, and immunization
• Distribute essential drugs and ORS packs
• Maintain records and reporting formats
7. Importance of Doula and ASHA in Maternity Care
Doula ASHA

Provides continuous emotional

Provides linkage to health system
support

Improves labour experience Improves access and utilization

Promotes respectful maternity care Provides home-based newborn care

Supports government health

Enhances mother’s confidence
programs
8. Evidence of Impact
• Studies show doula support reduces C-section rates, labour duration,
and improves maternal satisfaction.

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• ASHAs have significantly increased institutional deliveries and

immunization coverage in rural India.
Possible Outcome Questions
Two Marks
1. Who is a doula?
2. Mention any two functions of an ASHA.
3. What is the minimum educational qualification of an ASHA?
Five Marks
1. Write the role of ASHA in maternal and newborn care.
2. Differentiate between the functions of a doula and an ASHA.
Ten Marks
1. Describe the role of a doula and ASHA in improving maternal and child
health outcomes.
2. Discuss the contributions of ASHAs in the success of RMNCH+A
programs in India.
Third Stage of Labour – Physiology: Placental Separation, Expulsion, and
Hemostasis
1. Introduction
• The third stage of labour is the period from the birth of the baby to the
expulsion of the placenta and membranes.
• It typically lasts about 5 to 30 minutes and is a critical phase due to the
risk of postpartum hemorrhage (PPH).
• Effective management of this stage is essential for maternal safety and
preventing complications.
2. Objectives of Third Stage Management
• Ensure complete and safe expulsion of placenta and membranes
• Promote effective uterine contraction
• Prevent postpartum hemorrhage
• Maintain hemodynamic stability of the mother
3. Physiology of Placental Separation
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A. Mechanism of Placental Separation

1. After delivery of the baby, the uterus contracts strongly, causing:
o A reduction in the surface area of the placental site
o Resulting in the shearing and detachment of the placenta
2. Two main mechanisms of separation:
o Schultze Mechanism:
▪ Central separation starts first
▪ Blood is trapped behind placenta (concealed bleeding)
▪ Placenta presents fetal side (shiny Schultze)
o Duncan Mechanism:
▪ Separation begins from the margins
▪ Blood escapes immediately (external bleeding)
▪ Placenta presents maternal side (dirty Duncan)
4. Signs of Placental Separation
• Sudden gush of blood from the vagina
• Lengthening of the umbilical cord outside the vulva
• Uterus becomes firm, globular, and rises in the abdomen
• Feeling of fullness in the vagina (placenta descending)
5. Placental Expulsion
• After separation, placenta is expelled either spontaneously or by
assistance
• Two methods:
o Expectant Management: No drugs, placenta delivered by
maternal effort
o Active Management of Third Stage of Labour (AMTSL): Use
of uterotonics to reduce PPH
6. Hemostasis During Third Stage
• Achieved mainly by:

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o Strong uterine contractions compressing maternal blood vessels

o Formation of clots at the placental site
o Natural constriction of uterine blood vessels (physiological
ligature)
• Oxytocin helps to enhance contractions and maintain hemostasis
7. Active Management of the Third Stage of Labour (AMTSL)
Steps of AMTSL Purpose

Administer uterotonic within 1 minute

Stimulate strong uterine contractions
of birth

Controlled cord traction (CCT) Assist in safe placental expulsion

Uterine massage after placenta Maintain uterine tone and detect atony
expulsion early
• Common uterotonic agents:
o Oxytocin (10 IU IM) – first-line drug
o Misoprostol, Ergometrine (in specific cases)
8. Monitoring During Third Stage
• Monitor for:
o Signs of retained placenta (>30 minutes)
o Excessive bleeding
o Uterine firmness and fundal height
o Vital signs (pulse, BP)
9. Nursing Responsibilities
• Observe signs of placental separation
• Ensure proper administration of uterotonics
• Perform controlled cord traction using correct technique
• Examine the placenta and membranes for completeness
• Monitor bleeding, uterine tone, and vital signs
• Document time of placenta delivery, drugs given, estimated blood loss

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• Report immediately if:

o Retained placenta
o Signs of shock or hemorrhage
10. Possible Outcome Questions
Two Marks
1. Name the two mechanisms of placental separation.
2. What is the most commonly used uterotonic in AMTSL?
Five Marks
1. Write any five signs of placental separation.
2. Describe the physiology of placental expulsion.
Ten Marks
1. Explain the physiology of third stage of labour.
2. Describe the nursing care and physiological changes during the third
stage of labour.
Physiological Management of Third Stage of Labour
1. Introduction
• Third stage of labour: Period from birth of the baby to expulsion of
the placenta and membranes.
• Physiological (Expectant) management: A natural, non-interventional
approach allowing the placenta to deliver spontaneously, without the
use of uterotonic drugs or controlled cord traction.
• Based on the concept that the woman’s body can complete placental
delivery without active medical intervention, provided there are no
complications.
2. Key Features of Physiological Management
• No routine use of uterotonic drugs (e.g. oxytocin)
• No controlled cord traction (CCT)
• The umbilical cord is clamped after pulsations stop
• Placenta is delivered by maternal effort, sometimes aided by gravity or
nipple stimulation
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• Uterus allowed to contract naturally for placental separation and

hemostasis
3. Indications for Physiological Management
• Low-risk pregnancy
• Woman prefers natural childbirth
• No history of postpartum hemorrhage (PPH)
• Placenta separates and delivers spontaneously within 30 minutes
• Trained personnel are available to switch to active management if needed
4. Procedure: Step-by-Step Physiological Management
1. Watchful Waiting
o Observe for signs of placental separation (e.g. cord lengthening,
gush of blood)
2. Delayed Cord Clamping
o Clamp cord only after it stops pulsating (usually after 3–5
minutes)
o Benefits: Improves newborn hemoglobin and iron stores
3. Encourage Maternal Effort
o Ask mother to bear down (push) with contractions
o Use upright or squatting position to aid gravity
4. Placental Expulsion
o Placenta usually expelled with next few contractions
o Do not pull cord or apply abdominal pressure
5. Post-Expulsion Care
o Inspect placenta and membranes for completeness
o Observe uterine firmness and control bleeding naturally
o Encourage early breastfeeding to stimulate natural oxytocin
release
5. Advantages of Physiological Management
• Promotes natural hormonal balance (oxytocin release)
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• Reduces risk of uterine over-contraction or retained placenta due to

artificial drugs
• Enhances maternal satisfaction and bonding experience
• Less invasive, empowering for mother
6. Disadvantages and Limitations
• Increased risk of postpartum hemorrhage (PPH) if not closely
monitored
• May result in longer third stage
• Requires experienced personnel for safe practice
• May not be suitable in high-risk pregnancies
7. Contraindications
• History of PPH or uterine atony
• Multiple pregnancy
• Grand multiparity
• Hypertensive disorders
• Preterm labour
• Any risk factor for retained placenta or excessive bleeding
8. Differences Between Physiological and Active Management
Physiological
Aspect Active Management
Management

Used (Oxytocin 10 IU IM)

Use of uterotonics Not used routinely
immediately

Delayed until pulsation

Cord clamping Early (within 1–3 minutes)
stops

Assisted with controlled cord

Placental expulsion By maternal effort
traction

Duration of third
May be longer Shorter
stage

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Physiological
Aspect Active Management
Management

Slightly higher risk of

Blood loss Lower risk of PPH
PPH
9. Role of the Nurse
• Monitor signs of placental separation and bleeding
• Assist mother with breathing and bearing down
• Encourage skin-to-skin contact and breastfeeding
• Be prepared to switch to active management if needed
• Ensure sterile and safe environment
• Document time, amount of blood loss, placenta condition
10. Possible Outcome Questions
Two Marks
1. Define physiological management of third stage of labour.
2. Mention one benefit of delayed cord clamping.
Five Marks
1. Describe the procedure for physiological management of third stage of
labour.
2. Write the differences between physiological and active management of
third stage.
Ten Marks
1. Explain physiological management of third stage of labour and the
nurse’s role.
2. Discuss the advantages and disadvantages of physiological management.
Active Management of the Third Stage of Labour (AMTSL) – Recommended
Guideline
1. Introduction
• The third stage of labour is from the birth of the baby to the expulsion
of the placenta and membranes.

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• The active management of this stage is a recommended, evidence-

based strategy to prevent postpartum hemorrhage (PPH)—the leading
cause of maternal mortality.
• AMTSL significantly reduces the amount of blood loss, duration of
third stage, and need for manual removal of placenta.
2. Objectives of AMTSL
• Reduce the incidence of PPH
• Facilitate placental expulsion safely and promptly
• Promote uterine contraction and retraction
• Minimize maternal morbidity and mortality
3. Key Components of AMTSL (As per WHO and Government of India
Guidelines)
A. Administration of Uterotonic Drug
• Oxytocin 10 IU IM/IV within 1 minute of baby’s birth
• Oxytocin is the drug of choice due to its effectiveness and fewer side
effects
• Alternative uterotonics if oxytocin not available:
o Misoprostol 600 mcg orally
o Ergometrine 0.2 mg IM (avoid in hypertensive women)
o Oxytocin + Ergometrine (Syntometrine) IM
B. Controlled Cord Traction (CCT)
• Apply gentle, steady traction on the umbilical cord while supporting the
uterus (guarding the uterus above symphysis pubis)
• CCT assists in placenta expulsion without inversion or injury
• Ensure placental separation signs before traction
C. Uterine Massage After Placenta Expulsion
• Immediately after placenta delivery, gently massage the uterus through
the abdomen
• Purpose: promote uterine contraction, reduce atony
• Repeated massage is not routinely recommended unless uterus is soft
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4. Additional Essential Practices

• Delayed cord clamping (1–3 minutes after birth) unless the newborn
needs resuscitation
• Examine placenta and membranes for completeness
• Monitor for excessive bleeding, fundal height, uterine tone
• Record time of placenta expulsion, drug administration, estimated blood
loss
5. Comparison: AMTSL vs Expectant Management
Aspect AMTSL Expectant Management

Yes, immediately post-

Uterotonic use No
birth

No traction; placenta expelled

Cord traction Controlled cord traction
spontaneously

Yes, post placental

Uterine massage No
expulsion

Risk of PPH Significantly reduced Higher risk

Duration of third
Shorter (5–10 minutes) Longer (up to 30 minutes)
stage
6. Role of the Nurse
• Prepare uterotonic drug before delivery
• Administer uterotonic within 1 minute of birth
• Assist with controlled cord traction
• Observe for placental separation signs
• Monitor blood loss and uterine tone
• Maintain aseptic technique
• Document:
o Time of placenta delivery
o Drug administered

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o Amount of blood loss

o Condition of uterus
7. Contraindications to Certain Uterotonics
• Ergometrine/Syntometrine: Avoid in women with:
o Hypertension
o Pre-eclampsia/eclampsia
o Cardiac disorders
8. Key Points for Safe AMTSL
• Always guard the uterus during CCT to prevent inversion
• Ensure placenta has separated before applying traction
• Monitor mother closely for bleeding and uterine tone
• Be prepared to manage retained placenta or PPH
Possible Outcome Questions
Two Marks
1. Name the drug of choice in AMTSL.
2. Write any two steps of AMTSL.
Five Marks
1. Write the components of active management of third stage of labour.
2. Differentiate between AMTSL and expectant management.
Ten Marks
1. Describe in detail the active management of the third stage of labour.
2. Explain the role of the nurse in implementing AMTSL to prevent
postpartum hemorrhage.
Examination of Placenta, Membranes, and Vessels
1. Introduction
• The placenta, membranes, and cord must be examined immediately after
expulsion in the third stage of labor.

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• Purpose: Ensure completeness, identify abnormalities, and prevent

postpartum complications such as hemorrhage or infection.
2. Objectives of Examination
• Confirm complete expulsion of placenta and membranes.
• Detect retained fragments (can lead to postpartum hemorrhage or
sepsis).
• Assess cord vessels (normally 2 arteries and 1 vein).
• Identify abnormalities in shape, size, insertion, or color.
3. Equipment Required
• Sterile gloves
• Placenta basin
• Perineal light
• Antiseptic solution
• Cord clamp
• Sterile tray
• Suturing set (if required)
4. Steps of Examination
A. Maternal Surface (Rough Side)
• Place placenta with maternal side up (dark red, rough).
• Examine for:
o 15–20 cotyledons (should be complete)
o Missing lobes or ragged edges
o Blood clots or infarcts (indicates pathology)
B. Fetal Surface (Shiny Side)
• Turn to fetal surface (shiny, translucent).
• Look for:
o Umbilical cord insertion: central, eccentric, marginal,
velamentous

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o Vessels radiating across the membrane

o Presence of cysts or meconium staining
C. Umbilical Cord
• Normal length: 40–60 cm
• Cut cross-section to check vessels:
o 2 arteries (carry deoxygenated blood to placenta)
o 1 vein (carries oxygenated blood to fetus)
• Look for:
o Knots (true/false)
o Abnormal length or insertion
Type of Insertion Description

Central In the middle of fetal surface

Eccentric Slightly off-center

Marginal (Battledore) At the edge

Velamentous Into fetal membranes (dangerous)

D. Membranes
• Identify amnion (inner) and chorion (outer).
• Examine for:
o Completeness
o Tears or ruptures
o Foul odor or meconium staining (suggests infection/fetal distress)
5. Clinical Significance of Abnormal Findings
Abnormality Implication

Missing cotyledons Retained placenta – risk of PPH

Velamentous insertion Fetal hemorrhage risk

Two-vessel cord May indicate fetal anomalies

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Abnormality Implication

Meconium-stained membranes Fetal distress or intrauterine infection

6. Diagram Suggestions
• Labelled diagram of maternal and fetal surfaces of placenta
• Cord cross-section showing 2 arteries and 1 vein
• Diagram of types of cord insertio
7. Nursing Responsibilities
• Examine placenta and membranes immediately after delivery.
• Document findings and report abnormalities.
• Maintain aseptic technique.
• Monitor for signs of PPH and maternal distress.
• Label and store placenta if required (legal/clinical reasons).
8. Possible Outcome Questions
Two Marks
1. What is the normal number of vessels in the umbilical cord?
2. Name any two types of cord insertion.
Five Marks
1. Write the steps of placenta examination and their importance.
Ten Marks
1. Discuss the procedure and clinical significance of examination of
placenta, membranes, and vessels after delivery.
Assessment of Perineal and Vaginal Tears / Injuries and Suturing
1. Introduction
• Perineal and vaginal tears are common during vaginal childbirth,
especially in primigravida, large babies, or rapid labor.
• Immediate assessment and repair are critical to prevent infection,
hemorrhage, and long-term complications such as incontinence or
dyspareunia.

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2. Causes of Perineal and Vaginal Tears

• Large baby (macrosomia)
• Rapid or precipitate labor
• Operative delivery (forceps, vacuum)
• Rigid perineum (in primigravida)
• Inadequate perineal support during delivery
• Shoulder dystocia
3. Degrees of Perineal Tear
Degree Structures Involved

First-degree Only vaginal mucosa and/or perineal skin

Second-degree Vaginal mucosa + perineal muscles (not anal sphincter)

Third-degree Includes anal sphincter

Fourth-degree Extends to rectal mucosa

4. Assessment of Tear
• After delivery, place the mother in dorsal lithotomy position.
• Use good lighting.
• Gently inspect:
o Vulva
o Vagina
o Perineum
o Anus and rectum (gloved finger if 3rd/4th degree suspected)
• Use speculum to view vaginal tears clearly.
• Classify the tear based on extent and depth.
5. Equipment Required for Suturing
• Sterile gloves
• Perineal drapes
• Antiseptic solution

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• Local anesthetic (e.g., lignocaine)

• Syringe and needle
• Suturing set (needle holder, scissors, forceps)
• Absorbable sutures (e.g., chromic catgut, vicryl)
• Sterile pads and gauz
6. Procedure of Suturing
1. Consent and explain procedure to the mother.
2. Wash hands and wear sterile gloves.
3. Infiltrate local area with 1% lignocaine.
4. Begin repair in layers:
o Vaginal mucosa
o Perineal muscles
o Skin (subcutaneous)
5. Use absorbable sutures and proper technique (continuous or
interrupted).
6. Check for hemostasis before completing.
7. Clean and apply sterile pad
7. Post-Procedure Care
• Observe for bleeding, swelling, or infection.
• Give analgesics as prescribed.
• Encourage proper perineal hygiene:
o Wipe front to back
o Sitz bath after 24 hours
• Advise high fluid and fiber intake to avoid constipation.
• Teach warning signs: fever, pain, pus, or foul smell.
8. Nursing Responsibilities
• Monitor vital signs and lochia.
• Provide emotional support and privacy.
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• Ensure sterile technique throughout.

• Record degree of tear, procedure done, type of suture, and condition post-
repair.
• Educate on home care and need for follow-up.
9. Complications if Untreated
Complication Explanation

Infection Due to poor hygiene or incomplete repair

Postpartum hemorrhage From unrecognized deeper tears

Wound dehiscence Improper suturing or poor healing

Fistula formation Especially in third/fourth-degree tears

Pain or dyspareunia Due to nerve damage or scar formation

10. Prevention Strategies
• Use of episiotomy only when indicated.
• Controlled delivery of head (perineal support).
• Proper maternal positioning and coaching during delivery.
• Adequate hydration and nutrition during antenatal period
11. Diagram Suggestions
• Diagram of degrees of perineal tear
• Labeled image of suturing layers
• Instrument tray for perineal repair
12. Possible Outcome Questions
Two Marks
1. Name any two degrees of perineal tear.
2. List any two instruments used in perineal suturing.
Five Marks
1. Explain the procedure of assessment and repair of perineal tears.
Ten Marks

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1. Classify perineal tears and explain the nursing management in detail.

Insertion of Postpartum Intrauterine Contraceptive Device (PPIUCD)
1. Introduction
• Postpartum IUCD (PPIUCD) is a long-acting reversible contraceptive
method inserted within 48 hours after childbirth.
• It offers spacing between pregnancies and is safe, effective, and non-
hormonal.
• Most commonly used device: Copper T 380A.
2. Objectives of PPIUCD Insertion
• Provide immediate postpartum contraception.
• Prevent unintended pregnancy.
• Utilize the postnatal period for promoting family planning.
• Offer a long-term (up to 10 years) reversible method
3. Timing of Insertion
Timing Description

Post-placental Within 10 minutes after placenta expulsion

Intra-cesarean During cesarean section, before uterine closure

Within 48 hours After normal vaginal or cesarean delivery

Delayed insertion After 6 weeks (interval IUCD)

4. Advantages of PPIUCD
• Convenient: Done immediately after delivery.
• Safe: No interference with lactation.
• Highly effective: Over 99%.
• Reversible: Can be removed any time.
• Cost-effective and requires no daily effort
5. Contraindications

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Absolute Contraindications Relative Contraindications

Puerperal sepsis Anemia (monitor carefully)

Unresolved postpartum hemorrhage Distorted uterine cavity

PROM >18 hrs (risk of infection) Uterine fibroids

Chorioamnionitis Multiple cesarean sections

6. Equipment Required
• Sterile IUCD insertion kit
• Copper T 380A device
• Sponge holding forceps
• Long uterine forceps (Kelly’s/Allis)
• Vaginal speculum
• Antiseptic solution (betadine/savlon)
• Sterile gloves and drapes
• Light source
7. Procedure of PPIUCD Insertion (Post-Placental – Vaginal)
1. Explain procedure to the woman and obtain informed consent.
2. Ensure bladder is empty.
3. Maintain aseptic technique throughout.
4. Position woman in lithotomy position.
5. Insert speculum, clean cervix and vagina with antiseptic.
6. Hold anterior lip of cervix with vulsellum or sponge forceps.
7. Load IUCD into long forceps (without touching the device).
8. Gently pass IUCD high into the uterine fundus.
9. Ensure fundal placement to reduce expulsion risk.
[Link] not cut threads – leave them inside the uterus.
[Link] instruments and reassess vaginal bleeding.
8. Post-Insertion Care and Instructions

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• Monitor for signs of:

o Pain, bleeding, infection
o IUCD expulsion (especially in first few weeks)
• Educate woman on:
o IUCD does not interfere with breastfeeding
o Warning signs: PAINS
▪ P: Period late / abnormal bleeding
▪ A: Abdominal pain
▪ I: Infection signs
▪ N: Not feeling well
▪ S: String missing
• Schedule follow-up visit in 6 weeks.
9. Complications of PPIUCD
Complication Management

Expulsion Confirm with USG, re-insert if needed

Bleeding or pain NSAIDs, consider removal if persistent

Infection Antibiotics, remove if severe

Uterine perforation Rare; immediate referral

10. Diagram Suggestions
• Diagram of uterus showing fundal placement of IUCD
• Flowchart of IUCD insertion steps
• Image of IUCD (Copper T 380A) with labeled parts
11. Nursing Responsibilities
• Counsel and screen for eligibility
• Obtain informed consent
• Prepare equipment and assist during procedure
• Monitor vital signs and vaginal bleeding post-insertion

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• Provide post-insertion teaching and documentation

• Refer to physician in case of any complicatio
12. Possible Outcome Questions
Two Marks
1. When can a postpartum IUCD be inserted?
2. Mention any two contraindications for PPIUCD.
Five Marks
1. Describe the steps for insertion of a postpartum IUCD.
2. List the advantages and complications of postpartum IUCD.
Ten Marks
1. Explain the indications, procedure, and nursing care involved in
postpartum IUCD insertion.
Immediate Perineal Care
1. Introduction
• Immediate perineal care refers to the cleaning and inspection of the
perineal area immediately after childbirth, especially in cases of:
o Vaginal delivery
o Episiotomy
o Perineal tears or suturing
• The goal is to prevent infection, reduce discomfort, and promote healing.
2. Objectives of Immediate Perineal Care
• Maintain perineal hygiene
• Prevent infection and inflammation
• Assess for any perineal trauma or hematoma
• Ensure comfort and dignity of the mother
• Promote early healing and reduce pain
3. Indications
• After normal vaginal delivery

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• After episiotomy or perineal suturing

• Presence of lochia or blood stains
• After manual removal of placenta
• In postpartum women with urinary or fecal incontinenc
4. Articles Required
Item Purpose

Sterile gloves Maintain aseptic technique

Antiseptic solution (e.g., betadine) Cleanse perineal area

Cotton swabs/gauze pieces Cleaning and drying

Perineal pad Absorb lochia and bleeding

Kidney tray Waste collection

Disposable sheet Protect bedding

Perineal lamp/light source Proper visibility

5. Procedure of Immediate Perineal Care
1. Explain the procedure to the mother to reduce anxiety.
2. Provide privacy and proper positioning (dorsal or lithotomy).
3. Wash hands and wear sterile gloves.
4. Place disposable sheet under the buttocks.
5. Gently separate the labia and inspect the perineum for:
o Episiotomy wound
o Sutures
o Swelling or hematoma
o Ongoing bleeding
6. Clean the perineum from front to back using antiseptic-soaked
gauze/cotton:
o One swab for one stroke
o Start from the pubic area to anal area
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7. Dry the area with sterile dry gauze.

8. Apply new sterile perineal pad.
9. Discard waste appropriately and document the care given
6. Special Considerations
• Use aseptic technique always.
• Do not rub harshly over sutured areas.
• Avoid excessive moisture in the area to prevent maceration.
• If signs of infection or hematoma are present, report immediately.
• Use cold compress or ice packs if swelling is observed (first 24 hours).
7. Post-Procedure Instructions
• Educate the mother to:
o Change perineal pads frequently
o Maintain personal hygiene (wash hands before/after pad change)
o Clean from front to back after urination or defecation
o Use sitz bath as advised (after 24 hours)
• Encourage adequate fluid intake and nutrition for healin
8. Diagram Suggestions
• Anatomical diagram of perineal region
• Stepwise illustration of perineal cleaning
• Positioning for perineal care
9. Nursing Responsibilities
• Ensure proper infection control practices
• Provide emotional support
• Monitor for signs of:
o Excessive bleeding
o Foul-smelling lochia
o Hematoma

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o Separation of sutures
• Document:
o Time and details of care
o Condition of perineum
o Type of lochia and presence of swelling or pain
10. Possible Outcome Questions
Two Marks
1. What is the purpose of immediate perineal care?
2. List any two articles required for perineal care.
Five Marks
1. Describe the procedure for immediate perineal care.
2. Write nursing responsibilities in perineal care.
Ten Marks
1. Explain immediate perineal care with procedure, nursing responsibilities,
and post-care instructions.
Initiation of Breastfeeding
1. Introduction
• Breastfeeding is the natural way of feeding an infant, ensuring optimal
growth, immunity, and bonding.
• Initiation of breastfeeding refers to starting breastfeeding within the
first hour of birth.
2. Objectives of Early Initiation
• Provide the newborn with colostrum – rich in antibodies and nutrients
• Promote mother-infant bonding
• Stimulate oxytocin release – aids uterine contraction and reduces
postpartum bleeding
• Improve lactation reflex and long-term milk production
• Establish exclusive breastfeeding practices

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3. Ideal Time for Initiation

Time Significance

Within 1 hour of birth Helps with colostrum intake and bonding

During skin-to-skin contact Promotes warmth, suckling reflex activation

4. Benefits of Early Breastfeeding
A. For the Baby:
• Provides colostrum (rich in IgA, protein, fat-soluble vitamins)
• Protects against infections (respiratory, GI, etc.)
• Promotes brain development
• Reduces risk of hypoglycemia and hypothermia
B. For the Mother:
• Stimulates oxytocin → promotes uterine involution
• Reduces risk of postpartum hemorrhage (PPH)
• Aids in bonding and emotional satisfaction
• Delays return of menstruation (natural contraceptive effect)
5. Steps for Initiation of Breastfeeding
1. Immediate skin-to-skin contact after delivery
2. Dry the baby and place him/her on the mother’s chest
3. Encourage the baby to find the nipple and latch naturally
4. Help the mother with correct positioning and attachment
5. Ensure no prelacteal feeds are given (e.g., honey, sugar water)
6. Observe for signs of:
o Effective suckling
o Swallowing movements
o Burping after feed
6. Positioning and Attachment Techniques

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Position Description

Cradle hold Common; baby’s head rests in mother’s elbow

Cross-cradle hold Better control of baby's head by mother

Football hold Useful after cesarean delivery

Side-lying Good for nighttime or lying down position

Signs of Proper Latch:
• Baby’s mouth covers areola
• Chin touches the breast
• No clicking sounds
• Slow, deep sucking with swallowing
7. Common Barriers to Early Initiation
• Cesarean delivery without support
• Lack of privacy or knowledge
• Preterm or sick baby
• Delay in shifting the mother to postnatal ward
• Cultural practices/prelacteal feeding traditions
8. Nursing Responsibilities
• Educate mother and family about benefits of early initiation
• Ensure privacy and emotional support
• Assist with positioning and latching
• Monitor for nipple pain or breastfeeding issues
• Avoid unnecessary separation of mother and baby
• Document the time and success of first breastfeeding
9. Diagram Suggestions
• Latching technique and positions
• Anatomy of breastfeeding (areola, nipple, duct)
• Skin-to-skin placement diagram

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10. WHO Recommendations

• Initiate breastfeeding within the first hour
• Encourage exclusive breastfeeding for 6 months
• No bottle feeding or pacifiers
• Continued breastfeeding up to 2 years or beyond
11. Possible Outcome Questions
Two Marks
1. When should breastfeeding ideally be initiated after birth?
2. Name two benefits of colostrum.
Five Marks
1. Describe the steps involved in early initiation of breastfeeding.
2. Explain the benefits of early breastfeeding for the mother and baby.
Ten Marks
1. Explain the procedure and importance of initiating breastfeeding within
the first hour after birth, along with nursing responsibilities.
Skin-to-Skin Contact (SSC)
1. Introduction
• Skin-to-skin contact (SSC) is the practice of placing the naked
newborn (with or without a diaper) directly on the mother’s bare chest
immediately after birth.
• SSC is a key component of Essential Newborn Care and part of the
Baby-Friendly Hospital Initiative (BFHI) by WHO and UNICEF
2. Objectives of Skin-to-Skin Contact
• Promote early bonding between mother and baby
• Facilitate early initiation of breastfeeding
• Prevent neonatal hypothermia
• Improve newborn physiological stability
• Enhance maternal satisfaction and confidence
3. Timing and Duration
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When Duration

Immediately after birth At least 1 hour

Cesarean section (if stable) As soon as possible

During postnatal period Repeated sessions encouraged

4. Procedure of Skin-to-Skin Contact
1. Dry the baby thoroughly to prevent heat loss.
2. Place the naked baby (with cap and diaper) on the mother’s bare chest.
3. Cover both mother and baby with a warm, dry cloth or blanket.
4. Ensure baby’s head is turned sideways, neck slightly extended.
5. Monitor for:
o Breathing patterns
o Color and activity
o Initiation of breastfeeding
6. Continue uninterrupted SSC for at least 1 hour.
5. Benefits of Skin-to-Skin Contact
A. For the Baby:
• Maintains body temperature (thermoregulation)
• Stabilizes heart rate, respiratory rate, and blood sugar
• Reduces crying and stress
• Promotes early breastfeeding and colostrum intake
• Enhances immunological protection
B. For the Mother:
• Stimulates oxytocin release → aids uterine contraction and reduces
bleeding
• Enhances milk ejection reflex
• Increases maternal confidence and bonding
• Reduces postpartum stress and anxiety

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6. Skin-to-Skin in Special Situations

Situation Recommendation

Low birth weight babies Kangaroo Mother Care (KMC) recommended

Cesarean section SSC can be done on mother’s chest in recovery room

Preterm but stable baby Early SSC improves thermal regulation and outcomes
7. Diagram Suggestions
• Stepwise illustration of skin-to-skin placement
• Cross-sectional image showing baby on mother's chest
• Flowchart: Birth → Drying → SSC → Breastfeeding
8. Nursing Responsibilities
• Prepare for SSC immediately after delivery
• Ensure privacy and warmth
• Assist positioning of the baby and ensure safe breathing
• Educate the mother and family about SSC benefits
• Observe and record baby's condition during SSC
• Encourage repeated SSC sessions during hospital sta
9. WHO & UNICEF Recommendations
• Begin SSC within 1 minute of birth
• Encourage uninterrupted contact for at least 1 hour
• Integrate SSC into routine delivery care for all stable newborns
• Essential component of BFHI (Baby-Friendly Hospital Initiative)
10. Possible Outcome Questions
Two Marks
1. Define skin-to-skin contact.
2. Mention two benefits of skin-to-skin contact for the newborn.
Five Marks
1. List the steps and nursing responsibilities during skin-to-skin contact.

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2. Explain the benefits of SSC for mother and baby.

Ten Marks
1. Explain the procedure, benefits, and importance of skin-to-skin contact
immediately after birth.
Newborn Resuscitation
1. Introduction
• Newborn resuscitation is the emergency procedure performed on a
newborn who fails to initiate or sustain breathing immediately after
birth.
• Timely resuscitation can prevent birth asphyxia, hypoxic injury, and
neonatal death.
• Approximately 10% of newborns require some assistance at birth, and
1% require advanced resuscitation.
2. Objectives of Newborn Resuscitation
• Establish effective respiration
• Maintain airway, breathing, and circulation (ABC)
• Prevent hypoxia and organ damage
• Improve survival and long-term outcomes
3. Indications
Resuscitation is needed if the baby:
• Is not crying or breathing
• Has poor muscle tone (floppy)
• Has heart rate <100 bpm
• Shows central cyanosis or pallor
4. Equipment Required for Resuscitation
Equipment Purpose

Radiant warmer Maintain newborn body temperature

Suction device (bulb/suction catheter) Clear airway

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Equipment Purpose

Bag and mask (self-inflating) Positive pressure ventilation (PPV)

Oxygen supply and tubing Oxygen support

Laryngoscope and endotracheal tubes Advanced airway management

Stethoscope Assess heart and breath sounds

Clock/timer Monitor duration of steps

Gloves and towels Aseptic care and drying

5. Initial Steps (Within First 30 Seconds)
1. Provide warmth (under radiant warmer)
2. Position head slightly extended (“sniffing” position)
3. Clear airway if necessary:
o Suction mouth first, then nose
4. Dry the baby thoroughly
5. Stimulate breathing by rubbing back or flicking soles
6. Evaluation after Initial Steps
Parameter Action

Breathing Spontaneous or apnea/gasping?

Heart Rate (HR) ≥100 bpm or <100 bpm?

Color Pink or centrally cyanosed?

7. Resuscitation Algorithm (Simplified)
If baby is not breathing or HR < 100 bpm:
→ Start Positive Pressure Ventilation (PPV)
→ Reassess after 30 seconds:
- HR ≥ 100 bpm → Stop PPV, observe
- HR < 100 bpm → Improve ventilation (reposition, suction, mask seal)

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If HR < 60 bpm despite effective PPV:

→ Start chest compressions (3:1 ratio with PPV)
→ Consider oxygen and advanced support (ET tube, medications)
8. Positive Pressure Ventilation (PPV)
• Use self-inflating bag with appropriate mask size
• Deliver ventilation at 40–60 breaths/min
• Ensure chest rise with each breath
• Monitor HR and color continuously
9. Chest Compressions
• Indicated if HR <60 bpm after 30 seconds of PPV
• Technique:
o Place two thumbs on sternum, fingers around back
o Compression rate: 90 compressions + 30 breaths per minute (3:1
ratio)
o Depth: One-third of chest diameter
10. Medications (Advanced Resuscitation Only)
Drug Indication Route

Epinephrine If HR remains <60 bpm IV/ET tube

Normal Saline Volume expansion IV

11. Post-Resuscitation Care
• Monitor:
o Temperature, glucose, oxygen saturation, respiration
o Neurological status
• Transfer to NICU if needed
• Provide emotional support to parents
• Document all interventions with time and response
12. Diagram Suggestions

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• Neonatal Resuscitation Flowchart

• Bag and mask ventilation technique
• Chest compression positions and hand placement
13. Nursing Responsibilities
• Check and prepare resuscitation area before every delivery
• Recognize high-risk pregnancies (e.g., meconium-stained, preterm)
• Maintain sterility and warmth
• Assist in resuscitation (bag and mask ventilation)
• Monitor baby’s HR, respiration, color
• Document interventions and outcomes
• Educate and support parents
14. Mnemonic:
Initial Resuscitation: WARM – POSITION – CLEAR – DRY –
STIMULATE"
15. Possible Outcome Questions
Two Marks
1. Mention any two indications for newborn resuscitation.
2. Name two equipment used during neonatal resuscitation.
Five Marks
1. Describe the initial steps of newborn resuscitation.
2. Explain the procedure for positive pressure ventilation.
Ten Marks
1. Describe in detail the newborn resuscitation steps and nursing
responsibilities.
2. Explain the resuscitation algorithm with indications, procedures, and
post-care.
Fourth Stage of Labour – Observation, Critical Analysis, and Management of
Mother and Newborn
1. Introduction
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• The Fourth Stage of Labour begins immediately after the delivery of

the placenta and lasts for the first 1–2 hours postpartum.
• This is a critical observation period to monitor the mother's and
newborn’s adaptation and to detect early complications.
• Timely intervention and nursing care during this stage are essential for
preventing postpartum hemorrhage and other emergencies.
2. Objectives of Care in Fourth Stage
• Monitor for postpartum hemorrhage (PPH)
• Ensure uterine contraction and involution
• Assess vital signs and recovery
• Initiate and support breastfeeding
• Monitor the newborn for normal transition to extrauterine life
3. Maternal Observations (Every 15–30 minutes)
Parameter What to Check

Vital signs BP, pulse, respiration, temperature

Uterine tone and height Firm and contracted uterus; fundal level

Vaginal bleeding (lochia) Amount, color (rubra), clots

Bladder status Palpable bladder or need to void

Perineum Episiotomy or tear: bleeding, swelling

Pain or discomfort Pain level and need for analgesics

4. Critical Signs to Watch For
Sign Possible Cause Immediate Action

Uterine atony, retained Uterine massage, alert

Heavy vaginal bleeding
placenta doctor

Hypotension, Fluid resuscitation, O2, IV

Shock or hemorrhage
tachycardia access

Boggy uterus Uterine atony Fundal massage

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Sign Possible Cause Immediate Action

Perineal swelling or Apply cold compress,

Trauma or vessel rupture
hematoma monitor size

Fever or chills Infection Report immediately

5. Maternal Nursing Management
• Fundal massage: Ensure uterus remains firm
• Encourage bladder emptying: To prevent uterine displacement
• Monitor lochia: Should not be excessive; check for clots
• Apply perineal pad and inspect every 15–30 mins
• Provide warmth and comfort
• Offer oral fluids/light food if no contraindications
• Educate mother on breastfeeding and perineal care
• Provide emotional support and reassurance
6. Newborn Observation in Fourth Stage
Parameter What to Monitor

Breathing Regular, no grunting or retractions

Heart rate >100 bpm, strong and regular

Temperature Maintain warmth; avoid hypothermia

Color Pink (central), assess for cyanosis or pallor

Activity and tone Active, normal reflexes

Feeding cues Rooting, sucking reflex present

7. Newborn Management
• Dry and warm the newborn (use skin-to-skin contact)
• Place baby in prone position on mother’s chest
• Initiate breastfeeding within 1 hour
• Apply identification tags

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• Administer Vitamin K injection (as per protocol)

• Record birth weight, sex, and Apgar score
• Monitor for urine and meconium passage
8. Charting and Documentation
• Document maternal:
o Vital signs, uterine tone, bleeding amount
o Medications given
o Time of placenta delivery
• Document newborn:
o Time of first breath/cry
o Feeding initiation
o Apgar score at 1 and 5 minutes
o Identification bands and newborn condition
9. Diagram Suggestions
• Uterine involution and fundal height during fourth stage
• Monitoring chart (maternal and newborn vitals)
• WHO Birth and Emergency Record Template
10. Nursing Responsibilities
• Remain with mother and baby during first hour
• Observe and document changes every 15 minutes
• Assist mother with positioning and comfort
• Provide newborn care and breastfeeding support
• Maintain infection control practices
• Be alert for any signs of complications and report promptly
11. Possible Outcome Questions
Two Marks
1. Define the fourth stage of labor.

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2. Mention two maternal observations in the fourth stage.

Five Marks
1. List the critical signs to observe in the fourth stage of labor.
2. Describe nursing care of the mother during the fourth stage.
Ten Marks
1. Describe the observations, nursing responsibilities, and management of
both mother and newborn in the fourth stage of labor.
Maternal Assessment and Observation in the Postpartum Period
Fundal Height, Uterine Consistency, Urine Output, Blood Loss
1. Introduction
• Maternal assessment during the immediate postpartum period
(especially first 6 hours) is critical to ensure early detection of
complications such as postpartum hemorrhage, infection, and urinary
retention.
• Focus areas: Fundal height, uterine tone, urine output, and vaginal
bleeding (lochia).
2. Purpose of Maternal Assessment
• Monitor the mother’s physical recovery after childbirth
• Detect signs of PPH, infection, urinary retention, and uterine atony
• Support early interventions and prevent complication
3. Components of Postpartum Maternal Assessment
Parameter Normal Findings Clinical Significance

At the level of the umbilicus

Fundal Height after delivery; descends 1 Reflects uterine involution
cm/day

Uterine Prevents postpartum

Firm and contracted
Consistency hemorrhage

> 100 mL/hour, clear, no Indicates adequate renal

Urine Output
retention function and hydration

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Parameter Normal Findings Clinical Significance

500 mL or less after vaginal

Excessive loss = PPH
Blood Loss delivery; <1000 mL after
(Postpartum Hemorrhage)
cesarean
4. Assessment of Fundal Height
• Palpated through the abdominal wall with the bladder empty
• Use fingerbreadths to measure descent below the umbilicus
• Normally:
o Immediately after delivery: At or slightly below umbilicus
o By Day 10–14: Non-palpable abdominally (in pelvis)
Day Postpartum Fundal Height Approx.

Day 1 At umbilicus

Day 2 1 finger below

Day 3 2 fingers below

… …

Day 10–14 Not palpable

Deviation from this pattern may indicate subinvolution or retained products.
5. Assessment of Uterine Consistency
Consistency Interpretation Nursing Action

Firm Normal; adequate contraction Continue observation

Uterine atony – risk for Perform fundal massage, report if

Boggy
hemorrhage persists
A boggy uterus is a medical emergency and may lead to PPH.
6. Assessment of Blood Loss (Lochia)
Type Characteristics Duration

Lochia rubra Bright red, blood and debris 1–3 days post-birth

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Type Characteristics Duration

Lochia serosa Pinkish or brownish, less blood 4–10 days

Lochia alba Yellow-white, few leukocytes 10–14 days to 6 weeks

• Watch for:
o Soaking of >1 pad/hour → Abnormal
o Large clots (>50 paise coin) → Abnormal
o Foul odor → Suggests infection
7. Assessment of Urine Output
Normal Findings Abnormal Findings

Output > 100 mL/hour Retention or dribbling

Clear, yellow urine Cloudy, foul-smelling urine

No pain or discomfort Painful micturition (suggests UTI)

Retained urine may displace the uterus to the right and interfere with
contraction, increasing hemorrhage risk.
8. Nursing Responsibilities
• Assess uterus every 15 min for the first 2 hours post-delivery
• Palpate fundus with both hands (support lower uterus)
• Monitor lochia on pad: type, amount, color, odor
• Encourage the mother to empty bladder regularly
• Provide pain relief if uterine contractions are painful
• Document fundal height, tone, bleeding, and interventions
9. Charting Template Suggestion
Fundal Uterine Lochia Urine Action
Time
Height Tone Type/Amount Output Taken

8:00 Umbilicus Firm Rubra, moderate 150 mL Observed

Massage
8:15 1 cm below Firm Rubra, scant Voided
done

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10. Diagram Suggestions

• Uterine involution chart (day-wise descent)
• Hand technique for fundal palpation
• Visual guide to lochia types
11. Possible Outcome Questions
Two Marks
1. What is the normal descent rate of the uterus after delivery?
2. Mention the types of lochia in the postpartum period.
Five Marks
1. Describe the assessment of fundal height and uterine consistency after
delivery.
2. Write nursing responsibilities in assessing urine output and lochia.
Ten Marks
1. Explain the postpartum maternal assessment with focus on fundal height,
uterine tone, blood loss, and urine output.
Documentation and Record of Birth
1. Introduction
• Documentation and record-keeping are essential parts of nursing and
midwifery care during childbirth.
• Accurate records ensure legal protection, continuity of care, and data
for audit, research, and planning.
• Birth records are legal documents and should be factual, timely, and
complete.
2. Objectives of Birth Documentation
• Provide a clear account of the labor and delivery process
• Ensure safe continuity of maternal and newborn care
• Enable early detection of complications
• Serve as legal evidence if required
• Assist in data collection for health statistics

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3. Components of Birth Documentation

Category Details Included

Maternal Name, age, hospital ID, gravidity, parity, admission

Identification date/time

Onset of labor, cervical dilation, fetal heart rate,

Labour Notes
contractions, medications

Time of birth, mode of delivery (NVD/LSCS),

Delivery Details
presentation, condition of placenta

Sex, weight, Apgar score (1 & 5 min), condition at birth,

Newborn Data
any resuscitation

Immediate Vitamin K, cord care, eye care, initiation of

Interventions breastfeeding, skin-to-skin

Postpartum Fundal height, lochia, uterine tone, BP, pulse, urine

Assessment output

Newborn
Respiratory rate, HR, color, reflexes, feeding
Observations

Identification Tags Mother-baby matching ID bands

Signature Name/designation of attending nurse/midwife/doctor

4. Formats/Registers Commonly Used
Record/Register Purpose

Partograph Graphical record of labor progress

Birth Register Records of all live/stillbirths

Delivery Room Record Detailed note of delivery events and actions taken

Postnatal Chart Tracks mother’s recovery (vitals, fundus, lochia, etc.)

Newborn Chart Monitoring baby’s vitals, feeding, reflexes

Consent Forms For episiotomy, LSCS, procedures

Identification Record Tagging info for mother-baby pair

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5. Legal Aspects
• Confidentiality must be maintained (use initials/codes if needed).
• All entries must be:
o Legible
o Dated and timed
o Signed with full name and designation
• Never erase or use white-out – strike through errors with a single line
and initial it.
6. Documentation of Special Situations
Situation Additional Notes Required

Preterm/low birth
Gestational age, birth weight, special care instructions
weight

Neonatal resuscitation Steps taken, Apgar before and after, outcome

Time of diagnosis, condition of fetus, parental support

Stillbirth
given

Complications (PPH, Observations, interventions, medications, referrals if

tear) any
7. Sample Delivery Note Format (Short Version)
Name: _______ Age: ____ Gravida: ___ Para: ___
Date/Time of Delivery: __________
Mode of Delivery: __________
Baby: Male / Female | Weight: ___ kg | Apgar: 1 min ___ / 5 min ___
Placenta delivered completely: Yes / No
Cord Vessels: 2 arteries / 1 vein
Perineum: Intact / Episiotomy / Tear (degree)
Medications Given: __________
Initiated Breastfeeding: Yes / No
Signature: __________ Designation: __________

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8. Nursing Responsibilities in Documentation

• Record all events in real time
• Use standard abbreviations and terminology
• Ensure mother-baby matching is recorded properly
• Immediately report and document any abnormal events
• Maintain clean and secure storage of records
• Support team in entering data into digital systems, if applicable
9. Diagram Suggestions
• Sample filled birth record
• Flowchart of documentation process from admission to discharge
• Example of partograph use and interpretation
10. Possible Outcome Questions
Two Marks
1. Name two documents maintained during labor and birth.
2. What is the importance of Apgar score in birth records?
Five Marks
1. Write a short note on components of delivery room documentation.
2. List the nursing responsibilities during documentation and birth record
keeping.
Ten Marks
1. Explain in detail the documentation and record maintenance required
during labor, birth, and immediate postpartum period.
Breastfeeding and Latching
1. Introduction
• Breastfeeding is the natural method of feeding the newborn, providing
all essential nutrients and antibodies for growth and immunity.
• Latching refers to how the baby attaches to the breast — correct latching
ensures effective milk transfer and prevents nipple trauma.
2. Importance of Breastfeeding
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• Provides complete nutrition for the first 6 months

• Contains antibodies (especially IgA) to protect against infection
• Promotes bonding between mother and baby
• Reduces risk of postpartum hemorrhage through oxytocin release
• Aids uterine involution
• Economical and readily available
3. Physiology of Breastfeeding
Hormone Role

Prolactin Stimulates milk production

Oxytocin Causes milk ejection ("let-down")

• Colostrum is the first yellowish thick milk secreted for 2–4 days
postpartum — rich in protein, antibodies, and fat-soluble vitamins.
• Followed by transitional milk (day 4–10), then mature milk after 2
weeks.
4. Principles of Effective Breastfeeding
• Start breastfeeding within 1 hour of birth
• Feed on demand (8–12 times/day)
• Alternate both breasts during feeds
• Allow baby to empty one breast before switching
• Ensure correct latching to avoid cracked nipples and poor feeding
5. Signs of Good Latch
Observation Indicates Effective Latching

Baby’s mouth wide open Covers most of areola (not just nipple)

Chin touches the breast Nose is free

Baby’s lips flanged outward Tongue under the nipple

No clicking or smacking sounds Baby swallows audibly

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Observation Indicates Effective Latching

Mother feels strong tug but no pain Indicates deep latch

6. Breastfeeding Positions
Position Description

Cradle Hold Baby's head in crook of mother's arm, tummy to tummy

Cross-Cradle Baby supported with opposite arm to the breast being used

Football Hold Baby tucked under mother’s arm (useful after cesarean)

Side-lying Mother and baby lie facing each other (used at night/rest)
Ensure baby’s head, neck, and body are aligned in all positions.
7. Steps to Achieve Proper Latch
1. Wash hands and ensure privacy/comfort
2. Position baby close, facing the breast
3. Gently stimulate rooting reflex (touch baby’s lips with nipple)
4. Wait for mouth to open wide
5. Guide baby to latch deeply, taking in areola
6. Observe for sucking and swallowing
7. Burp baby after feeding
8. Common Breastfeeding Challenges
Problem Cause Management

Correct latch, nipple creams, air

Cracked nipples Poor latch, dryness
exposure

Warm compresses, manual

Engorgement Infrequent feeds
expression

Infection in breast
Mastitis Antibiotics, continue breastfeeding
tissue

Insufficient milk Stress, poor latch, Frequent feeding, rest, hydration,

supply illness nutrition

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9. Nursing Responsibilities
• Educate mother on positioning and latching
• Support early initiation of breastfeeding
• Observe feeds and correct poor latch
• Assess for feeding cues: rooting, sucking, hand-to-mouth movement
• Provide emotional support and encouragement
• Identify and manage feeding difficulties early
10. Diagram Suggestions
• Diagram of proper latch (baby’s mouth wide open, covers areola)
• Breastfeeding positions (cradle, cross-cradle, side-lying)
• Cross-section of breast showing milk ducts and let-down reflex
11. Possible Outcome Questions
Two Marks
1. Define latching.
2. Mention two signs of good latching.
Five Marks
1. List and explain any two breastfeeding positions.
2. Describe the steps for achieving a proper latch.
Ten Marks
1. Explain the physiology of breastfeeding and describe in detail the signs of
a good latch and nursing care related to it.
Managing Uterine Cramp (Afterpains) in Postpartum Mothers
1. Introduction
• Uterine cramps, commonly known as afterpains, are contractions of the
uterus after childbirth.
• These pains help the uterus return to its pre-pregnancy size and reduce
the risk of postpartum hemorrhage.
• More common and intense in multiparous women, breastfeeding
mothers, and those with uterine overdistension.
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2. Causes of Uterine Cramps

Cause Explanation

Uterine involution Natural shrinking and firming of uterus after delivery

Breastfeeding Oxytocin release during breastfeeding stimulates cramps

Clot expulsion Uterus contracts to expel retained blood/clots

Multiparity Less uterine tone increases frequency of cramps

Full bladder Displaces uterus, causing painful contractions

3. Characteristics of Uterine Cramps
• Sharp, intermittent lower abdominal pain
• Lasts for 2–4 days postpartum
• Increases during breastfeeding or uterine massage
• Often felt more strongly in second or subsequent pregnancies
4. Nursing Assessment
• Ask mother to describe pain: onset, duration, severity
• Palpate uterine fundus for firmness, height, and position
• Assess relation to breastfeeding or bladder distension
• Monitor for signs of abnormal bleeding or infection
5. Non-Pharmacological Management
Intervention Rationale

Educate mother that cramps are a normal part of

Reassurance
recovery

Breathing and relaxation Helps reduce perception of pain

Warm compress/heating Relieves muscle tension and soothes uterine

pad cramps

Prevents displacement of uterus that can worsen

Empty bladder regularly
cramps

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Intervention Rationale

Proper positioning Lying prone may help improve uterine drainage

Can assist in uterine involution and blood clot

Gentle massage
expulsion
6. Pharmacological Management
Drug Dose & Route Purpose

NSAIDs (e.g., 200–400 mg orally, 6–8

Pain relief
Ibuprofen) hourly

500–650 mg orally, 4–6 Mild pain

Paracetamol
hourly management

Relieve muscle
Antispasmodics As per physician’s order
cramps
Note: Pain medications should be prescribed with caution in breastfeeding
mothers
7. Nursing Responsibilities
• Educate mother on normal uterine involution and afterpains
• Encourage breastfeeding despite discomfort (it promotes uterine
contraction)
• Teach and assist in relaxation techniques and warm application
• Monitor pain severity and report any unusual symptoms (fever, foul
lochia, persistent pain)
• Document pain score, interventions, and outcomes
8. When to Report Immediately
• Severe cramps not relieved by medication
• Pain associated with heavy bleeding or foul-smelling lochia
• Fever, chills, or uterine tenderness (possible infection)
9. Diagram Suggestions
• Uterine involution chart (day-wise fundal descent)
• Oxytocin release and let-down reflex pathway
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• Pain management nursing care plan structure

10. Possible Outcome Questions
Two Marks
1. What is uterine cramp or afterpain?
2. Name one non-drug method to relieve uterine cramps.
Five Marks
1. Describe nursing interventions to manage uterine cramps.
2. List any two causes and two nursing responsibilities in afterpains
management.
Ten Marks
1. Explain the causes, assessment, and nursing management of uterine
cramps during the postpartum period.
Alternative / Complementary Therapies in Postnatal Care
1. Introduction
• Complementary and alternative therapies (CATs) are non-
conventional treatments used alongside or in place of standard medical
care.
• In postpartum care, they support physical recovery, pain management,
lactation, and emotional well-being.
2. Goals of Complementary Therapies in Postpartum Period
• Relieve pain and discomfort (perineal, uterine, musculoskeletal)
• Promote healing of tissues
• Enhance lactation and breastfeeding
• Reduce stress, anxiety, and postnatal depression
• Improve sleep and emotional balance
3. Commonly Used Complementary Therapies
Therapy Uses in Postpartum Care

Lavender, chamomile oils used for relaxation and

Aromatherapy
mood upliftment

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Therapy Uses in Postpartum Care

Massage therapy Improves circulation, reduces pain and anxiety

Stimulates points to reduce uterine cramps and

Acupressure
promote lactation

Warm compresses Used for perineal pain, breast engorgement

Herbal remedies Fenugreek, fennel for lactation; turmeric for healing

Yoga and deep

Enhances relaxation, reduces anxiety, improves sleep
breathing

Hydrotherapy (sitz
Relieves perineal discomfort, improves hygiene
bath)

Music therapy Soothes mood, reduces anxiety and pain perception

4. Herbal Remedies Used in Postpartum Care

Herb Common Use

Fenugreek Enhances breast milk production (galactagogue)

Fennel Reduces gas and helps in lactation

Turmeric Anti-inflammatory, helps in wound healing

Ashwagandha Reduces stress and anxiety

Note: Herbal remedies should be used under guidance to avoid side effects and
drug interactions
5. Indications for Use
• Postpartum uterine cramps
• Perineal pain or discomfort
• Breast engorgement
• Low milk supply
• Emotional disturbances like baby blues or postpartum depression
• Sleep disturbances or fatigue

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6. Contraindications / Precautions
• Avoid unverified herbal remedies without consultation
• Some therapies (e.g., certain oils or herbs) may cause allergic reactions
• Not a replacement for emergency medical treatment
• Ensure therapy is safe for breastfeeding mother
7. Nursing Responsibilities
• Assess mother's readiness and preference for complementary therapies
• Provide education and informed consent
• Ensure clean, safe, and hygienic use of materials
• Monitor for adverse reactions
• Coordinate with healthcare provider before administering herbs or
therapies
• Document therapy used and the response of the mother
8. Benefits of Complementary Therapies
• Non-invasive and cost-effective
• Promotes natural healing and comfort
• Enhances maternal satisfaction
• Supports holistic care (physical, emotional, psychological
9. Diagram/Table Suggestions
• Chart comparing conventional vs. complementary care
• Illustration of pressure points used in acupressure for lactation
• Sample postpartum complementary care plan
10. Possible Outcome Questions
Two Marks
1. Name any two complementary therapies used in postpartum care.
2. Mention one herbal remedy used to increase lactation.
Five Marks

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1. Write a short note on the role of aromatherapy and massage in postnatal

care.
2. Explain any three complementary therapies used to manage postpartum
discomfort.
Ten Marks
1. Discuss various complementary and alternative therapies used in the
postpartum period and explain the nurse’s role in ensuring safe and
effective use.
Role of Doula / ASHA (Accredited Social Health Activist)
1. Introduction
• A Doula or ASHA worker plays a key role in supporting pregnant and
postpartum women, especially in rural and underserved areas.
• They complement professional healthcare services by offering
physical, emotional, informational, and referral support.
2. Who is a Doula?
• A Doula is a trained, non-medical birth companion.
• Provides continuous support during pregnancy, labour, and
postpartum period.
• Works alongside medical staff, but does not perform clinical tasks.
3. Who is an ASHA Worker?
• ASHA stands for Accredited Social Health Activist.
• A female health activist chosen from the local community under the
National Rural Health Mission (NRHM).
• Acts as a bridge between community and health system.
4. Roles and Responsibilities of a Doula
Function Details

Emotional support Provides reassurance, presence, and stress relief

Assists with breathing, positioning, massage during

Physical support
labor

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Function Details

Informational Offers evidence-based education on birth and

support postpartum care

Advocacy Helps the mother express her birth preferences

Supports breastfeeding, newborn care, and emotional

Postpartum care
recovery

5. Roles and Responsibilities of ASHA Worker

Area of Care Role of ASHA

Community
Promotes institutional deliveries and immunization
Mobilization

Home visits At least 6 postnatal home visits for mother and baby

On nutrition, hygiene, family planning, and newborn

Health education
care

Helps with antenatal registration, transport, and

Birth preparedness
referral

Identifies danger signs in mother or baby and refers

Postnatal support
accordingly

Maintains health records, registers, and ensures

Record keeping
follow-up care

For TB, and supports national programs like JSY,

Act as DOT provider
JSSK
6. Contribution to Postnatal Care
Task Contribution by Doula / ASHA

Early breastfeeding Encourages initiation and supports proper latching

Perineal hygiene Educates mother on postnatal hygiene

Family planning Counsels on contraceptive options

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Task Contribution by Doula / ASHA

Provides reassurance and reduces risk of postpartum

Emotional care
depression

Teaches skin-to-skin care, warmth, feeding, and

Newborn care
hygiene

Identification of danger
Guides immediate referral if needed
signs
7. Importance of Their Role
• Builds trust and cultural connection with community
• Improves maternal and child health outcomes
• Increases institutional delivery rate
• Decreases maternal and neonatal morbidity and mortality
• Provides continuity of care from pregnancy to postnatal period
8. Diagram Suggestions
• Flowchart of ASHA’s roles from pregnancy to postnatal care
• Comparison table: Role of Doula vs. ASHA
• ASHA in the community health system hierarchy
9. Possible Outcome Questions
Two Marks
1. Who is an ASHA?
2. Mention any two postnatal roles of a Doula.
Five Marks
1. Describe any five responsibilities of an ASHA worker in postnatal care.
2. Write a short note on the contribution of a Doula during childbirth.
Ten Marks
1. Compare and contrast the roles of a Doula and an ASHA in maternal and
postnatal care. Explain their significance in improving maternal
outcomes.

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Various Childbirth Practices

1. Introduction
• Childbirth practices refer to methods, customs, and clinical approaches
followed during labor and delivery.
• These practices may be traditional, modern (evidence-based), or
culturally influenced, and vary across regions and healthcare settings.
• The goal is to ensure a safe delivery, minimize maternal and neonatal
complications, and respect the woman’s choices.
2. Classification of Childbirth Practices
Type Examples

Conventional/Clinical Hospital-based delivery, use of medications

Alternative/Natural Home birth, water birth, hypnobirthing

Traditional/Cultural Squatting, herbal use, birth attendants (dais)

Evidence-Based Skin-to-skin contact, delayed cord clamping, active

Practices labor support
3. Modern (Evidence-Based) Childbirth Practices
Practice Benefits

Reduces complications, promotes timely

Birth preparedness counseling
care-seeking

Continuous labor support Reduces cesarean rate and need for pain relief

Active management of third

Prevents postpartum hemorrhage
stage

Delayed cord clamping (1–3

Increases neonatal iron reserves
mins)

Skin-to-skin contact Promotes bonding and thermoregulation

Initiation of breastfeeding Improves neonatal survival

Freedom of movement during

Reduces labor pain and duration
labor

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Practice Benefits

Use of partograph Monitors labor progression effectively

4. Traditional/Cultural Childbirth Practices (India-specific Examples)
Practice Description Risk/Benefit

Considered natural and Can be beneficial in some

Squatting for delivery
easier for pushing cases

Massage with herbal Given during labor for Caution: potential skin
oils pain relief sensitivity

Applied to lower back or

Use of hot compresses Generally safe if hygienic
abdomen for pain

Consumption of Risk of toxicity, needs

Believed to ease labor
herbal decoctions regulation

Rituals or chants Provide emotional comfort Psychologically beneficial

Mother and baby kept in Risk of delayed care if

Isolation post-delivery
seclusion for 40 days complications arise
Nurses must respect cultural practices unless they are unsafe.
5. Alternative Childbirth Practices
Practice Description Notes

Needs trained
Water birth Labor and/or delivery in warm water
personnel

Delivery at home with skilled birth Risky if no

Home birth
attendant emergency access

Self-hypnosis techniques to reduce

Hypnobirthing Requires preparation
fear and pain

Doula-supported Emotional and physical support by Improves

birth trained birth companion satisfaction
6. Harmful or Outdated Practices (To Be Avoided)

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Practice Why It Is Discouraged

Routine enema during labor Uncomfortable, no proven benefit

Shaving of perineal hair Increases risk of infection

Routine episiotomy Should be performed only when indicated

Supine (flat) birthing position Slows labor, increases discomfort

Withholding food during labor May cause maternal fatigue

. Nurse’s Role in Safe Childbirth Practices

• Educate women and families about safe and evidence-based practices
• Respect cultural beliefs while discouraging harmful customs
• Monitor labor using partograph and provide continuous emotional
support
• Encourage informed decision-making
• Facilitate early breastfeeding and bonding
• Ensure clean delivery practices to prevent infection
8. Diagram/Table Suggestions
• Chart: Comparison of Traditional vs. Evidence-Based Practices
• Flowchart: Steps in Evidence-Based Normal Delivery
• WHO's 10 Recommendations for Intrapartum Care (simplified)
9. Possible Outcome Questions
Two Marks
1. Give two examples of evidence-based childbirth practices.
2. What is the role of a partograph in labor?
Five Marks
1. List five traditional childbirth practices followed in rural India.
2. Describe the nurse’s role in promoting safe childbirth practices.
Ten Marks

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1. Explain various childbirth practices and discuss the significance of

evidence-based care in ensuring safe delivery.
Safe Environment for Mother and Newborn to Promote Bonding
1. Introduction
• Mother–newborn bonding is the emotional connection that forms
between a mother and her baby immediately after birth.
• A safe, supportive, and calm environment is essential to initiate this
bond and to ensure the physical and emotional well-being of both
mother and newborn.
• Promoting bonding enhances infant development, maternal confidence,
and successful breastfeeding.
2. Importance of Bonding
• Encourages breastfeeding initiation and success
• Improves thermoregulation, heart rate, and oxygen levels in newborns
• Enhances emotional stability in the mother
• Promotes secure attachment and long-term developmental benefits for
the baby
3. Elements of a Safe and Supportive Environment
Aspect Key Considerations

Clean, warm, well-ventilated delivery and

Physical environment
postnatal rooms

Dim lights and reduced noise to create a calming

Lighting and noise
atmosphere

Room temp 24–26°C; use of warm wraps, skin-

Temperature control
to-skin contact

Ensure mother has privacy during initial

Privacy
bonding and breastfeeding

Hand hygiene, clean linen, and infection control

Cleanliness and hygiene
measures

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Aspect Key Considerations

Presence of partner/support Encourages emotional comfort and confidence

person in the mother

Ensure mother is comfortable, especially post-

Pain relief
delivery
4. Interventions to Promote Bonding in a Safe Environment
Intervention Purpose/Effect

Helps regulate baby’s temperature, heartbeat,

Early skin-to-skin contact
and supports attachment

Rooming-in (mother-baby Allows continuous closeness and easier

together) breastfeeding

Delayed cord clamping (1–3

Supports infant iron stores and allows transition
mins)

Immediate initiation of
Within 1 hour of birth for immunity and bonding
breastfeeding

Gentle handling of newborn Avoids stress and enhances trust and security

Helps baby recognize mother’s voice and

Soothing voice and touch
promotes attachment

Allow time without unnecessary procedures or

Uninterrupted rest
visitors post-delivery
5. Role of Nurse in Creating a Safe Bonding Environment
• Prepare and maintain a clean and warm space for delivery and postnatal
care
• Support skin-to-skin contact and initiate early breastfeeding
• Protect privacy and ensure the mother feels emotionally safe and
respected
• Educate the family about the importance of bonding and safe newborn
care
• Minimize interruptions during the bonding period

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• Observe for signs of maternal distress and provide support or referral if

needed
6. Barriers to Bonding and Their Solutions
Barrier Solution

Maternal exhaustion or pain Provide pain relief, rest, emotional support

Neonatal separation (NICU care) Encourage kangaroo care when possible

Cultural beliefs about handling Educate with sensitivity about evidence-

newborn based practices

Advocate for mother-friendly hospital

Hospital policies or interruptions
practices
7. Diagram/Table Suggestions
• Illustration of skin-to-skin contact position
• Flowchart: Steps to promote bonding in immediate postpartum
• Table: Nurse’s responsibilities to ensure bonding and safety
8. Possible Outcome Questions
Two Marks
1. Mention two ways to promote bonding between mother and newborn.
2. What is the ideal room temperature to maintain for a newborn?
Five Marks
1. Write a short note on the role of a nurse in creating a safe bonding
environment.
2. Describe the importance of rooming-in in promoting mother–baby
bonding.
Ten Marks
1. Discuss how a safe environment contributes to mother–newborn bonding.
Include nursing interventions and barriers to bonding.
Maintaining Records and Reports
1. Introduction

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• Records and reports are essential tools in nursing that provide accurate,
legal, and continuous documentation of care given to the mother and
newborn.
• Maintaining records ensures accountability, continuity of care, legal
protection, and data for planning and evaluation.
2. Definitions
• Records: Written or electronic factual documentation of observations,
nursing interventions, outcomes, and patient responses.
• Reports: Verbal or written communication of patient-related
information shared among healthcare professionals.
3. Importance of Records and Reports
Purpose Details

Legal documentation Acts as legal evidence of care provided

Ensures continuity between shifts and healthcare

Communication
teams

Helps assess the quality of care and plan

Evaluation and audit
improvements

Useful for maternal and child health research and

Research and statistics
policymaking

Acts as a reference for teaching and case study

Education and training
discussions

Insurance and
Needed for insurance claims and legal settlements
reimbursement
4. Types of Records in Postnatal and Maternity Care
Record Type Description

Personal details, reason for admission, antenatal

Admission record
history

Labor and delivery

Labor progress, interventions, delivery details
record

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Record Type Description

Partograph Graphic record of labor progress

Vitals, lochia, uterine involution, breastfeeding

Postnatal record (mother)
status

Vital signs, feeding, elimination, jaundice, cord

Postnatal record (baby)
care

Drug administration
Time, dose, and route of medications administered
record

Problems identified, interventions, goals, and

Nursing care plan
evaluation

Summary of care and instructions to be followed at

Discharge summary
home
5. Essential Components of a Good Record
• Accuracy – Avoid errors and overwriting
• Clarity – Use clear, understandable language
• Legibility – Write neatly if on paper
• Timeliness – Document care as soon as possible
• Confidentiality – Maintain patient privacy (do not share without
consent)
• Completeness – Cover all necessary details (date, time, signature)
6. Types of Reports in Maternity Nursing
Report Type Purpose

Change-of-shift
Handover between nurses to ensure continuity of care
report

Document any unusual event (e.g., fall, medication

Incident report
error)

Transfer report When patient is moved to another ward or facility

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Report Type Purpose

Information on patient condition and follow-up care

Discharge report
needed

Death/birth report Legally required for government records

7. Nurse’s Responsibilities in Record-Keeping
• Document all observations and nursing actions accurately and promptly
• Use only standard medical abbreviations
• Maintain confidentiality and privacy
• Ensure records are stored properly
• Report any changes in patient condition to the appropriate authority
• Sign every entry with date and time
8. Legal and Ethical Considerations
• Incomplete or false documentation may lead to legal consequences
• Records must be preserved as per hospital or government policies
• Any alteration or tampering is punishable
• Respect for patient rights and privacy is essentia
9. Diagram/Table Suggestions
• Table of common maternity records and their contents
• Flowchart: Record maintenance process from admission to discharge
• Example of filled partograph or postnatal chart (for visual aid)
10. Possible Outcome Questions
Two Marks
1. Mention two types of records maintained in postnatal care.
2. Why is maintaining confidentiality in records important?
Five Marks
1. Write the nurse’s responsibilities in maintaining maternity records.
2. List the essential characteristics of a good nursing record.

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Ten Marks
1. Discuss the importance, types, and nurse’s responsibilities in maintaining
records and reports in postnatal care.
2. Explain how effective documentation helps in legal, educational, and
clinical aspects of maternal care.

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Unit – 05
Postpartum care/Ongoing care of women
Normal Puerperium: Physiology and Duration
1. Introduction
• Puerperium is the period following childbirth during which the
mother's body returns to its non-pregnant physiological state.
• Also known as the postnatal period, it begins immediately after
delivery and typically lasts for 6 weeks (42 days).
• It is a critical time for physical recovery, hormonal adjustment,
emotional changes, and establishing breastfeeding.
2. Duration and Phases of Puerperium
Phase Duration Features

First 24 hours after Monitor for hemorrhage, uterine tone,

Immediate
delivery vitals

Rapid physiological changes, involution,

Early Day 2 to Day 7
lochia present

Day 8 to 6 weeks Return of menstruation, stabilization of

Late
postpartum lactation
3. Physiological Changes During Puerperium
A. Uterine Involution
• Uterus returns to pre-pregnancy size and position.
• Immediately after delivery: Size of a grapefruit (1 kg)
• By end of 6 weeks: 50–60 g (normal size)
• Fundal height decreases ~1 cm/day
Day Postpartum Fundal Position

Immediately At umbilicus

Day 1–2 1–2 cm below umbilicus

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Day Postpartum Fundal Position

Day 10–14 No longer palpable abdominally

B. Lochia (Postpartum Vaginal Discharge)
Type Color & Content Duration

Lochia rubra Red, contains blood, decidua 1–4 days postpartum

Lochia serosa Pink/brown, contains serous fluid 5–10 days

Lochia alba Yellow-white, mucus and leukocytes 11–14 days or longer

• Total average volume: 250–500 mL
C. Cervical and Vaginal Changes
• Cervix contracts but remains slightly open after delivery
• Vaginal walls remain edematous and soft; tone restores by 3–4 weeks
• Perineum may be swollen or bruised (especially if episiotomy/tear
occurred)
D. Breast and Lactation Changes
• Triggered by prolactin (milk production) and oxytocin (milk ejection)
• Engorgement may occur on day 2–3
• Colostrum → transitions to mature milk by day 3–
E. Cardiovascular System
• Blood volume normalizes gradually
• Pulse rate decreases, but monitor for tachycardia (may indicate
hemorrhage)
• Risk of thromboembolism is increased in early puerperium
F. Urinary System
• Increased urination due to diuresis
• Risk of urinary retention due to perineal trauma
• Must monitor urine output and bladder distention
G. Gastrointestinal System

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• Appetite returns but constipation is common due to:

o Reduced motility
o Fear of pain due to stitches or hemorrhoids
• Encourage fiber-rich diet and fluids
H. Endocrine System
• Fall in estrogen and progesterone levels
• Prolactin remains high if breastfeeding
• Ovulation may return within 6 weeks (non-lactating women)
I. Psychological Adaptations
Stage Description

Taking-in phase First 1–2 days; mother focused on own recovery

Taking-hold phase Day 2–10; interest shifts to baby care

Letting-go phase After 10 days; adjusts to maternal role

4. Nursing Responsibilities During Normal Puerperium
• Monitor vital signs, fundal height, and lochia
• Assess for signs of infection or hemorrhage
• Promote breastfeeding and maternal–infant bonding
• Educate on perineal care, nutrition, and family planning
• Provide psychological support and observe for postpartum depression
5. Red Flags That Require Immediate Attention
• Excessive vaginal bleeding
• Foul-smelling lochia
• Painful or hard uterus
• Fever or chills
• Breast engorgement with fever (possible mastitis)
• Signs of postpartum depression
6. Diagram Suggestions

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• Uterine involution chart (fundal height timeline)

• Types of lochia and their duration
• Stages of psychological adaptation
7. Possible Outcome Questions
Two Marks
1. What is the normal duration of the puerperium period?
2. Name the three types of lochia.
Five Marks
1. Write a short note on uterine involution.
2. List and explain physiological changes during puerperium.
Ten Marks
1. Define puerperium and describe the normal physiological changes in the
postnatal period.
2. Explain the phases of puerperium with nursing responsibilities during
each phase.
Post-natal Assessment and Care – Facility and Home-Based Care
1. Introduction
• Post-natal care refers to the care provided to the mother and newborn
from birth until 6 weeks postpartum.
• The aim is to promote recovery, prevent complications, support
breastfeeding, and ensure the well-being of both mother and baby.
• Care may be provided in health facilities or through home-based visits
by community health workers (e.g., ANM, ASHA).
2. Objectives of Postnatal Care
• Ensure physical and psychological recovery of the mother
• Promote exclusive breastfeeding
• Monitor newborn growth and development
• Prevent and manage complications (e.g., infection, hemorrhage)
• Educate family on nutrition, hygiene, contraception, and infant care

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3. Facility-Based Postnatal Care (Hospital/PHC/CHC)

A. Maternal Assessment
Parameter What to Assess

Vital signs BP, pulse, temperature, respiratory rate

Uterus Fundal height, uterine consistency (should be firm)

Lochia Amount, color, odor

Perineum Wound status (episiotomy/tear), hygiene

Breast Engorgement, nipple condition, breastfeeding issues

Bladder & bowel Voiding, constipation, urinary retention

Psychological state Signs of baby blues, anxiety, depression

B. Newborn Assessment
Parameter What to Monitor

Vital signs Temperature, heart rate, respiratory rate

Feeding Latching, sucking, frequency

Elimination Urine and stool passage

Cord care Dry and clean, no signs of infection

Jaundice Observe for yellowing of skin or eyes

C. Health Education
• Importance of exclusive breastfeeding
• Perineal care, personal hygiene
• Nutrition and adequate rest
• Immunization schedule
• Contraceptive advice
• Danger signs to watch in mother and newborn
4. Home-Based Postnatal Care
• Delivered by ASHA/ANM/community nurse in rural/remote areas
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• Based on Home-Based Newborn Care (HBNC) and Home-Based

Postnatal Care (HBPNC) programs under NHM
A. Schedule of Home Visits (as per NHM)
Day Postpartum Visit By ASHA/ANM

Day 1 Within 24 hrs of delivery

Day 3

Day 7

Day 14

Day 21

Day 28/42 Final follow-up

B. Services Provided
• Assess mother’s general condition, lochia, perineal healing
• Promote early initiation of breastfeeding
• Educate on danger signs: bleeding, fever, breast pain, newborn issues
• Weigh the newborn, monitor for hypothermia, jaundice
• Ensure immunization, cord care, warmth, and nutrition
• Counsel on family planning and follow-up visits
5. Common Postnatal Problems and Early Detection
Problem Nurse’s Action

Excessive bleeding Assess uterine tone, report immediately

Fever Check for infection (lochia, wound, UTI), report

Check for engorgement, mastitis; guide on feeding

Breast issues
technique

Baby not feeding

Check latch, position, and sucking reflex
well

Signs of PPD Refer for mental health support

6. Role of Nurse in Postnatal Care
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• Provide physical care and monitoring

• Offer emotional support
• Teach self-care and newborn care
• Document all findings and interventions
• Promote early detection of complications
• Ensure continuity of care through follow-up
7. Diagram/Table Suggestions
• Table: Comparison of facility-based vs home-based care
• Flowchart: Steps of postnatal assessment
• Checklist format: Postnatal assessment of mother and baby
8. Possible Outcome Questions
Two Marks
1. Mention any two assessments done for a postnatal mother.
2. Write two objectives of postnatal care.
Five Marks
1. Write short notes on home-based postnatal care.
2. Explain the maternal and newborn assessment during postnatal period.
Ten Marks
1. Describe in detail the facility-based and home-based postnatal care.
2. Discuss nursing responsibilities and interventions during postnatal period.
Perineal Hygiene and Care
1. Introduction
• Perineal hygiene refers to maintaining cleanliness and proper care of the
vulva, vagina, and anus area, especially after vaginal delivery.
• Important for healing of episiotomy or tears, infection prevention, and
comfort in the postpartum period
2. Importance of Perineal Hygiene
• Prevents puerperal infection

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• Promotes wound healing (especially in episiotomy or tear cases)

• Reduces pain, swelling, and discomfort
• Enhances mother’s mobility and confidence
3. Indications for Perineal Care
• After normal vaginal delivery
• In case of episiotomy or perineal lacerations
• After urination or defecation
• For heavy lochia discharge
• To maintain personal hygien
4. Equipment Required
• Sterile gloves
• Mild antiseptic solution (e.g., diluted povidone-iodine)
• Cotton balls or gauze pieces
• Warm water
• Kidney tray
• Perineal pad
• Disposable sheet or underpad
• Towel
5. Procedure of Perineal Care
1. Explain procedure to the mother and ensure privacy
2. Place mother in dorsal position (legs slightly flexed)
3. Wash hands and wear gloves
4. Place disposable sheet under buttocks
5. Use warm sterile water or prescribed antiseptic
6. Clean from front to back (vulva → perineum → anus)
o Prevents fecal contamination
o Use one swab for one stroke; discard after each use

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7. Dry area gently using sterile gauze or towel

8. Apply perineal pad properly
9. Document the procedure and any abnormalities (e.g., swelling,
discharge, pain)
6. Special Care for Episiotomy or Tear
• Monitor wound for redness, swelling, or discharge
• Administer analgesics or antiseptics as prescribed
• Use sitz bath (warm water soak) 2–3 times a day to promote healing
• Instruct mother to avoid straining during bowel movement
• Teach Kegel exercises (after healing) for pelvic muscle strengthenin
7. Health Education for Mothers
• Always wipe from front to back after urination or defecation
• Change perineal pads frequently (every 4–6 hours or sooner if soaked)
• Keep area dry and clean
• Avoid using perfumed soaps or talcum powder on the perineal area
• Avoid tight undergarments; use clean cotton panties
• Seek help if signs of infection (fever, foul smell, increased pain) appear
8. Nursing Responsibilities
• Provide hygienic environment and clean linen
• Encourage regular perineal cleaning
• Assess and report signs of infection
• Provide emotional support and privacy
• Ensure proper disposal of soiled materials
• Teach mother self-care and when to seek help
9. Complications Due to Poor Perineal Hygiene
Complication Result

Puerperal sepsis Fever, foul lochia, uterine tenderness

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Complication Result

Delayed healing Persistent pain, infection of stitches

Fistula formation Especially in infected deep tears

Emotional distress Due to pain, discomfort, foul odor

10. Diagram/Table Suggestions
• Diagram of perineal care steps (cleaning direction)
• Table: Do's and Don'ts of perineal care
• Anatomy of the perineum for visual referenc
11. Possible Outcome Questions
Two Marks
1. Mention any two principles of perineal hygiene.
2. Why is front-to-back cleaning important in perineal care?
Five Marks
1. Write a short note on perineal hygiene after normal delivery.
2. Describe the steps of perineal care and the nurse’s role.
Ten Marks
1. Define perineal care. Discuss its importance, procedure, and nursing
responsibilities in detail.
2. Explain the health education and nursing management of a postnatal
mother with perineal stitches.
Bladder and Bowel Function in the Postpartum Period
1. Introduction
• After childbirth, the bladder and bowel functions undergo temporary
changes due to:
o Pressure during delivery
o Perineal trauma or sutures
o Hormonal effects
o Use of anesthesia or episiotomy

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• Proper elimination is vital for comfort, healing, and preventing

complications such as infection or urinary retention.
2. Bladder Function
A. Normal Postpartum Changes
• Increased urinary output due to diuresis (to remove pregnancy fluids)
• Decreased bladder tone and sensation from stretched muscles or
epidural anesthesia
• Possible urinary retention from pain or swelling
B. Problems Related to Bladder Function
Problem Cause Consequences

Trauma, edema, anesthesia, UTI, bladder

Urinary retention
fear of pain overdistention

Stress incontinence
Incontinence Weak pelvic floor muscles
(laugh/cough)

UTI (urinary tract Poor perineal hygiene, Fever, burning, urgency,

infection) catheter use foul odor
C. Assessment of Bladder Function
• Observe for first void after delivery (within 6 hours)
• Monitor frequency, amount, and ease of urination
• Palpate for bladder distension
• Check for incomplete emptying or dribbling
D. Nursing Interventions
• Encourage early ambulation and voiding
• Provide privacy and support during urination
• Use techniques like pouring warm water over perineum
• If retention persists, catheterization may be required
• Monitor for UTI signs and report promptly
3. Bowel Function

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A. Normal Postpartum Changes

• Delayed bowel movement for 2–3 days is common due to:
o Decreased abdominal tone
o Fear of pain (episiotomy/tear)
o Hormonal changes
o Reduced peristalsis post-delivery
B. Problems Related to Bowel Function
Condition Causes Effects

Pain, dehydration, low fiber diet, Discomfort, straining,

Constipation
immobility rectal pain

Pressure during pushing or Swelling, pain, rectal

Hemorrhoids
constipation bleeding

Severe perineal tears (3rd/4th Loss of bowel control

Incontinence
degree) (rare)
C. Assessment of Bowel Function
• Ask about gas passage, bowel movement, discomfort
• Check for hemorrhoids, abdominal distension, or pain
• Observe frequency and consistency of stools
D. Nursing Interventions
• Encourage early ambulation to stimulate bowel activity
• Provide high-fiber diet, adequate fluids
• Offer stool softeners or mild laxatives if prescribed
• Instruct to avoid straining during defecation
• Use sitz baths or cold packs for hemorrhoids
• Provide emotional reassurance if hesitant due to pain
4. Health Education to Mother
• Hydration: 8–10 glasses of water daily
• Fiber-rich foods: fruits, vegetables, whole grains

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• Importance of early voiding and bowel movement

• Report if:
o Unable to urinate
o Painful urination
o No bowel movement for more than 3 days
o Signs of UTI or hemorrhoids
5. Nursing Responsibilities
• Monitor and record urine output and bowel activity
• Encourage mother to use toilet regularly
• Assess for signs of infection or retention
• Provide privacy and emotional support
• Report abnormalities promptly to medical tea
6. Diagram/Table Suggestions
• Table: Comparison of normal vs abnormal bladder/bowel function
• Flowchart: Nursing care for urinary retention
• Visuals: Pelvic floor muscles, Kegel exercise instructio
7. Possible Outcome Questions
Two Marks
1. Mention any two causes of urinary retention in the postpartum period.
2. List two nursing interventions to prevent constipation after delivery.
Five Marks
1. Describe the assessment and care of bladder function in a postpartum
woman.
2. Explain bowel function changes and nursing management during the
puerperium.
Ten Marks
1. Discuss the physiological changes in bladder and bowel function in the
postpartum period. Add nursing interventions to promote healthy
elimination.
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Minor Disorders of Puerperium and Their Management

1. Introduction
• During the puerperium period (first 6 weeks after childbirth), women
may experience several minor disorders.
• Though not serious, they can affect comfort, recovery, and motherhood
experience.
• Nurses play a key role in early identification, comfort measures, and
health education
2. Common Minor Disorders and Their Management
Nursing
Disorder Description Causes
Management

Reassure mother,
Cramping pain provide analgesics,
Uterine involution,
After-pains due to uterine encourage
breastfeeding
contractions breastfeeding for
natural oxytocin

Pain in perineum
Sitz baths, analgesics,
(esp. with Stretching, trauma,
Perineal pain perineal hygiene, ice
episiotomy or sutures
packs
tear)

Encourage frequent
Painful, swollen
breastfeeding, warm
Breast breasts due to Delayed/infrequent
compress before, cold
engorgement milk feeding
after feeds, manual
accumulation
expression

High-fiber diet,
Hard stools or Hormonal changes,
fluids, early
Constipation difficulty in pain fear,
ambulation, stool
defecation dehydration
softeners if prescribed

Sitz bath, stool

Swollen rectal
Constipation, softeners, topical
Hemorrhoids veins causing
pushing during labor ointments, avoid
pain/discomfort
straining

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Nursing
Disorder Description Causes
Management

Encourage voiding,
Urinary Inability to void Edema, trauma, fear, privacy, pour warm
retention urine easily epidural water, catheter if
needed

Encourage fluids,
Urinary tract Burning, urgency,
Poor hygiene, perineal hygiene,
infection foul-smelling
catheter use antibiotic if
(UTI) urine
prescribed

Postural strain, Proper posture, rest,

Pain in lower
Backache epidural, weak back massage,
back
abdominal muscles support belt

Reassure, maintain
Sweating Excessive night Hormonal
hygiene, change
(Diaphoresis) sweating withdrawal
clothing as needed

Encourage rest,
Persistent Sleep deprivation,
Fatigue nutritious food, iron
tiredness anemia, stress
supplementation

Emotional support,
Mood swings, Hormonal changes,
Baby blues reassurance, family
crying, irritability stress, sleep loss
involvement
3. Nursing Responsibilities
• Assess for signs and symptoms of discomfort
• Listen empathetically and offer reassurance
• Provide comfort measures and assist with hygiene
• Encourage early ambulation and rest alternately
• Educate mother on self-care and danger signs
• Refer to doctor for persistent or worsening symptoms
4. Health Education to Mothers
• Take prescribed medications regularly

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• Maintain perineal hygiene and breast care

• Take adequate fluids and nutritious diet
• Rest whenever possible
• Encourage family support
• Watch for signs of postpartum depression or infection
5. Table: Summary of Disorders
Minor Disorder Key Management

After-pains Analgesics, reassurance

Constipation Fiber, fluid, stool softeners

Breast engorgement Breastfeeding, cold/warm compress

Perineal pain Sitz bath, hygiene, ice packs

UTI Fluids, hygiene, antibiotics

Hemorrhoids Ointments, stool softeners

Backache Massage, posture correction

Baby blues Emotional support, monitoring

6. Diagram/Table Suggestions
• Table comparing symptoms and care of each disorder
• Flowchart: Nurse’s role in managing minor disorders
• Visual: Sitz bath setup, breast care
7. Possible Outcome Questions
Two Marks
1. Mention any two minor disorders of puerperium.
2. List two nursing interventions for perineal pain.
Five Marks
1. Describe the nursing management of breast engorgement.

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2. Write short notes on baby blues and after-pains.

Ten Marks
1. Enumerate common minor disorders of puerperium. Discuss their causes
and nursing management in detail.
2. Explain various discomforts during puerperium and the role of nurse in
managing them.
Physiology of Lactation and Lactation Management
1. Introduction
• Lactation is the process of milk production and secretion from the
mammary glands.
• Begins during pregnancy but becomes fully functional after delivery
due to hormonal and reflexive mechanisms.
• Exclusive breastfeeding is recommended for the first 6 months of life
2. Anatomy of the Breast
• Each breast contains:
o 15–20 lobes divided into lobules
o Alveoli (milk-producing units)
o Lactiferous ducts (carry milk to nipple)
o Areola and nipple (contain smooth muscles and sensory receptors
3. Hormonal Control of Lactation
Hormone Source Function

Stimulates breast duct growth (in

Estrogen Placenta
pregnancy)

Stimulates lobular development, inhibits

Progesterone Placenta
milk secretion before birth

Anterior
Prolactin Stimulates milk production
pituitary

Posterior Stimulates milk ejection (let-down

Oxytocin
pituitary reflex)

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Hormone Source Function

Human placental Helps in preparation of breast tissue for

Placenta
lactogen lactation
Note: After delivery, progesterone and estrogen levels drop, allowing
prolactin to act and initiate milk production.
4. Phases of Lactation
Phase Timing Characteristics

Breast tissue growth and alveolar

Mammogenesis During pregnancy
development

Mid-pregnancy to Milk secretion begins, but is

Lactogenesis I
early postpartum inhibited by high progesterone

Sudden onset of copious milk

Lactogenesis II 2–3 days postpartum secretion (due to drop in
progesterone)

4 days to months Maintenance of milk production

Galactopoiesis
post-delivery (stimulated by suckling)

Milk ejection (let- Oxytocin causes contraction of

At each feed
down) myoepithelial cells
5. Milk Ejection Reflex (Let-Down Reflex)
• Triggered by baby’s suckling at the breast
• Sensory nerves in the nipple send signals to the hypothalamus
• Hypothalamus stimulates posterior pituitary to release oxytocin
• Oxytocin causes contraction of myoepithelial cells → milk is ejected
from alveoli to nipple
6. Composition of Breast Milk
Component Function

Water (87%) Hydration

Lactose Energy source, promotes gut flora

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Component Function

Fat Energy, brain development

Proteins Includes casein and whey (easily digestible)

Immunoglobulins (IgA) Protects against infections

Enzymes and hormones Aid digestion and growth

Vitamins and minerals Nutritional support

7. Types of Breast Milk
Type Time of Production Characteristics

First 3–5 days after Thick, yellow, rich in antibodies,

Colostrum
birth protein, vitamin A

Transitional
Day 5–14 Increasing in fat and lactose
milk

Mature milk After 2 weeks Watery appearance, complete nutrition

8. Lactation Management
A. Early Initiation of Breastfeeding
• Within first 1 hour of birth
• Promotes bonding, colostrum intake, and stimulates oxytocin (helps
uterine contraction)
B. Feeding Techniques
• Ensure good positioning and latching
o Baby’s mouth wide open
o Chin touching breast
o Areola mostly inside mouth
C. Feeding Frequency
• On demand, 8–12 times/day
• At night too (prolactin levels are higher)
D. Breast Care

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• Wash with plain water, avoid soaps

• Expose to air to prevent cracks
• Use nipple creams if cracks occur
E. Prevention and Management of Problems
Issue Management

Engorgement Express milk, warm compress before feed, cold after

Cracked nipples Correct latch, nipple cream, air dry nipples

Mastitis Antibiotics, continue breastfeeding, warm compress

Inverted nipple Use breast pump, manual stimulation, nipple shields

9. Contraindications to Breastfeeding
Absolute Relative

HIV positive mother (if safe alternatives Active tuberculosis (until

available) treated)

Infant with galactosemia Herpes lesion on nipple

10. Role of Nurse
• Educate mother on benefits and techniques
• Assist in early initiation and positioning
• Assess for signs of feeding problems
• Provide emotional support and privacy
• Monitor for maternal and infant health
11. Diagram/Table Suggestions
• Diagram of breast anatomy (lobes, ducts, nipple)
• Flowchart: Hormonal pathway of lactation
• Table: Comparison of colostrum, transitional, and mature mil
12. Possible Outcome Questions
Two Marks
1. Name two hormones responsible for lactation.
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2. What is colostrum? Mention one benefit.

Five Marks
1. Explain the let-down reflex with the role of oxytocin.
2. Describe management of common breastfeeding difficulties.
Ten Marks
1. Describe the physiology of lactation and discuss nursing management to
promote successful breastfeeding.
2. Explain phases of lactation and nurse’s role in breastfeeding education.
Postnatal Counseling and Psychological Support
1. Introduction
• Postnatal counseling refers to guidance and emotional support provided
to women after childbirth.
• It helps mothers adjust physically, emotionally, and socially to the new
role.
• Nurses play a central role in identifying concerns, offering
psychological support, and providing timely interventions.
2. Objectives of Postnatal Counseling
• Promote maternal mental well-being
• Educate on postpartum changes and care
• Enhance mother-infant bonding
• Identify early signs of mental health disorders
• Support partner and family involvement
3. Common Emotional Changes After Delivery
Change Description

Mild mood swings, crying, irritability (3–5 days

Baby Blues
postpartum)

Postpartum Persistent sadness, anxiety, poor bonding, lasts

Depression weeks/months

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Change Description

Postpartum Psychosis Rare but severe; delusions, confusion, suicidal thoughts

Note: Baby blues are common and self-limiting, while depression and
psychosis need urgent attention.
4. Signs of Postpartum Emotional Disturbances
• Excessive crying or sadness
• Loss of interest in surroundings
• Irritability or anger
• Sleep disturbances
• Anxiety about caring for the baby
• Thoughts of harming self or baby (urgent referral needed)
5. Areas to Cover During Postnatal Counseling
Topic Details

Physical recovery Bleeding, perineal care, fatigue, rest

Latching techniques, feeding positions, common

Breastfeeding
issues

Emotional well-being Validate feelings, normalize emotions, address fears

Baby care Newborn handling, feeding, bathing, sleep routines

Contraceptive
Discuss safe methods during lactation
counseling

Encourage emotional and practical support from

Partner involvement
partner

When to seek help – physical or psychological

Warning signs
symptoms
6. Nursing Role in Providing Psychological Support
• Create trust and a non-judgmental environment
• Listen actively to the mother's concerns
• Validate her feelings (e.g., "It's okay to feel overwhelmed.")
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• Offer reassurance, and normalize common emotional changes

• Encourage rest, nutrition, and self-care
• Promote open communication with family
• Educate on community resources (support groups, counselors)
• Refer to mental health professionals if needed
7. Partner and Family Involvement
• Educate family on maternal mood changes and support needs
• Encourage shared caregiving
• Promote inclusive counseling involving the father or support person
• Help reduce stigma about mental health care
8. Counseling Techniques for Nurses
Technique Purpose

Active listening Builds trust, helps mother feel heard

Open-ended questions Encourages mother to express feelings

Empathy Makes mother feel understood

Non-verbal support Through body language, eye contact

Simple language Makes communication effective and friendly

9. Health Education Topics
• Postpartum body changes and hygiene
• Importance of nutrition and hydration
• Rest and sleep management
• Coping with fatigue
• Setting realistic expectations
• Building a daily routine with the baby
• Role of positive reinforcement
10. Diagram/Table Suggestions
• Table: Differentiation between baby blues, PPD, and psychosis
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• Flowchart: Nurse’s role in psychological support

• Visual: Postnatal education checklist
11. Possible Outcome Questions
Two Marks
1. Define baby blues.
2. List two signs of postpartum depression.
Five Marks
1. Describe the nurse’s role in providing emotional support during
puerperium.
2. Write a short note on postnatal counseling.
Ten Marks
1. Explain the importance of postnatal psychological support and the role of
the nurse in its implementation.
2. Discuss the common psychological changes during the postnatal period
and nursing interventions to manage them.
Normal Postnatal Baby Blues and Recognition of Postnatal Depression
1. Introduction
• The postnatal period brings major physical, hormonal, and emotional
changes.
• It is common for mothers to feel overwhelmed, tired, or tearful in the
days after childbirth.
• These emotional changes range from normal baby blues to postnatal
depression (PPD), which needs medical attention
2. Baby Blues (Maternity Blues)
Definition:
• A mild, short-term emotional disturbance occurring in the first week
after childbirth.
Onset and Duration:
• Begins around 3rd to 5th day postpartum
• Resolves within 1 to 2 weeks without treatment
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Causes:
• Sudden hormonal changes (drop in estrogen and progesterone)
• Physical exhaustion after childbirth
• Sleep deprivation
• Stress about caring for a newborn
Signs and Symptoms:
• Mood swings
• Tearfulness without reason
• Anxiety
• Irritability
• Poor concentration
• Feeling overwhelmed
• Fatigue
Management:
• Reassurance and emotional support
• Rest and adequate sleep
• Help from family with baby care
• Open communication and normalizing the experience
• No medical treatment needed unless symptoms persist or worsen
3. Postnatal Depression (PPD)
Definition:
• A serious mood disorder occurring in the postpartum period, usually
within 2–6 weeks after childbirth, but may begin any time in the first
year.
Risk Factors:
• Personal/family history of depression or anxiety
• Stressful life events
• Lack of partner/family support

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• Complicated pregnancy or delivery

• Hormonal sensitivity
Signs and Symptoms:
• Persistent sadness or crying
• Loss of interest or pleasure in daily activities
• Feelings of guilt or worthlessness
• Difficulty bonding with the baby
• Sleep disturbances (insomnia or oversleeping)
• Appetite changes
• Anxiety, panic attacks
• Fatigue or low energy
• Thoughts of harming self or the baby (medical emergency)
4. Differences Between Baby Blues and Postnatal Depression
Feature Baby Blues Postnatal Depression

Onset 3–5 days postpartum 2–6 weeks postpartum or later

Duration Up to 2 weeks More than 2 weeks

Severity Mild mood swings Moderate to severe depression

Self-limiting? Yes No – requires treatment

Impact on daily Significant, interferes with mother’s

Minimal
life functioning

Support and Psychological therapy, medication if

Management
reassurance needed
5. Nursing Role in Recognition and Support
• Monitor emotional well-being during postnatal assessments
• Educate the mother and family about normal vs. abnormal emotional
changes
• Encourage open discussion of feelings

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• Use screening tools (e.g., Edinburgh Postnatal Depression Scale)

• Refer to mental health professionals when symptoms persist or worsen
• Provide supportive counseling and involve family in care
6. Health Education for Mothers and Families
• Baby blues are common and temporary
• Seek help if:
o Symptoms last beyond 2 weeks
o Mood worsens
o Thoughts of self-harm or harming baby occur
• Importance of adequate rest, nutrition, and family support
• Share care responsibilities with others
7. Diagram/Table Suggestions
• Table: Differences between baby blues and PPD
• Flowchart: Nurse’s role in early detection of PPD
• Graph: Onset and duration comparison
8. Possible Outcome Questions
Two Marks
1. What is the duration of baby blues?
2. List two symptoms of postnatal depression.
Five Marks
1. Differentiate between baby blues and postnatal depression.
2. Describe the nurse’s role in early detection of postnatal depression.
Ten Marks
1. Explain baby blues and postnatal depression with signs, causes, and
management.
2. Discuss the psychological changes after delivery and the nursing
interventions to support maternal mental health.
Transition to Parenthood

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1. Introduction
• Transition to parenthood refers to the physical, emotional, social, and
psychological adjustments that individuals and couples make as they
assume the role of parents.
• This transition begins during pregnancy and continues after childbirth.
• It can be a rewarding but stressful period, requiring adaptation to new
responsibilities.
2. Phases of Transition (Based on Reva Rubin’s Theory)
Phase Description

Taking-in 1–2 days postpartum – Mother is passive, dependent, focused

phase on own recovery

Taking-hold 2–10 days postpartum – Becomes more active, eager to learn

phase newborn care

Letting-go 2 weeks onward – Adapts to parent role, accepts new reality

phase and identity
3. Factors Influencing the Transition
Factor Impact

Maternal and paternal Physical and emotional readiness affects

readiness adaptation

Presence of partner, family, and social support

Support system
improves adjustment

Child’s health status Caring for a preterm/sick baby adds stress

Parental expectations Unrealistic expectations may lead to frustration

Influence beliefs and practices regarding newborn

Cultural practices
care and roles

Financial status Economic stability reduces stress

4. Emotional Changes During Transition
• Sense of joy and excitement
• Fear and anxiety about responsibility

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• Fatigue and sleep deprivation

• Concerns about self-identity and body image
• Changes in relationship with partner
• Feelings of inadequacy or guilt
5. Challenges Faced by New Parents
Area Common Challenges

Physical Recovery from childbirth, fatigue, hormonal shifts

Emotional Mood swings, anxiety, fear of failure

Social Role strain, isolation, changes in lifestyle

Relationship Reduced intimacy, need for shared responsibilities

Parenting New routines, understanding baby cues, sleep issues

6. Role of Nurse in Supporting the Transition
• Educate parents on newborn care and self-care
• Provide emotional support and reassurance
• Encourage bonding through skin-to-skin contact, breastfeeding
• Promote partner involvement
• Offer resources and referrals (parenting classes, mental health support)
• Identify and address early signs of postpartum stress or depression
• Respect cultural beliefs while encouraging evidence-based practice
7. Strategies to Promote Positive Transition
• Allow parents time to practice caregiving during hospital stay
• Encourage rooming-in with baby
• Reinforce that mistakes are part of learning
• Encourage open communication between partners
• Promote support group participation
• Use positive reinforcement and affirm their efforts
8. Cultural Considerations
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• Some cultures have specific postpartum rituals, dietary restrictions,

and support systems
• Nurses must respect traditions while promoting safe practices
• Encourage family involvement if culturally appropriate
9. Diagram/Table Suggestions
• Table: Comparison of Reva Rubin’s three phases
• Flowchart: Factors affecting the transition to parenthood
• Table: Nurse’s interventions to support new parents
10. Possible Outcome Questions
Two Marks
1. What are the three phases of parental role adaptation according to Reva
Rubin?
2. Mention two emotional changes experienced by new parents.
Five Marks
1. Describe the challenges faced by new parents during the transition to
parenthood.
2. Explain the role of the nurse in supporting parents during this transition.
Ten Marks
1. Explain the process of transition to parenthood. Discuss nursing
interventions to assist new parents in adapting to their role.
2. Describe the emotional, social, and psychological adjustments required
during the postnatal period.
Care for the Woman Up to 6 Weeks After Childbirth (Postnatal/Postpartum
Care)
1. Introduction
• The first 6 weeks after childbirth is called the puerperium or postnatal
period.
• During this time, the woman’s body gradually returns to its pre-pregnant
state, and she adjusts to motherhood physically, emotionally, and
socially.

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• Proper care during this period is crucial to ensure healing, prevent

complications, and promote successful breastfeeding and parenting.
2. Objectives of Postnatal Care
• Monitor physical recovery
• Support emotional well-being
• Prevent, detect, and manage complications
• Provide guidance on breastfeeding, nutrition, hygiene, contraception,
and newborn care
3. Components of Postnatal Care (0–6 Weeks)
Area Care Provided

Uterine Monitor fundal height and firmness daily; uterus should not
involution be palpable after 14 days

Observe for amount, color, odor (rubra → serosa → alba);

Lochia
foul odor = infection

Keep area clean and dry; use antiseptics; inspect for

Perineal care
swelling or infection

Check for engorgement, sore nipples, signs of mastitis;

Breast care
encourage proper latch

Encourage regular urination; fiber and fluids for bowel

Bladder/Bowel
movement

Balanced diet rich in iron, calcium, protein; adequate sleep

Rest & Nutrition
and hydration

Psychological Screen for baby blues and postnatal depression; offer

care reassurance and support

Provide counseling and options safe during lactation (e.g.,

Contraception
IUD, condoms)

Follow-up visits Regular check-ups at 3–5 days and 6 weeks postpartum

4. Nursing Responsibilities
• Assess vital signs, bleeding, uterine tone, and lochia pattern

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• Teach perineal hygiene, wound care, and signs of infection

• Counsel on nutrition, rest, and hydration
• Support breastfeeding and address problems
• Educate on baby care, immunization schedule, and hygiene
• Provide emotional support and screen for postpartum depression
• Offer family planning information
• Ensure safe environment at home for mother and baby
• Document all assessments and interventions
5. Warning Signs Requiring Immediate Attention
• Heavy vaginal bleeding or foul-smelling lochia
• High fever, chills
• Severe abdominal or perineal pain
• Signs of mastitis (red, painful, swollen breast)
• Difficulty urinating or painful urination
• Signs of depression or suicidal thoughts
6. Health Education Topics for the Mother
• Personal hygiene and perineal care
• Importance of rest and proper nutrition
• Breastfeeding techniques and nipple care
• Baby care, including bathing, cord care, and immunization
• Early recognition of danger signs in both mother and baby
• Contraceptive options and spacing between pregnancies
• Emotional adjustment and when to seek help
7. Follow-Up Schedule
Time Postpartum Focus of Visit

Day 3–5 Wound healing, breastfeeding, lochia, general recovery

Day 7–14 Perineal healing, bowel/bladder function, mood observation

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Time Postpartum Focus of Visit

6 Weeks Full physical and emotional check-up, family planning

8. Diagram/Table Suggestions
• Table: Postnatal care checklist for each week
• Flowchart: Nurse's role in postpartum care
• Diagram: Uterine involution timeline (fundal height changes over 2
weeks
9. Possible Outcome Questions
Two Marks
1. How long does the normal postnatal period last?
2. Mention two danger signs a mother must report during puerperium.
Five Marks
1. Describe the role of a nurse in postnatal care of the mother.
2. Write a short note on breastfeeding support during the postnatal period.
Ten Marks
1. Explain the care of a postnatal woman during the first six weeks after
delivery.
2. Discuss the physiological and psychological needs of a mother during the
postnatal period and nursing interventions
Cultural Competence – Taboos Related to Postnatal Diet and Practices
1. Introduction to Cultural Competence
• Cultural competence in nursing refers to the ability to understand,
respect, and effectively respond to the cultural beliefs, values, and
practices of patients from diverse backgrounds.
• In the postnatal period, many women follow traditional dietary and
behavioral taboos that are deeply rooted in cultural practices and beliefs.
• Nurses must balance respecting cultural practices while promoting
evidence-based care for maternal and newborn health.
2. Common Cultural Taboos Related to Postnatal Diet

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Explanation / Reason Possible Nursing

Cultural Belief/Practice
(Cultural) Action

Belief that cold foods Educate that warm

Avoiding cold foods cause imbalance or food is fine, but
illness encourage hydration

Avoiding certain Believed to cause Explain nutritional

fruits/vegetables (e.g., diarrhea or 'cold' in the benefits of variety in
papaya, banana, leafy greens) body diet

Thought to cleanse or
Drinking only warm water or Ensure hydration is
balance the body after
herbal decoctions maintained safely
delivery

Eating only specific foods like Believed to strengthen Encourage a balanced

rice, jaggery, ghee, garlic, or the mother and increase diet and explain
dry fruits milk nutritional needs

Fear of indigestion or Clarify that dairy is a

Avoiding milk or dairy poor digestion post- good source of
delivery calcium and protein

Some cultures delay Gradually introduce

Delay in starting normal diet normal eating to allow normal food; educate
body to heal on recovery
3. Common Cultural Practices and Taboos in Postnatal Period
Practice Belief Behind It Nursing Perspective

Mother and baby kept in To prevent evil spirits Respect isolation but ensure
isolation (for 7–40 days) or infections hygiene and ventilation

Protects mother and Ensure emotional support is

Avoidance of visitors
baby from illness still available

Restricted bathing or Avoid “weakening” Educate on personal hygiene

hair washing the mother and infection prevention

Application of herbs/oils Thought to promote Assess for allergic reaction

on baby or cord healing or protection or infection risk

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Practice Belief Behind It Nursing Perspective

Tying threads, using Used for protection Respect if safe; discourage

amulets against evil if unhygienic or restrictive

Respect and educate about

No sexual activity for 40 Cultural belief in
reproductive health and
days healing time
spacing
4. Nurse’s Role in Providing Culturally Competent Postnatal Care
• Assess and document cultural practices and preferences respectfully.
• Educate families using non-judgmental, evidence-based information.
• Negotiate safe alternatives if a practice is potentially harmful.
• Encourage family involvement while maintaining the woman’s
autonomy.
• Promote hygiene, nutrition, breastfeeding, and danger sign awareness
within cultural context.
• Support emotional well-being and screen for postnatal depression.
• Involve ASHA workers or doulas to bridge gaps between traditional and
modern practices.
5. Principles of Cultural Competence in Nursing
Principle Application in Postnatal Care

Respect for diversity Accept and acknowledge different beliefs and rituals

Self-awareness Avoid imposing personal beliefs on the patient

Learn about common cultural practices in the

Knowledge building
community

Skillful Use simple, sensitive language; consider using

communication interpreters

Patient-centered care Involve the mother and family in care planning

6. Diagram/Table Suggestions
• Table: Taboos vs Scientific Recommendation
• Flowchart: Nurse’s approach to handling cultural conflicts respectfully

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• Table: Role of nurse in promoting culturally safe postnatal care

7. Possible Outcome Questions
Two Marks
1. Mention two cultural food taboos followed during the postnatal period.
2. Define cultural competence in nursing care.
Five Marks
1. Describe common traditional dietary practices during the postnatal period
and nursing implications.
2. What is the nurse’s role in providing culturally sensitive postnatal care?
Ten Marks
1. Explain cultural taboos related to postnatal diet and practices. How can a
nurse provide culturally competent care during this period?
2. Discuss the impact of cultural practices on postnatal recovery and how
the nurse can address them effectively.
Diet During Lactation – Review
1. Introduction
• A lactating mother requires an enhanced and balanced diet to support
breast milk production, maintain her own health, and meet the
nutritional needs of the baby.
• Nutritional requirements are higher during lactation than in pregnancy
due to energy and nutrient transfer through breast milk.
2. Objectives of a Lactation Diet
• Ensure adequate quantity and quality of breast milk
• Maintain maternal health and energy levels
• Prevent nutritional deficiencies in both mother and infant
• Promote postpartum recovery
3. Caloric and Nutritional Requirements (ICMR Guidelines)

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Nutrient Requirement (Approximate)

Additional 500–600 kcal/day (based on pre-pregnancy

Calories
needs)

Protein Additional 20–25 g/day

Calcium 1000–1200 mg/day

Iron 10–15 mg/day (lower than pregnancy but still essential)

Fluids At least 3 liters/day (includes water, milk, soups)

Vitamin A 950 µg/day

Vitamin C 100 mg/day

Folic acid 500 µg/day

Omega-3 fatty
For brain development of baby
acids
4. Components of an Ideal Lactation Diet
Food Group Recommended Items

Cereals & Grains Whole wheat, rice, oats, millets (energy source)

Pulses &
Lentils, chickpeas, soybeans (protein and iron source)
Legumes

Dairy Products Milk, curd, paneer, cheese (calcium and protein source)

Fruits Banana, papaya, apple, oranges, guava (vitamins and fiber)

Green leafy vegetables, carrots, beets, bottle gourd (fiber,

Vegetables
iron)

Nuts & Seeds Almonds, flaxseeds, sesame seeds (healthy fats, calcium)

Ghee, butter, mustard oil, coconut oil (energy and omega-

Fats & Oils
3s)

Fluids Water, milk, soups, coconut water (hydration)

5. Foods that Promote Lactation (Galactagogues)
• Fenugreek seeds (methi)
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• Fennel seeds (saunf)

• Garlic
• Cumin seeds (jeera)
• Ajwain (carom seeds)
• Drumstick leaves
• Almonds and oats
Note: These are culturally used and believed to promote milk production,
though scientific evidence varies.
6. Foods to Avoid or Limit
• Caffeinated drinks (tea, coffee) – in excess can cause irritability in baby
• Alcohol – passes into breast milk
• Spicy or gas-forming foods (may affect baby's digestion)
• Smoking – decreases milk supply and harms baby
• Excessive sugar and junk food – adds empty calories, causes weight
gain
7. Nutritional Tips for Lactating Mothers
• Eat small frequent meals throughout the day
• Avoid skipping meals or long fasting periods
• Stay hydrated with plain water and healthy fluids
• Ensure iron and calcium supplements if advised by doctor
• Include postnatal traditional recipes if nutritious and safe
• Continue nutritional care till at least 6 months postpartum or as long as
breastfeeding continues
8. Sample One-Day Diet Plan (Approx. 2200–2400 kcal)
Meal Time Sample Menu

Morning Warm water + soaked almonds + methi seeds + milk

Breakfast Vegetable poha + boiled egg + fruit juice

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Meal Time Sample Menu

Mid-morning Coconut water + seasonal fruit (papaya/banana)

Lunch Roti + dal + vegetable curry + rice + curd

Evening Herbal tea (jeera or fennel) + roasted chana or murmura

Dinner Khichdi or roti + green vegetable + paneer + salad

Bedtime Warm milk with turmeric or dry fruit powder

9. Diagram/Table Suggestions
• Table: Comparison of nutrient needs during pregnancy vs lactation
• Plate diagram: Balanced diet for lactating mother
• Flowchart: Impact of poor maternal diet on lactation and infant health
10. Possible Outcome Questions
Two Marks
1. Mention any two galactagogues.
2. State the additional caloric requirement during lactation.
Five Marks
1. Write a short note on the dietary considerations during lactation.
2. Mention five essential nutrients for a lactating mother and their sources.
Ten Marks
1. Discuss the dietary requirements of a lactating mother. What advice will
you give to ensure proper nutrition and milk production?
Postpartum Family Planning
1. Introduction
• Postpartum family planning (PPFP) is the initiation and use of
contraceptive methods during the first 12 months following childbirth.
• Its goal is to help women delay, space, or limit future pregnancies and
ensure optimal maternal and child health.
2. Importance of Postpartum Family Planning
• Prevents unintended or closely spaced pregnancies
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• Reduces maternal and infant mortality and morbidity

• Allows sufficient time for the mother's body to recover
• Supports exclusive breastfeeding and reduces nutritional burden
• Helps couples plan for the desired number of children at the right time
3. WHO Recommendations
Spacing Between
Health Benefit
Pregnancies

Reduces risks of preterm birth, low birth weight,

At least 2 years
maternal anemia
4. Characteristics of Ideal Contraceptive in Postpartum Period
• Safe during lactation
• Reversible and acceptable
• Easy to use and access
• Minimal side effects
• Supports woman’s health goals
5. Available Contraceptive Methods in Postpartum Period
Safe for
Method Time of Initiation Notes
Breastfeeding

Within 6 months
Lactational postpartum (if
98% effective if
Amenorrhea exclusively Yes
used correctly
Method (LAM) breastfeeding &
amenorrheic)

Within 10 minutes of Long-term (up to

Postpartum IUCD
placenta delivery or up Yes 10 years);
(PPIUCD)
to 48 hours reversible

Prevents STIs;
Condoms Anytime Yes
suitable for all

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Safe for
Method Time of Initiation Notes
Breastfeeding

After 6 weeks
Progestin-only Daily use needed
postpartum (or earlier Yes
Pills (POP) for effectiveness
as per guidelines)

3-month
Injectables After 6 weeks duration; may
Yes
(DMPA) postpartum affect
menstruation

After 6 weeks Long-acting (3–5

Implants Yes
postpartum years); reversible

Contains
Combined Oral After 6 months No (not
estrogen, can
Contraceptives postpartum (if not recommended
reduce milk
(COCs) breastfeeding) earlier)
supply

Permanent;
Female After delivery or 6
Yes requires
Sterilization weeks later
informed consent
6. Nurse’s Role in Postpartum Family Planning
• Educate and counsel mother and couple during antenatal, postnatal, and
immunization visits
• Assess woman’s readiness and eligibility for various methods
• Support informed choice without pressure
• Provide or refer for selected method (e.g., IUCD insertion, POPs)
• Ensure follow-up and management of side effects or concerns
• Maintain records of counseling and contraceptive services
7. Benefits of Family Planning for the Mother and Baby
Mother Baby

Reduces pregnancy-related
Ensures adequate breastfeeding
complications

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Mother Baby

Lowers risk of anemia, uterine rupture Better nutrition and growth

Reduced neonatal and infant

Allows emotional and physical recovery
mortality
8. Counseling Points for Postpartum Family Planning
• Discuss options during antenatal period or post-delivery
• Explain each method's advantages, side effects, and reversibility
• Involve partner if possible
• Encourage postpartum follow-up and method switching if needed
• Respect cultural and religious beliefs while offering evidence-based
advice
9. Diagram/Table Suggestions
• Flowchart: Timeline of contraceptive eligibility postpartum
• Table: Comparison of PPFP methods by timing and breastfeeding
compatibility
• Diagram: WHO Medical Eligibility Criteria for postpartum contraception
10. Possible Outcome Questions
Two Marks
1. What is Lactational Amenorrhea Method (LAM)?
2. Mention any two contraceptive methods safe during breastfeeding.
Five Marks
1. List and explain any four contraceptive methods used in the postpartum
period.
2. Describe the nurse’s role in postpartum family planning.
Ten Marks
1. Define postpartum family planning. Explain the various contraceptive
methods suitable for lactating mothers and the nurse’s role in providing
these services.
Follow-Up of Postnatal Mothers

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1. Introduction
• Postnatal follow-up refers to the scheduled and systematic assessment of
the mother after childbirth to ensure physical recovery, emotional well-
being, and successful infant care.
• Follow-up is a vital part of continuity of care to detect and manage any
complications early.
2. Objectives of Postnatal Follow-Up
• Assess the mother’s physical recovery (uterus, perineum, lochia, etc.)
• Monitor mental health, especially for postnatal depression
• Support breastfeeding and infant bonding
• Educate on family planning and nutrition
• Detect and manage delayed complications
3. Recommended Postnatal Visit Schedule (As per WHO & MoHFW)
Timing of Visit Purpose

Early detection of postpartum hemorrhage, sepsis,

Within 24–48 hours
urinary issues

Day 3–5 (early Assessment of lochia, uterine involution,

postnatal) breastfeeding support

Day 7–14 Emotional status, wound healing, breast/nipple

(intermediate) condition

6 weeks (late Final evaluation, family planning, menstrual cycle,

postnatal) general health
4. Components of Follow-Up Assessment
A. Physical Assessment
• Vital signs: BP, temperature, pulse, respiratory rate
• Uterus: Position, consistency, involution status
• Lochia: Amount, color, odor
• Perineum: Healing, signs of infection or pain (if episiotomy/tear)
• Breasts: Engorgement, cracked nipples, signs of mastitis

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• Bladder and bowel function: Elimination issues, constipation, UTI

symptoms
• Weight and nutritional status
B. Psychological Assessment
• Assess for:
o Postnatal blues
o Postpartum depression
o Emotional support and coping
• Use screening tools if needed (e.g., Edinburgh Postnatal Depression
Scale)
C. Infant Assessment
• Feeding adequacy
• Weight gain
• Jaundice, sleep pattern, signs of illness
• Immunization status
5. Nursing Responsibilities During Follow-Up
• Monitor and record maternal and newborn findings
• Educate about:
o Breastfeeding techniques
o Hygiene and perineal care
o Infant care and immunizations
o Family planning options
o Nutrition and rest
• Provide psychological support
• Refer to physician if any abnormality is noted
• Encourage follow-up even if mother feels normal
6. Red Flags During Postnatal Follow-Up

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Symptom Possible Concern

Heavy vaginal bleeding Secondary postpartum hemorrhage

Fever with foul-smelling lochia Endometritis or infection

Painful, red breast Mastitis or breast abscess

Severe headache, blurred vision Postpartum hypertension or preeclampsia

Persistent sadness, disinterest Postpartum depression

7. Counseling and Health Education Areas
• Balanced diet and fluid intake
• Personal hygiene (especially perineal and breast care)
• Contraceptive methods and safe sex
• Danger signs requiring medical attention
• Infant care – feeding, bathing, immunizations
8. Documentation
• Maintain records of each postnatal visit:
o Date of visit
o Observations (mother and baby)
o Advice given
o Interventions or referrals made
• Use standardized postnatal care forms if applicable
9. Diagram/Table Suggestions
• Table: Timing and purpose of postnatal visits
• Checklist: Postnatal follow-up assessment items
• Flowchart: Nursing process during postnatal follow-up
10. Possible Outcome Questions
Two Marks
1. When is the final postnatal follow-up visit recommended?
2. Mention any two purposes of postnatal follow-up.
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Five Marks
1. Write the components of maternal assessment during postnatal follow-up.
2. Describe the nurse’s role in postnatal follow-up visits.
Ten Marks
1. Define postnatal follow-up. Discuss the assessment areas and nursing
responsibilities in detail.
Drugs Used in the Postnatal Period
1. Introduction
• The postnatal period (first 6 weeks after childbirth) may require various
medications for the mother's recovery, lactation support, infection
control, and pain relief.
• Nurses must be aware of indications, dosages, side effects, and
breastfeeding safety of these drugs.
2. Classification of Common Postnatal Drugs
Category Purpose Examples

Oxytocin,
Uterotonics Promote uterine contraction
Methylergometrine

Analgesics Pain relief Paracetamol, Ibuprofen

Amoxicillin,
Antibiotics Treat or prevent infections
Metronidazole

Lactation-promoting Domperidone,
Enhance milk production
agents Metoclopramide

Stool
Prevent/treat constipation Lactulose, Bisacodyl
softeners/laxatives

Ferrous sulfate, ferrous

Iron supplements Treat postpartum anemia
fumarate

Bone health and lactation Calcium carbonate,

Calcium supplements
support calcium citrate

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Category Purpose Examples

Manage postpartum
Antidepressants SSRIs (e.g., Sertraline)
depression (if diagnosed)

Family planning (safe

Contraceptives POPs, IUCD
during breastfeeding)
3. Uterotonics
Drug Use Nursing Considerations

Controls bleeding, helps

Oxytocin (IM/IV) Monitor uterine tone and BP
involution

Strong uterine
Methylergometrine Contraindicated in hypertension
contraction

Can be given orally, rectally or

Misoprostol Alternative uterotonic
sublingually
4. Analgesics and Antipyretics
Drug Use Safe in Breastfeeding?

Paracetamol Pain and fever relief Yes

Ibuprofen Anti-inflammatory, pain relief Yes

Diclofenac Post-episiotomy or CS pain relief Caution – short term

5. Antibiotics
Prescribed post-cesarean, for perineal tears, UTI, or endometritis.
Drug Common Use Notes

General
Amoxicillin Usually safe in breastfeeding
infections

Anaerobic May affect milk taste (short term use

Metronidazole
infections preferred)

Cefixime / Broad-spectrum
Generally safe
Ceftriaxone use

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6. Lactation Support Drugs

• Used only if milk production is insufficient after non-pharmacological
methods.
Drug Class Notes

Domperidone Prokinetic Increases prolactin, fewer side effects

Metoclopramide Anti-emetic Rarely used due to CNS side effects

Always try frequent breastfeeding and good hydration first.
7. Supplements
A. Iron and Folic Acid
• Continue for at least 3 months postpartum.
• Prevent and treat iron deficiency anemia.
B. Calcium + Vitamin D
• Supports bone health and lactation.
Drug Combination Notes

Calcium + Vitamin D3 tablets Take separately from iron for better absorption
8. Stool Softeners
Drug Use Note

Lactulose Softens stool Encourage fluids

Bisacodyl Mild laxative Avoid long-term use

9. Hormonal Contraceptives
Safe in
Method Time to Start Notes
Lactation

Progestin-only pills Taken daily, no

After 6 weeks Yes
(POP) estrogen

DMPA Injection After 6 weeks Yes 3-month injectable

Immediate/6 Long-term, non-

IUCD (PPIUCD) Yes
weeks hormonal

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10. Antidepressants (If Diagnosed with Postpartum Depression)

Drug Class Notes

Sertraline SSRI Commonly used, considered safe in breastfeeding

Fluoxetine SSRI Longer half-life; monitor baby for side effects

Use only under psychiatric consultation.
11. Nursing Responsibilities
• Administer drugs as per doctor’s orders
• Ensure drugs are safe during lactation
• Educate the mother about:
o Purpose, dosage, side effects
o Importance of adherence
o Storage and timing (especially for POPs and iron/calcium)
• Monitor for adverse effects
• Encourage non-drug measures when suitable (diet, hydration, rest)
12. Possible Outcome Questions
Two Marks
1. Name any two uterotonic drugs used postpartum.
2. Mention two supplements commonly prescribed in the postnatal period.
Five Marks
1. List and explain the uses of common drugs prescribed after delivery.
2. Write short notes on lactation-promoting drugs.
Ten Marks
1. Describe the classification and nursing responsibilities related to the
drugs used in the postnatal period.
Records and Reports in Postnatal Care
1. Introduction
• Records and reports are essential tools in nursing practice that ensure
continuity of care, legal protection, and quality control.
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• In postnatal care, maintaining accurate documentation helps monitor the

health status of mother and baby, evaluate outcomes, and support
research and audits.
2. Definitions
• Records: Written or electronic permanent documentation of patient
care.
• Reports: Verbal or written communication about patient condition,
progress, or events.
3. Importance of Records and Reports
• Ensures continuity of care across shifts and departments
• Serves as a legal document in case of medical or legal disputes
• Facilitates data collection for audits and research
• Supports evaluation of nursing performance
• Helps in planning future care and follow-up visits
• Required for training and supervision of healthcare staff
4. Types of Postnatal Records
Type of Record Content

Vital signs, uterine involution, lochia,

Mother's Postnatal Record
breastfeeding, perineal status, emotional state

APGAR score, birth weight, feeding pattern,

Newborn Care Record
immunization, any abnormalities

Time of labor stages, mode of delivery, placenta

Labor and Delivery Record
expulsion details

Drug Administration
Uterotonics, analgesics, antibiotics, supplements
Record

Family Planning Counseling

Contraceptive method advised/accepted
Record

Follow-up Visit Record Date, findings, complaints, actions taken

Nursing Notes Observations, interventions, patient education

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Type of Record Content

Incident/Abnormality Postpartum hemorrhage, infection, retained

Report placenta, neonatal complications
5. Essential Components of Good Record Keeping
• Accuracy: Avoid errors and record correct data
• Legibility: Should be easy to read and understand
• Timeliness: Document care immediately after providing it
• Confidentiality: Keep patient information private and secure
• Completeness: No information should be omitted
• Objectivity: Avoid personal opinions—record factual observations only
6. Formats Used in Postnatal Records
Format Use

Flow charts To monitor trends (e.g., vital signs)

Checklists To ensure complete care steps

Narrative notes To explain nursing care/interventions

Electronic records For hospital-wide information access

7. Legal and Ethical Aspects
• Documentation is a legal proof of care given
• Records must be signed and dated
• Do not erase or overwrite; if needed, make a single line and initial
• Only authorized personnel should access and update records
8. Nurse’s Responsibilities
• Record every nursing intervention and patient response
• Update patient records at each shift change
• Use standard terminology and approved abbreviations
• Maintain privacy and security of records
• Report significant findings to doctors or supervisors

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• Ensure all entries are dated and signed

9. Common Reporting Situations in Postnatal Care
• Vital signs abnormalities
• Excessive bleeding or infection
• Poor breastfeeding or maternal refusal
• Emotional distress or postpartum depression signs
• Drug reactions or complications
10. Diagram/Table Suggestions
• Sample page of a postnatal chart
• Format of drug administration record
• Checklist for daily postnatal assessment
11. Possible Outcome Questions
Two Marks
1. Mention any two types of postnatal records.
2. What is the importance of accurate documentation?
Five Marks
1. Describe the components of a mother's postnatal record.
2. Explain the nurse's responsibilities in maintaining records and reports.
Ten Marks
1. Define records and reports. Discuss their importance, types, and the legal
aspects of documentation in postnatal care.

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Unit – 06
Assessment and ongoing care of normal neonates

Family-Centered Care
1. Introduction
• The neonatal period refers to the first 28 days of life.
• Assessment and care during this time are critical to ensure normal
growth, development, and early detection of complications.
• Family-centered care (FCC) is a model of care that respects and
involves the family as active participants in the newborn's care.
2. Goals of Neonatal Assessment and Care
• Promote thermal protection, early breastfeeding, and infection
prevention
• Detect early signs of illness or abnormality
• Ensure emotional bonding between baby and parents
• Support growth, development, and safe environment
3. Initial Assessment at Birth (Immediate Newborn Care)
Parameter Normal Value/Findings

Apgar Score 7–10 at 1 and 5 minutes

Respiration 30–60 breaths/min, no retractions

Heart rate >100 bpm

Temperature 36.5–37.5°C (axillary)

Color Pink body; blue extremities may be normal initially

Activity/Tone Active movements, good tone

4. Ongoing Daily Neonatal Assessment

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Assessment Area Observation Details

Weight Slight loss in first 3–5 days is normal; regain by day 10

Feeding Effective sucking, 8–12 feeds/day

Elimination Urine: 6–8 times/day; Stool: yellow, seedy

Cord care Keep dry and clean; no redness or pus

Skin Observe for rashes, jaundice, birthmarks

Thermoregulation Maintain warm environment

Sleep pattern Sleeps 16–20 hours/day

Reflexes Sucking, rooting, Moro, grasp reflex present

Immunizations BCG, OPV-0, Hepatitis B at birth

5. Components of Family-Centered Neonatal Care (FCC)
• Respecting family role: Recognizing parents as primary caregivers
• Open communication: Explaining baby's condition, progress, and care
• Involving parents in decision-making and routine baby care
• Encouraging skin-to-skin contact (Kangaroo Mother Care)
6. Advantages of Family-Centered Care
For Baby For Parents

Better thermoregulation Increased confidence in caregiving

Improved weight gain Emotional satisfaction

Reduced hospital infections Reduced anxiety and stress

Better breastfeeding outcomes Strengthened parent-baby bond

7. Role of Nurse in Neonatal & Family-Centered Care
• Perform daily assessment and monitor vital signs
• Ensure infection control and proper cord/skin care
• Educate family on:

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o Breastfeeding techniques
o Danger signs (poor feeding, fever, yellowing of skin, etc.)
o Hygiene and safety
• Encourage rooming-in and mother-baby bonding
• Record all findings and inform pediatrician if abnormalities are noted
8. Danger Signs in Neonates (Refer for Immediate Care)
• Not feeding well
• Fever or hypothermia
• Breathing difficulty
• Convulsions
• Jaundice appearing before 24 hours or spreading rapidly
• Umbilical redness or discharge
• Lethargy or poor activity
9. Table: Schedule of Newborn Follow-Up Visits
Visit Time Purpose

Within 3 days Early identification of issues

At 7–14 days Weight check, feeding assessment

At 6 weeks Immunization, growth check

10. Diagram Suggestions
• Apgar Score Chart
• Table of normal newborn parameters
• Kangaroo Mother Care positioning
• Baby danger signs pictogram
11. Possible Outcome Questions
Two Marks
1. List any two signs of a healthy neonate.
2. Mention two advantages of family-centered care.

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Five Marks
1. Write short notes on family-centered neonatal care.
2. Describe daily assessment parameters of a normal neonate.
Ten Marks
1. Discuss the components of assessment and ongoing care of a normal
neonate.
2. Explain the concept, advantages, and nursing role in family-centered
neonatal care.
Respectful Newborn Care and Communication
1. Introduction
• Respectful newborn care refers to the approach of providing care to a
newborn with dignity, compassion, empathy, and non-harmful
practices, ensuring the rights of the newborn are upheld.
• It emphasizes effective communication with family and considers
cultural sensitivity, parental involvement, and non-discriminatory
practices.
2. Key Principles of Respectful Newborn Care
Principle Description

Dignity and Respect Treat the newborn as a human being with rights

Ensure warmth, skin-to-skin contact, and gentle

Privacy and Comfort
handling

Parental Involvement Encourage parents to be involved in newborn care

Provide clear, honest, and compassionate

Effective Communication
communication with family

Equal care regardless of gender, caste, ethnicity, or

No Discrimination
disability

Safe and Evidence-Based Use current guidelines and avoid harmful

Care traditional practices

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Principle Description

Parents must be informed and consent to care plans

Informed Consent
and procedures
3. Components of Respectful Newborn Care
• Immediate skin-to-skin contact
• Delayed cord clamping (1–3 minutes)
• Early initiation of breastfeeding
• Thermal protection (drying and wrapping)
• Avoid separation from the mother unless medically indicated
• Avoid unnecessary medical interventions
• Gentle handling during all procedures
4. Respectful Communication with Family
Good Communication Practices Avoid These Practices

Speak clearly in the family's

Using medical jargon without explanation
language

Involve both parents in discussion Ignoring or excluding father or caregiver

Listen to concerns without judgment Being dismissive or rude

Be calm and empathetic Shouting or handling family roughly

Performing procedures without

Explain every procedure in advance
explanation

Provide reassurance and support Making parents feel guilty or inadequate

5. Nurse’s Role in Respectful Newborn Care
• Maintain hygiene and safety at all times
• Provide emotional support to the parents
• Educate on:
o Feeding
o Danger signs

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o Cord care
• Promote skin-to-skin contact and rooming-in
• Advocate for gender equality in care
• Ensure documentation and report any abnormal findings
• Respect religious and cultural beliefs within safety limits
6. Common Scenarios and Nursing Response
Scenario Respectful Response

Family worried about baby's

Explain causes calmly and offer guidance
crying

Respect their decision, explain

Parent declines a procedure
risks/benefits

Family upset over newborn sex Provide unbiased, supportive response

Grandparent asks for traditional Educate about safe practices and risks
remedy respectfully
7. Practices to Avoid in Newborn Care
• Slapping, shaking, or rough handling
• Bathing immediately after birth (should be delayed)
• Separating baby from mother unnecessarily
• Discouraging or delaying breastfeeding
• Gender-based neglect
8. Table: DOs and DON’Ts in Respectful Newborn Care
DOs DON’Ts

Handle baby gently Avoid rough or hurried handling

Maintain warmth and cleanliness Do not expose newborn to cold surfaces

Explain procedures to parents Avoid ignoring family queries

Respect cultural beliefs Avoid mocking or dismissing beliefs

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9. Diagram Suggestions
• Respectful care checklist
• Skin-to-skin contact method
• Nurse-parent communication flowchart
10. Possible Outcome Questions
Two Marks
1. Mention any two principles of respectful newborn care.
2. Write two features of effective communication with newborn's family.
Five Marks
1. Describe the nurse’s role in ensuring respectful newborn care.
2. Write a short note on effective communication with parents during
neonatal care.
Ten Marks
1. Explain respectful newborn care. Discuss its principles and nursing
implications.
2. Describe communication strategies that promote respectful and family-
centered newborn care.
Normal Neonate – Physiological Adaptation
1. Introduction
• A normal neonate must undergo rapid and critical physiological
adaptations after birth to survive in the extrauterine environment.
• These adaptations involve the respiratory, cardiovascular,
thermoregulatory, metabolic, and renal systems.
2. Key Systems Involved in Neonatal Adaptation
System Key Changes After Birth

Respiratory System Establishment of spontaneous breathing

Cardiovascular System Closure of fetal shunts and circulation redirection

Thermoregulatory System Ability to maintain body temperature

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System Key Changes After Birth

Metabolic System Regulation of glucose, bilirubin, and fluid balance

Renal System Initiation of urination and electrolyte regulation

Gastrointestinal System First feeding, digestion, and meconium excretion

3. Respiratory Adaptation
• At birth, the baby takes the first breath which expands the lungs.
• Fluid in alveoli is absorbed, and air fills the lungs.
• Surfactant (produced by lungs) prevents alveolar collapse.
• Normal respiratory rate: 30–60 breaths per minute.
• Signs of successful adaptation: regular breathing, pink color, no
grunting/retractions.
4. Cardiovascular Adaptation
Change Description

Closure of foramen ovale Blood now flows from right to left atrium

Closure of ductus arteriosus Shunts blood from pulmonary artery to lungs

Closure of ductus venosus Liver starts processing blood from umbilical vein

Heart rate 120–160 beats per minute

Color Pink skin indicates good perfusion

5. Thermoregulation
• Newborns are at high risk of hypothermia due to:
o Large body surface area
o Thin skin and little subcutaneous fat
• Mechanisms of heat production:
o Non-shivering thermogenesis using brown fat
o Skin-to-skin contact with mother (Kangaroo care)
• Prevent heat loss by:

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o Drying the baby immediately

o Wrapping in warm cloth
o Avoiding exposure to cold surfaces
6. Metabolic Adaptation
Parameter Adaptation Details

Glucose Initial drop after birth; breastfeeding stabilizes it

Breakdown of fetal RBCs increases bilirubin; immature liver may

Bilirubin
cause physiological jaundice

Feeding Early feeding enhances glucose regulation and digestion

7. Renal Adaptation
• Kidneys begin to function, but immature at birth.
• Urination starts within 24 hours of birth.
• Urine output gradually increases to 6–8 wet diapers/day.
• Poor concentration ability; babies are prone to dehydration.
8. Gastrointestinal Adaptation
• Meconium (first stool) passed within 24–48 hours.
• Stomach capacity is small (~5–10 ml at birth).
• Digestive enzymes are functional except amylase (low initially).
9. Immune System Adaptation
• Passive immunity via maternal IgG (crosses placenta)
• IgA from colostrum/breast milk protects mucous membranes
• Neonate is vulnerable to infections; hygiene is critical
10. Reflex Adaptation
Reflex Description

Moro reflex Startle response

Rooting Turns head toward touch on cheek

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Reflex Description

Sucking Sucks when nipple/tongue touched

Grasp Grasps finger when palm is touched

11. Diagram/Table Suggestions
• Diagram showing closure of fetal circulation shunts
• Table summarizing adaptations in each system
• Flowchart of thermoregulation mechanisms
12. Nursing Responsibilities
• Monitor vital signs and reflexes regularly
• Encourage early breastfeeding
• Maintain warmth and hygiene
• Educate mother on danger signs (cyanosis, poor feeding, jaundice)
• Document urine/stool output, feeding pattern, and temperature
13. Possible Outcome Questions
Two Marks
1. Mention any two fetal shunts that close after birth.
2. State two signs of successful respiratory adaptation in a newborn.
Five Marks
1. Write short notes on thermoregulation in a newborn.
2. Explain cardiovascular changes in a neonate after birth.
Ten Marks
1. Describe the physiological adaptations that occur in a normal neonate
after birth.
2. Explain respiratory, cardiovascular, and thermoregulatory adaptations in a
newborn.
Newborn Assessment – Screening for Congenital Anomalies
1. Introduction

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• Congenital anomalies (also called birth defects) are structural or

functional abnormalities present at birth.
• Early screening and detection help in early intervention, management,
and reducing long-term disability or death.
• Screening includes both clinical examination and diagnostic tests in the
first 48–72 hours of life.
2. Objectives of Screening
• Identify structural or functional abnormalities early
• Prevent complications by initiating treatment early
• Provide parental counseling and support
• Record for public health surveillance
3. Timing of Screening
Type of Screening Time of Assessment

Physical examination At birth and within first 24–48 hours

Newborn screening tests (blood) Between 24–72 hours of life

Hearing screening Before hospital discharge

Cardiac screening (CCHD) After 24 hours of birth

4. Physical Assessment for Visible Congenital Anomalies
Area Assessed Common Anomalies Identified

Head and Face Cleft lip/palate, craniosynostosis

Eyes Cataract, microphthalmia

Ears Low-set ears (linked with Down syndrome)

Limbs Polydactyly, syndactyly, club foot

Spine Spina bifida, sacral dimple

Abdomen Umbilical hernia, omphalocele

Genitalia Hypospadias, ambiguous genitalia, cryptorchidism

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Area Assessed Common Anomalies Identified

Skin Birthmarks, jaundice, cyanosis

Heart sounds Murmurs may indicate congenital heart disease

5. Mandatory Newborn Screening Tests (Blood Spot Screening)
These are often called “heel-prick tests” done after 24 hours of feeding.
Condition Purpose of Screening

Prevent mental retardation with early

Congenital Hypothyroidism
treatment

Prevent cognitive delay via dietary

Phenylketonuria (PKU)
management

Congenital Adrenal Detect adrenal crisis; start hormone

Hyperplasia replacement

G6PD Deficiency Avoid triggers to prevent hemolytic anemia

Galactosemia Detect inability to digest galactose in milk

Sickle Cell Anemia /

Genetic counseling and early care
Thalassemia
In India, screening programs may vary state-to-state; the RBSK (Rashtriya Bal
Swasthya Karyakram) includes screening for 30+ conditions.
6. Hearing Screening
• Tool: Otoacoustic Emission (OAE) or Auditory Brainstem Response
(ABR)
• Detects congenital hearing loss (1–2 in every 1000 births)
• Should be done before discharge or by 1 month of age
• Early detection improves language and cognitive development
7. Critical Congenital Heart Disease (CCHD) Screening
• Done using pulse oximetry after 24 hours of birth
• Checks oxygen saturation in right hand and foot
• Detects silent but critical heart conditions needing surgery

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• SpO₂ < 90% is abnormal and needs urgent evaluation

8. Imaging and Additional Screening (If Indicated)
• Ultrasound of abdomen and brain if anomalies are suspected
• Echocardiography if murmur or abnormal SpO₂
• X-rays in case of limb/spinal deformities
9. Nursing Responsibilities
• Perform initial physical examination and report anomalies
• Ensure timely blood sample collection for screening
• Assist in hearing and pulse oximetry testing
• Educate parents on:
o Need and importance of newborn screening
o Follow-up visits for abnormal results
• Document all findings and communicate with pediatrician
10. Table: Common Congenital Anomalies and Their Features
Anomaly Signs/Symptoms

Cleft lip/palate Visible gap in lip/palate, feeding issues

Spina bifida Sacral swelling or tuft of hair

Congenital cataract Cloudy lens, no red reflex

Club foot Foot twisted downward/inward

Down Syndrome Flat face, low-set ears, single palmar crease

11. Diagram Suggestions
• Diagram of heel prick test collection site
• Flowchart: Steps in Newborn Screening
• Table of common anomalies with illustrations
12. Possible Outcome Questions
Two Marks
1. Name two conditions detected in newborn screening tests.
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2. At what age is hearing screening ideally done?

Five Marks
1. Describe the procedure and purpose of the newborn blood spot screening.
2. Write a short note on physical assessment of a newborn for congenital
anomalies.
Ten Marks
1. Explain the screening procedures used to detect congenital anomalies in a
newborn.
2. Discuss the nurse's role in assessing and screening for congenital
anomalies in neonates.
Care of Newborn up to 6 Weeks After Childbirth (Routine Care of Newborn)
1. Introduction
• The first 6 weeks of life (neonatal period) is a critical phase for growth,
development, and survival.
• Proper routine care is essential to ensure thermoregulation, feeding,
hygiene, safety, and early detection of any complications.
• Neonatal care involves both facility-based care (immediate) and home-
based care (ongoing).
2. Objectives of Routine Newborn Care
• Ensure smooth transition to extrauterine life
• Promote optimal growth and development
• Prevent infections and complications
• Support parental bonding and breastfeeding
• Educate caregivers for safe home care
3. Components of Routine Newborn Care (0–6 Weeks)
A. Thermal Protection
• Maintain warmth using:
o Immediate drying after birth
o Skin-to-skin contact (Kangaroo care)

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o Room temperature 26–28°C

o Proper wrapping and covering of head and feet
• Avoid cold stress and hypothermia
B. Cord Care
• Keep cord clean and dry
• Use no antiseptic unless advised
• Fold diaper below cord to avoid contamination
• Cord usually falls off in 7–10 days
C. Eye Care
• Clean eyes with sterile gauze and warm water
• Wipe from inner to outer canthus
• Prevents infection like ophthalmia neonatorum
D. Skin Care
• Bathe only after 24 hours (once temperature is stable)
• Use mild soap and lukewarm water
• Avoid use of talcum powder or harsh products
E. Feeding
• Initiate breastfeeding within 1 hour
• Exclusive breastfeeding up to 6 months
• Feed every 2–3 hours (8–12 times/day)
• Check for effective latching and suckling
Breastfeeding
For Baby For Mother
Benefits

Provides colostrum Immunity boost Helps uterine involution

Prevents Reduces postpartum

Ideal nutrition
diarrhea/infections bleeding

Promotes bonding Aids brain development Delays next ovulation

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F. Hygiene and Clothing

• Wash hands before handling the baby
• Use clean clothes and frequent diaper changes
• Avoid over- or under-dressing
G. Immunization
• As per National Immunization Schedule (at birth):
o BCG
o OPV-0 (Oral Polio Vaccine)
o Hepatitis B – 1st dose
4. Danger Signs in Newborn (for caregiver education)
Warning Sign Possible Cause

Poor feeding Infection, lethargy

Fever or hypothermia Sepsis, cold stress

Fast breathing, chest in-drawing Pneumonia

Jaundice on day 1 or severe Hemolysis, liver dysfunction

Convulsions Hypoglycemia, infection

Vomiting or diarrhea Infection, dehydration

5. Growth Monitoring
• Regular weight checks:
o May lose up to 10% birth weight in first week
o Regains by 10–14 days
o Gains ~20–30 g/day
• Length and head circumference tracked
• Document milestones and feeding pattern
6. Home-Based Newborn Care (HBNC)
• Conducted by ANMs/ASHA workers up to 6 weeks

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• Visits on: Day 3, 7, 14, 21, 28, 42

• Provide:
o Thermal care
o Breastfeeding support
o Infection prevention
o Immunization follow-up
o Family counseling
7. Role of Nurse
• Conduct full newborn assessment
• Promote exclusive breastfeeding
• Educate parents on hygiene, immunization, danger signs
• Assist in immunization
• Document all findings, growth, and care given
8. Flowchart: Routine Newborn Care
Birth → Dry and Warm → Skin-to-Skin → Breastfeeding → Cord & Eye Care
→ Immunization → Daily Hygiene → Growth Monitoring → Home Visits →
6-week check-up
9. Diagram Suggestions
• Labeled newborn assessment chart
• Kangaroo mother care illustration
• Danger signs in newborn (poster-type visual)
10. Possible Outcome Questions
Two Marks
1. Mention any two components of routine newborn care.
2. Name two vaccines given at birth.
Five Marks
1. Describe the role of ASHA in home-based newborn care.
2. Write short notes on thermal protection in a newborn.

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Ten Marks
1. Explain the routine care of a newborn from birth to 6 weeks.
2. Describe the nursing responsibilities in the care of a normal newborn.
Skin-to-Skin Contact and Thermoregulation in Newborns
1. Introduction
• Skin-to-skin contact (SSC) refers to placing a naked newborn on the
bare chest of the mother or father immediately after birth.
• It is a vital practice to support thermoregulation, bonding, early
breastfeeding, and overall neonatal well-being.
• Thermoregulation is the ability of a newborn to maintain a normal body
temperature.
2. Importance of Skin-to-Skin Contact
• Promotes thermal stability in the newborn.
• Encourages early initiation of breastfeeding.
• Enhances bonding between mother and baby.
• Helps regulate heart rate and breathing.
• Reduces stress and crying in newborns.
• Supports better blood glucose levels.
3. WHO Recommendations
• Begin SSC immediately after birth and continue for at least one hour.
• SSC should be maintained as frequently as possible during the first few
days of life, especially for low-birth-weight and preterm infants.
4. Procedure of Skin-to-Skin Contact
1. Dry the newborn immediately after birth.
2. Place the naked baby (except diaper and cap) prone on the mother’s
bare chest.
3. Cover both mother and baby with a warm blanket.
4. Monitor the baby’s color, breathing, and warmth.
5. Encourage breastfeeding within the first hour.

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6. Continue as long as mother and baby are stable.

5. Role of SSC in Thermoregulation
• A newborn loses heat rapidly due to:
o Large body surface area
o Limited subcutaneous fat
o Immature thermoregulatory system
• SSC helps prevent all four modes of heat loss:
Mode of Heat Loss Prevented by SSC

Evaporation Baby is dried and kept warm

Conduction Direct contact with warm mother's skin

Convection Baby covered with a blanket

Radiation Reduced by skin-to-skin shielding

6. Benefits of Thermoregulation via SSC
Benefits Outcomes for Newborn

Maintains body temperature Reduces risk of hypothermia

Promotes weight gain Improves digestion and feeding

Reduces energy expenditure Conserves glucose stores

Enhances immunity Decreases neonatal infections

7. Kangaroo Mother Care (KMC)
A method of prolonged skin-to-skin care especially for low birth weight or
preterm babies.
• Continuous SSC for at least 6–8 hours/day
• Promotes growth, breastfeeding, and bonding
• Reduces hospital stay and neonatal mortality
8. Nursing Responsibilities
• Initiate SSC immediately after birth.

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• Educate parents about the importance and procedure.

• Monitor:
o Baby's temperature, breathing, and color
o Mother's comfort and ability to maintain SSC
• Record duration and outcomes of SSC.
9. Diagram Suggestions
• Illustration of SSC position between mother and baby
• Table comparing body temperatures with and without SSC
• Flowchart of SSC → Thermoregulation → Breastfeeding → Bonding
10. Possible Outcome Questions
Two Marks
1. Define skin-to-skin contact.
2. Mention two advantages of SSC in thermoregulation.
Five Marks
1. Describe the procedure of skin-to-skin contact.
2. Write a short note on the role of SSC in preventing heat loss in newborns.
Ten Marks
1. Explain the importance of skin-to-skin contact in newborn care and
thermoregulation.
2. Discuss the principles and nursing responsibilities involved in SSC and
Kangaroo Mother Care.
Infection Prevention in Newborns
1. Introduction
• Newborns are highly vulnerable to infections due to an immature
immune system.
• Infection is a major cause of neonatal morbidity and mortality,
especially in the first 28 days of life.
• Preventive measures are essential to ensure a safe and healthy neonatal
period.

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2. Common Infections in Neonates

Type of Infection Examples

Umbilical infection Omphalitis

Skin infection Pustules, boils

Respiratory infection Pneumonia

Eye infection Ophthalmia neonatorum

Gastrointestinal Diarrhea due to poor hygiene

Systemic Sepsis, meningitis

3. Sources of Infection
• Unclean hands of caregivers
• Contaminated delivery surfaces or instruments
• Poor cord care practices
• Infected birth canal
• Visitors or environment
• Unhygienic feeding practices
4. Infection Prevention Strategies
A. Hand Hygiene
• Wash hands with soap and water or use sanitizer before:
o Handling baby
o Breastfeeding
o Changing diapers or clothes
• Keep nails short and clean
B. Cord Care
• Keep cord clean and dry
• Do not apply any substances (powder, ghee, ash, etc.)
• Fold diaper below stump

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• Watch for redness, foul smell, or pus (signs of infection)

C. Breastfeeding
• Start within 1 hour of birth
• Exclusive breastfeeding for 6 months:
o Provides antibodies (IgA, IgG)
o Enhances immunity
• Prevents contamination from other feeds
D. Clean Clothing and Environment
• Use clean, soft, washed cotton clothes
• Change diapers/pads regularly
• Ensure proper room ventilation
• Limit visitors in early days
E. Safe Handling and Bathing
• Bathe only after 24 hours or once stable
• Clean only with lukewarm water and mild soap
• Avoid overhandling by multiple people
F. Immunization
• Give all birth vaccines:
o BCG (for TB)
o OPV-0
o Hepatitis B – 1st dose
• Follow national immunization schedule
5. Danger Signs of Neonatal Infection
Sign Meaning

Fever or cold body Temperature instability

Poor feeding Lethargy or sepsis

Fast or difficult breathing Pneumonia or sepsis

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Sign Meaning

Red/swollen cord stump Omphalitis

Eye discharge/redness Eye infection

Pustules or boils on skin Skin infection

Convulsions or stiff body Meningitis

Refer immediately to healthcare facility if danger signs are present.
6. Role of Nurse and Caregivers
• Educate parents on hygiene, danger signs, and exclusive breastfeeding
• Ensure aseptic technique in delivery and newborn handling
• Monitor and report early signs of infection
• Promote clean delivery and postnatal practices in the community
7. Home-Based Newborn Care by ASHA/ANM
• Visit schedule: Day 3, 7, 14, 21, 28, and 42
• Observe for signs of infection
• Guide on clean feeding, cord care, and breastfeeding
• Refer sick newborns as per HBNC protocol
8. Diagram Suggestions
• 5 Moments of Hand Hygiene (for caregivers)
• Clean cord care dos and don’ts
• Flowchart: Risk → Prevention → Early Signs → Referral
9. Possible Outcome Questions
Two Marks
1. Mention two danger signs of infection in a newborn.
2. Name two vaccines given at birth for infection prevention.
Five Marks
1. Describe the measures to prevent infection in a newborn.
2. Explain the role of breastfeeding in infection prevention.

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Ten Marks
1. Discuss in detail the nursing measures for infection prevention in
newborns.
2. Explain the sources, signs, and prevention of neonatal infections.
Immunization in Newborns
1. Introduction
• Immunization is the process of making a person immune or resistant to
an infectious disease, typically by the administration of vaccines.
• Newborns are particularly vulnerable to infections; hence, timely
vaccination is critical in preventing morbidity and mortality.
• Immunization in newborns begins at birth and continues as per the
National Immunization Schedule (NIS).
2. Importance of Immunization in Newborns
• Boosts natural immunity in infants
• Prevents life-threatening infections such as tuberculosis, hepatitis B, and
polio
• Reduces neonatal and infant mortality
• Promotes herd immunity and public health
3. Vaccines Given at Birth
Disease Time of
Vaccine Route Site Dose
Prevented Administration

0.05
At birth or as
Left upper mL
BCG Tuberculosis Intradermal early as possible
arm (<1
till 1 year of age
yr)

2
OPV-0 Poliomyelitis Oral Oral cavity At birth
drops

Hepatitis
Anterolateral 0.5 Within 24 hours
B – 1st Hepatitis B Intramuscular
thigh (right) mL of birth
dose
4. National Immunization Schedule (NIS) for Infants
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Age Vaccines

At Birth BCG, OPV-0, Hepatitis B (birth dose)

6 Weeks OPV-1, Pentavalent-1, Rotavirus-1, IPV-1

10 Weeks OPV-2, Pentavalent-2, Rotavirus-2

14 Weeks OPV-3, Pentavalent-3, Rotavirus-3, IPV-2

9–12 Months Measles-Rubella (1st dose), Vitamin A (1st dose)

Note: Pentavalent = DPT + Hepatitis B + Hib (Haemophilus influenzae type B
5. Cold Chain Maintenance
• Vaccines must be stored within +2°C to +8°C.
• Prevent freezing of freeze-sensitive vaccines like Hepatitis B.
• Use of ice-lined refrigerators (ILRs) and vaccine carriers during
transport.
6. Nurse’s Role in Immunization
• Verify vaccination schedule and eligibility
• Use aseptic technique while administering injections
• Maintain cold chain during storage and transportation
• Educate caregivers about:
o Importance of vaccines
o Next due dates
o Possible side effects (e.g., fever, local swelling)
• Observe for adverse events following immunization (AEFI)
• Document all administered vaccines in the Mother-Child Protection
Card
7. Adverse Events Following Immunization (AEFI)
Reaction Management

Mild fever Paracetamol, tepid sponging

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Reaction Management

Pain/swelling at site Cold compress

Anaphylaxis (rare) Immediate emergency care (Adrenaline IM)

8. Parent Counseling Topics
• Why immunization is essential
• Immunization schedule (hand out card)
• What to expect post-vaccination
• When to return for the next dose
• What to do in case of side effects
9. Diagram Suggestions
• National Immunization Schedule chart
• Vaccine administration sites for infants
• Cold chain equipment diagram
10. Possible Outcome Questions
Two Marks
1. Name any two vaccines given at birth.
2. What is the route of administration for BCG vaccine?
Five Marks
1. Describe the role of a nurse in immunization.
2. Write a short note on vaccines given at birth.
Ten Marks
1. Discuss immunization of newborns and explain the National
Immunization Schedule.
2. Explain cold chain maintenance and nurse’s responsibility in ensuring
vaccine efficacy.
Minor Disorders of Newborn and Their Management
1. Introduction

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• Minor disorders in newborns are commonly occurring, non-serious

conditions that usually resolve on their own or with minimal medical
care.
• These are part of normal adaptation to extrauterine life.
• Early identification and proper parental education help prevent
unnecessary anxiety and complications.
2. Common Minor Disorders of the Newborn
Disorder Description Management

Physiological Yellowish skin/eyes after 2–3 Monitor bilirubin, ensure

Jaundice days of life adequate feeding

Caput Swelling on the head due to Resolves within days, no

Succedaneum pressure during birth treatment needed

Collection of blood under Observe, resolves in 2–6

Cephalhematoma
scalp bone weeks

Tiny white spots on face No treatment, disappears

Milia
(sebaceous gland blockage) on its own

Red blotchy rash on trunk Benign, no treatment

Erythema Toxicum
and limbs needed

Bluish patches (usually on

Mongolian Spots Normal, fades with time
back or buttocks)

Breast Swelling of breast tissue due Warm compress, gentle

Engorgement to maternal hormones massage if needed

Umbilical Small red tissue at stump Keep clean, apply salt or

Granuloma after cord falls off prescribed ointment

White cysts on gums or roof No treatment needed,

Epstein’s Pearls
of mouth disappear naturally

Delayed stool passage or Ensure proper feeding,

Constipation
hard stool massage abdomen

Burp after feeding, feed

Regurgitation Spitting milk after feed
slowly

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Disorder Description Management

Normal reflex actions in

Sneezing/Hiccups No treatment needed
newborns
3. Key Differences: Caput Succedaneum vs. Cephalhematoma
Feature Caput Succedaneum Cephalhematoma

Onset At birth Several hours after birth

Location Overlapping sutures Confined within bone boundaries

Crosses sutures Yes No

Contents Serous fluid Blood

Resolution time Few days Weeks to months

4. Parental Education
• Reassure parents that these are common and self-limiting.
• Avoid using home remedies unless prescribed.
• Educate on signs that need immediate attention:
o High fever
o Refusal to feed
o Excessive vomiting or diarrhea
o Lethargy or irritability
5. Nursing Responsibilities
• Perform regular newborn assessments
• Differentiate between physiological and pathological conditions
• Counsel parents about:
o Expected changes
o Normal timelines of resolution
• Maintain hygiene and appropriate skin care
• Document findings and any referrals
6. Diagram Suggestions
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• Images comparing:
o Milia vs neonatal acne
o Caput succedaneum vs cephalhematoma
• Chart showing common disorders with time of appearance and resolution
7. Possible Outcome Questions
Two Marks
1. What is milia in newborns?
2. Mention any two minor disorders of a newborn.
Five Marks
1. Differentiate between caput succedaneum and cephalhematoma.
2. Describe the management of physiological jaundice in a newborn.
Ten Marks
1. List common minor disorders of newborn and explain their management.
2. Discuss the role of a nurse in identifying and educating caregivers about
minor neonatal conditions

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Unit -07
Family welfare services

Impact of Early and Frequent Childbearing

1. Introduction to Family Welfare Services
• Family Welfare Services are a part of public health programs aimed at
reducing fertility, improving maternal-child health, and promoting
reproductive rights.
• These services offer:
o Family planning
o Counseling on safe motherhood
o Education on spacing and limiting childbirth
o Support for women's and children's health
2. Early Childbearing: Definition and Prevalence
• Early childbearing refers to pregnancy and childbirth in adolescents or
young women under the age of 18.
• More common in rural and low-income settings, often due to early
marriage, lack of education, and limited access to contraception.
3. Frequent Childbearing: Definition
• Refers to multiple pregnancies in a short span of time, with less than 2
years spacing between births.
• Common among women with limited family planning knowledge or
resources.
4. Impact of Early and Frequent Childbearing
A. Health Impact on Mother
Risk/Condition Consequences

Anemia Increased risk of complications, PPH

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Risk/Condition Consequences

Pregnancy-induced
Risk of seizures, preterm labor
hypertension

Obstructed labor Due to immature pelvis in teenage mothers

Malnutrition Poor maternal weight gain and weakness

Uterine rupture or Common in repeated cesareans or short

complications intervals

Higher among young and overburdened

Maternal mortality
mothers
B. Health Impact on Baby
Risk/Condition Consequences

Low birth weight (LBW) Prematurity, poor development

Birth asphyxia Brain damage, long-term disability

Increased neonatal mortality Poor immunity, infections, SIDS

Congenital malformations Associated with poor antenatal care

Poor bonding and care Due to maternal inexperience or exhaustion

C. Social and Psychological Impact
• Interrupted education of the mother
• Limited employment opportunities
• Increased dependency on partner/family
• Higher risk of domestic violence
• Mental health problems: depression, anxiety, postpartum stress
5. Benefits of Delayed and Spaced Childbearing
Benefits to Mother Benefits to Child

Improved maternal health Higher birth weight

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Benefits to Mother Benefits to Child

Enhanced cognitive and emotional

Better emotional preparedness
development

Opportunity for education/career Better economic security

Reduced maternal and infant

Improved breastfeeding and bonding
mortality
6. Role of Family Welfare Services
• Provide contraceptive options (oral pills, IUD, condoms, sterilization)
• Promote adolescent reproductive health education
• Offer pre-marital and pre-conception counseling
• Ensure access to maternal and child health services
• Engage ASHA, ANM, and community health workers in awareness
generation
• Promote spacing of at least 2 years between pregnancies
7. Government Initiatives in India
• National Family Welfare Program (1952 – first in the world)
• RMNCH+A Strategy – Reproductive, Maternal, Newborn, Child +
Adolescent Health
• Mission Parivar Vikas – Promotes spacing methods in high-fertility
districts
• JSY (Janani Suraksha Yojana) – Encourages institutional deliveries
8. Diagram/Table Suggestions
• Bar chart: Maternal mortality vs. age of mother
• Flowchart: Early marriage → Early pregnancy → Health consequences
• Table comparing outcomes of early vs. ideal-age childbirth
9. Possible Outcome Questions
Two Marks
1. Define early childbearing.

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2. List two effects of frequent childbirth on the mother.

Five Marks
1. Mention the impact of early childbearing on maternal and child health.
2. Describe the role of family welfare services in preventing early and
frequent childbearing.
Ten Marks
1. Discuss in detail the impact of early and frequent childbearing and the
role of nursing in prevention.
2. Explain the services provided under the family welfare program and their
importance in reproductive health.
Comprehensive Range of Family Planning Methods
1. Introduction
• Family planning involves conscious decision-making by individuals or
couples to determine the number and spacing of children using
scientifically approved methods.
• It promotes maternal and child health, reduces unplanned
pregnancies, and improves quality of life.
• A comprehensive range includes temporary and permanent methods, for
both men and women.
2. Classification of Family Planning Methods
Type Methods Included

Temporary Natural methods, Barrier methods, Hormonal methods,

Methods Intrauterine devices (IUDs)

Permanent Female sterilization (Tubectomy), Male sterilization

Methods (Vasectomy)
3. Temporary Family Planning Methods
A. Natural (Traditional) Methods

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Method Description Limitation

Avoid sex during fertile period Requires regular

Calendar method
(based on cycle tracking) cycles

Detect ovulation by temperature

Basal body temp. Time-consuming
rise

Monitoring mucus changes to Requires training

Cervical mucus
detect ovulation and observation

Effective up to 6 months if
Lactational Temporary
breastfeeding fully and no
Amenorrhea (LAM) protection
menstruation
B. Barrier Methods
Method Description Advantages

Prevents sperm entry; also Widely available, no

Male condom
protects against STIs side effects

Female-controlled
Female condom Placed inside vagina
method

Diaphragm/Cervical Reusable, used with

Covers cervix to block sperm
cap spermicide
C. Hormonal Methods
Method Composition / Route Examples Features

Mala-N, Taken daily,

Oral pills Estrogen + progesterone
Mala-D regulates cycles

Depot medroxyprogesterone Depo- Every 3 months IM

Injectables
acetate (DMPA) Provera injection

Long-term (3–5
Implants Progesterone-releasing rods Norplant
years) reversible

Emergency Within 72 hours of

Levonorgestrel i-pill
pill unprotected sex

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Method Composition / Route Examples Features

Transdermal
Skin patch with hormones - Weekly patch
patch
D. Intrauterine Devices (IUDs)
Type Examples Duration Mechanism

Non- Copper-T (CuT Up to 10 Prevents sperm motility &

hormonal 380A) years implantation

LNG-IUS Up to 5 Releases progestin, thickens

Hormonal
(Mirena) years cervical mucus
4. Permanent Family Planning Methods
A. Female Sterilization (Tubectomy)
• Surgical method involving blocking or cutting fallopian tubes.
• Performed via minilaparotomy or laparoscopy.
• Done within 7 days of menstruation or postpartum (within 7 days of
delivery).
B. Male Sterilization (Vasectomy)
• Vas deferens are cut and sealed to block sperm transport.
• Simple, outpatient procedure.
• Requires 3 months of backup contraception post-procedure.
5. Comparison Table
Protection
Method Male/Female Temporary/Permanent Reversibility
from STIs

Condom Male/Female Temporary Yes Yes

Oral pills Female Temporary No Yes

Yes (on
IUD Female Temporary (Long-term) No
removal)

Rare, not
Tubectomy Female Permanent No
guaranteed

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Protection
Method Male/Female Temporary/Permanent Reversibility
from STIs

Rare, not
Vasectomy Male Permanent No
guaranteed
6. Nurse’s Role in Family Planning Services
• Provide counseling on available methods and help choose suitable ones
• Assess for eligibility and contraindications
• Maintain privacy and informed consent
• Educate on correct usage and side effects
• Monitor for complications and follow-up
7. Government Initiatives
• Mission Parivar Vikas – High focus on spacing methods in high fertility
districts
• Free distribution of contraceptives through:
o ASHA workers
o Primary Health Centers (PHCs)
o Anganwadi centers
8. Diagram/Table Suggestions
• Chart comparing methods: type, duration, side effects
• WHO Medical Eligibility Criteria (MEC) wheel (summary table)
• Diagram of IUD insertion site
• Flowchart for selection of contraceptive method
9. Possible Outcome Questions
Two Marks
1. Mention two temporary methods of family planning.
2. What is the full form of LAM?
Five Marks
1. Describe the advantages and disadvantages of IUD.

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2. Explain the nurse’s role in providing family planning services.

Ten Marks
1. Classify family planning methods and explain each with advantages and
limitations.
2. Discuss various contraceptive methods available under the National
Family Welfare Program.
Temporary Methods of Family Planning
Hormonal, Non-Hormonal, and Barrier Methods
1. Introduction
• Temporary methods are reversible contraceptive techniques used to
prevent pregnancy for a desired period.
• They allow couples to delay, space, or limit pregnancies without
permanent sterilization.
• Classified into:
o Hormonal methods
o Non-hormonal methods
o Barrier method
2. Hormonal Methods
• Work by altering ovulation, thickening cervical mucus, or changing the
uterine lining.
Duration /
Method Description Examples
Use

Combined Oral
Contain estrogen +
Contraceptives Taken daily Mala-N, Mala-D
progestin
(COC)

Only progestin, safe

Progestin-only Pills Cerazette,
for breastfeeding Taken daily
(POP) Micronor
mothers

Progestin injection Every 3 Depo-Provera

Injectables
(IM) months (DMPA)

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Duration /
Method Description Examples
Use

Rods inserted under

Implants 3–5 years Norplant, Implanon
skin of arm

Progestin-releasing Up to 5
Hormonal IUDs Mirena
intrauterine system years

Emergency High-dose progestin Within 72

i-Pill, Unwanted 72
Contraceptive Pills after unprotected sex hours

Ortho Evra (not

Skin patch delivering Changed
Contraceptive Patch commonly used in
hormones weekly
India)
Advantages:
• Highly effective
• Regulates menstrual cycles
• Reduces risk of anemia and ovarian cysts
Disadvantages:
• Needs regular use
• Side effects: nausea, headache, weight gain
• No protection from STIs
3. Non-Hormonal Methods
• Do not interfere with hormonal balance; mainly act mechanically or
chemically.
Method Description Examples

Prevents fertilization by affecting CuT 380A, CuT

Copper IUD (CuT)
sperm motility 200 B

Lactational
Natural method during exclusive Up to 6 months
Amenorrhea Method
breastfeeding postpartum
(LAM)

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Method Description Examples

Includes calendar method, basal

Natural Methods -
body temp, mucus observation

Foam, cream,
Chemical Methods Spermicides used with barriers
jellies
Advantages:
• Long-acting (IUDs)
• Safe for breastfeeding mothers
• No hormonal side effects
Disadvantages:
• Risk of PID with IUD
• LAM effective only if strict conditions met
• Natural methods require discipline and regular cycles
4. Barrier Methods
• Physically prevent sperm from reaching egg; reversible and often
available over-the-counter.
A. Male Barrier Methods
Method Features

Male Condom Latex/rubber sheath worn over penis

Prevents STIs + pregnancy

Easily available, low cost

B. Female Barrier Methods
Method Features

Female Condom Inserted into the vagina before intercourse

Greater control for women

Diaphragm/Cervical Cap Covers cervix, used with spermicide

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Method Features

Reusable, needs fitting by healthcare provider

Advantages:
• Protects against STIs (especially condoms)
• No hormonal side effects
• Easily reversible
Disadvantages:
• May reduce spontaneity
• User-dependent effectiveness
• Allergic reactions to latex possible
5. Summary Table: Comparison of Temporary Methods
Protects from
Category Examples Duration Reversibility
STIs

Pills, injections, Daily to 5

Hormonal No Yes
implants years

Non- IUD, LAM, natural Months to

No Yes
Hormonal methods years

Condoms,
Barrier Per act Yes (condoms) Yes
diaphragm
6. Nurse’s Role in Counseling
• Provide information on all available methods
• Help client choose the most suitable method
• Educate on correct use
• Monitor for side effects
• Ensure follow-up and support
7. Diagram Suggestions
• Chart comparing hormonal vs. non-hormonal vs. barrier methods
• Picture of IUD insertion

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• Condom application diagram

• Flowchart: How hormonal pills prevent pregnanc
8. Possible Outcome Questions
Two Marks
1. Name two hormonal contraceptive methods.
2. What is the full form of LAM?
Five Marks
1. Explain any two barrier methods of contraception.
2. Describe the advantages and disadvantages of Copper-T.
Ten Marks
1. Classify temporary methods of contraception and explain hormonal, non-
hormonal, and barrier methods in detail.
2. Discuss temporary family planning methods and their nursing
implications.
Permanent Methods of Family Planning
Male Sterilization and Female Sterilization
1. Introduction
• Permanent methods of contraception involve surgical procedures to
irreversibly prevent pregnancy.
• Recommended for couples who have completed their family and do not
desire more children.
• Includes:
o Male sterilization – Vasectomy
o Female sterilization – Tubectom
2. Female Sterilization (Tubectomy)
A. Definition
• Surgical procedure where fallopian tubes are cut and tied or sealed to
block ovum transport from ovaries to uterus.
B. Timing of Tubectomy

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Type of Timing Description

Interval sterilization Performed 6 weeks or more after childbirth

Postpartum sterilization Within 48 hours after delivery

Post-abortion sterilization Performed immediately after MTP or abortion

C. Methods of Tubectomy
Method Description

Minilaparotomy Small abdominal incision to access and block tubes

Laparoscopy Uses laparoscope for visualization and tubal ligation

D. Advantages
• Permanent and effective
• No effect on hormonal balance or sexual activity
• Can be done immediately postpartum
E. Disadvantages / Risks
• Surgical risks (bleeding, infection)
• Permanent (reversal difficult and not guaranteed)
• Psychological adjustment may be needed
3. Male Sterilization (Vasectomy)
A. Definition
• Surgical method where vas deferens (ducts carrying sperm) are cut and
sealed, preventing sperm from mixing with semen.
B. Procedure
• Minor procedure done under local anesthesia
• Outpatient basis; quick recovery
• No impact on sexual performance or hormone levels
C. Post-Procedure Instructions
• Use alternative contraception for 3 months (till sperm count becomes
zero)

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• Follow-up for semen analysis at 6 weeks and 12 weeks

• Avoid heavy lifting for a few days
D. Advantages
• Safe, simple, and effective
• No effect on sexual function or hormone levels
• Less invasive than female sterilization
E. Disadvantages / Risks
• Requires follow-up semen testing
• Minor swelling or bruising post-op
• Reversal is difficult and not always successfu
4. Comparison: Tubectomy vs. Vasectomy
Feature Tubectomy (Female) Vasectomy (Male)

Invasiveness More invasive Less invasive

Anesthesia Often general or spinal Local

Procedure time 20–30 minutes 10–15 minutes

Recovery time 7–10 days 1–2 days

Complications More likely Less likely

Reversibility Difficult and not guaranteed Also difficult but slightly better
5. Eligibility Criteria
According to WHO Medical Eligibility Criteria and Indian government
guidelines:
• Married individuals/couples with at least one living child (preferably
over 1 year old)
• Age: 22–45 years for women, 22–50 years for men
• Mentally sound and providing informed consent
• Free from reproductive tract infections or other contraindications
6. Counseling Before Sterilization

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• Permanent nature of the procedure

• Available alternatives (e.g., IUD, injectables)
• Benefits, risks, and side effects
• Time for post-op recovery
• Partner involvement encouraged
7. Nurse’s Role
• Provide pre-op and post-op care
• Assist in counseling and informed consent
• Maintain aseptic technique during the procedure
• Educate about wound care and follow-up
• Provide psychological suppor
8. Government Schemes in India
• National Family Welfare Program (NFWP) supports free sterilization
services
• Incentives for clients and ASHA workers
• Use of standardized kits and protocols
9. Diagram Suggestions
• Female reproductive system showing blocked fallopian tubes
• Male reproductive system showing severed vas deferens
• Flowchart: Counseling → Consent → Procedure → Follow-u
10. Possible Outcome Questions
Two Marks
1. What is the ideal age range for female sterilization under the national
program?
2. What is the name of the surgical method used for male sterilization?
Five Marks
1. List differences between tubectomy and vasectomy.
2. What instructions should be given to a man after vasectomy?

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Ten Marks
1. Define permanent methods of contraception. Explain tubectomy and
vasectomy in detail.
2. Describe the nurse’s role in counseling and post-operative care of a
woman undergoing sterilization.
Family Planning Methods – Action, Effectiveness, Advantages, Disadvantages,
Myths & Medical Eligibility Criteria (MEC)
1. Introduction
• Family planning methods help in spacing or limiting pregnancies.
• Categorized as:
o Temporary methods – Reversible
o Permanent methods – Irreversible
• Each method has different mechanisms of action, effectiveness, and
eligibility requirements.
2. Action of Family Planning Methods
Method Category Mechanism of Action

Hormonal methods Inhibit ovulation, thicken cervical mucus

Barrier methods Physically block sperm from reaching the egg

IUDs (Copper) Immobilize sperm, prevent implantation

Sterilization Surgically block sperm or egg pathway

Natural methods Abstain during fertile periods

3. Effectiveness (Typical Use)
Method Effectiveness (%)

Male condom 85%

Female condom 79%

Combined oral pills 91%

Progestin-only pills 93%

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Method Effectiveness (%)

DMPA Injection 94%

Implants 99%

Copper IUD 99.2%

Hormonal IUD (Mirena) 99.8%

Female sterilization 99.5%

Male sterilization (vasectomy) 99.9%

Natural methods (e.g., rhythm) 76%

Lactational Amenorrhea (LAM) 98% (first 6 months)

4. Advantages of Family Planning Methods
• Health benefits: Reduces maternal and infant mortality.
• Economic benefits: Allows families to plan financial resources.
• Empowerment: Women gain control over reproductive choices.
• Spacing: Ensures proper care and nutrition of children.
• STI prevention: Barrier methods reduce risk of infections.
5. Disadvantages / Limitations
Method Disadvantages

Hormonal Side effects (nausea, spotting, weight gain)

Barrier May interrupt spontaneity; lower effectiveness

IUD Risk of infection, expulsion, or perforation

Sterilization Irreversible; regret in young age or marital changes

Natural Requires discipline, regular cycles

6. Common Myths & Misconceptions

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Myth / Misconception Fact / Reality

Fertility returns soon after stopping

"Pills cause permanent infertility"
pills

"IUD moves to other body parts" IUD remains in uterus unless expelled

No effect on erection, libido, or

"Vasectomy affects sexual function"
hormones

Correct use ensures safety and

"Condoms reduce pleasure"
comfort

"Breastfeeding always prevents LAM is effective only under strict

pregnancy" criteria

"Sterilization is reversible" Rarely reversible, consider permanent

7. Medical Eligibility Criteria (MEC) by WHO
WHO classifies contraceptive use into 4 categories:
Category Explanation Use Status

1 No restriction Safe to use

2 Advantages outweigh risks Can be used

3 Risks outweigh advantages Use with caution

4 Unacceptable health risk Do not use

MEC Example for Selected Conditions
Condition COC POP IUD (CuT)

Age > 40 2 1 2

Breastfeeding < 6 wks 4 2 4

Smoking > 15/day (age >35) 3/4 1 2

Severe hypertension 3/4 2 2

Unexplained vaginal bleeding 3 2 4

Active pelvic infection 2 2 4

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8. Nursing Responsibilities
• Assess eligibility using MEC
• Provide non-judgmental counseling
• Educate on correct use and follow-up
• Clarify myths and misconceptions
• Monitor and report any side effects
• Promote informed decision-making
9. Diagram Suggestions
• Flowchart: Steps of choosing family planning method
• WHO MEC category table
• Pie chart of contraceptive effectiveness comparison
10. Possible Outcome Questions
Two Marks
1. What is the full form of MEC?
2. Mention any one hormonal and one barrier method of contraception.
Five Marks
1. List any five myths related to family planning and clarify them.
2. Explain medical eligibility criteria for contraceptive use with examples.
Ten Marks
1. Describe the action, advantages, disadvantages, and eligibility of various
family planning methods.
2. Discuss the effectiveness, myths, and nurse’s role in promoting family
planning services.
Emergency Contraceptives
1. Introduction
• Emergency contraception (EC) is used after unprotected sex or
contraceptive failure to prevent pregnancy.
• Also called post-coital contraception or the morning-after pill.

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• Should be used within 72–120 hours depending on the method.

2. Indications for Use
• Unprotected intercourse
• Contraceptive failure (e.g., condom breakage, missed pills)
• Sexual assault or rape
• Expulsion of IUD
• Miscalculation in natural family planning
3. Types of Emergency Contraceptives
Time Frame for
Method Mechanism of Action
Use

Levonorgestrel (LNG) Within 72 hours Inhibits ovulation, fertilization

Ulipristal acetate (UPA) Within 120 hours Delays or inhibits ovulation

Yuzpe regimen (COC High-dose estrogen +

Within 72 hours
pills) progestin

Within 5 days (120 Inhibits fertilization,

Copper T IUD
hrs) implantation
4. Dosage and Timing
A. Levonorgestrel (LNG)
• Single dose: 1.5 mg orally once
• Or two doses: 0.75 mg, 12 hours apart
• Best if taken within 24 hours, but effective up to 72 hours
B. Ulipristal Acetate
• Single dose: 30 mg orally
• Can be taken up to 120 hours (5 days) after intercourse
C. Yuzpe Regimen
• Use combined oral pills (e.g., 100 mcg ethinylestradiol + 0.5 mg
levonorgestrel)
• Repeat after 12 hours

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• Less preferred due to side effects (nausea/vomiting)

D. Copper T IUD
• Inserted by a trained provider within 5 days
• Most effective EC method (~99%
5. Effectiveness
Method Effectiveness (%)

LNG pills 85–89%

Ulipristal ~98%

Yuzpe regimen ~75%

Copper IUD >99%

6. Side Effects
• Nausea, vomiting (common with Yuzpe)
• Headache, dizziness
• Fatigue, breast tenderness
• Irregular menstrual bleeding
• Delayed or early periods
7. Contraindications
Method Contraindications

LNG/UPA Known allergy to components, undiagnosed vaginal bleeding

Yuzpe History of thromboembolism, migraine with aura

Copper Active pelvic infection, undiagnosed genital tract bleeding,

IUD Wilson’s disease, pregnancy
8. Myths vs. Facts
Myth Fact

EC causes abortion No – it prevents fertilization or implantation

EC affects long-term fertility False – no effect on future fertility

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Myth Fact

False – not guaranteed, but reduces

EC is 100% effective
pregnancy risk

Can be used as regular

Not advisable – for emergency use only
contraception
9. Medical Eligibility Criteria (WHO MEC)
Group LNG / UPA Copper IUD

Adolescents Category 1 (safe) Category 2 (use with caution)

LNG – Safe
Breastfeeding Copper IUD – Safe
UPA – Caution

History of ectopic pregnancy Safe Caution (monitor carefully)

Severe liver disease Use with caution Avoid (in UPA)

10. Nursing Responsibilities
• Counsel on correct use and timing
• Ensure informed consent
• Provide information on side effects
• Discuss the importance of regular contraception
• Refer to healthcare provider if IUD is considered
• Educate about menstrual changes and pregnancy test if period is
delayed by 1 week
11. Diagram Suggestions
• Timeline chart: EC pills vs Copper IUD
• Flowchart: When and how to use each EC method
• Table of EC types with action, timing, side effects
12. Possible Outcome Questions
Two Marks
1. Name any two emergency contraceptive methods.
2. What is the ideal time frame for using levonorgestrel as EC?
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Five Marks
1. List the indications and side effects of emergency contraceptives.
2. Explain the difference between LNG and Ulipristal acetate in EC.
Ten Marks
1. Describe the various types of emergency contraceptives, their actions,
advantages, and nursing responsibilities.
2. Explain the indications, contraindications, and effectiveness of
emergency contraception in preventing unplanned pregnancy.
Recent Trends and Research in Contraception
1. Introduction
• Contraceptive technology has significantly evolved with newer, safer,
and user-friendly methods.
• Focus is on improving efficacy, acceptability, male participation, and
reversibility.
• Research emphasizes long-acting, reversible, and non-hormonal
options with minimal side effects.
2. Goals of Recent Contraceptive Research
• Improve effectiveness and compliance
• Reduce hormonal side effects
• Expand male contraceptive options
• Provide user-controlled, discreet methods
• Target reproductive rights and adolescent-friendly services
3. Recent and Emerging Contraceptive Methods
Method Description Status

Subcutaneous self-injectable
Sayana Press (DMPA SC) In use
version of DMPA

Male contraceptive pills Under trial – reduces sperm

Clinical trials
(Nestorone + testosterone) without affecting libido

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Method Description Status

Injectable male contraception Phase III trials

Vasalgel (RISUG)
– blocks vas deferens in India

Non-hormonal pills (e.g., Prevents sperm production

Pre-clinical
Oleanolic acid) without hormones

Slowly release hormones, no

Biodegradable implants Research stage
need for surgical removal

Track placement and release

Smart IUDs Prototype
via digital monitoring

Skin patch with painless

Microneedle patches Animal trials
hormonal delivery

Contraceptive vaginal rings Reusable ring, works for 1 Approved in

(Annovera) year US

Cycle tracking apps integrated

Digital health tools Widely used
with wearable tech
4. WHO-Endorsed Innovations
• Self-care methods (e.g., self-injection, self-removal of IUDs)
• Male participation promotion
• Multipurpose prevention technologies (MPTs): combine contraception
+ STI protection
5. National Initiatives in India
Innovation Description

Antara Injectable contraceptive (DMPA, every 3 months)

Chhaya
Weekly non-hormonal oral pill
(Centchroman)

Focused contraceptive services in high-fertility

Mission Parivar Vikas
districts

ASHAs and ANMs Training for community-based contraceptive delivery

6. Research Focus Areas

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• Male contraception (vas deferens blockage, reversible)

• User-controlled devices (patches, rings, apps)
• Long-acting reversible contraception (LARC): for adolescents and
postpartum women
• Multipurpose products: STI prevention + contraception
• Eco-friendly and biodegradable contraceptive materials
7. Advantages of New Trends
• Increased privacy and convenience
• Promotes shared responsibility in contraception (men included)
• Enhanced accessibility in remote or underserved areas
• Focus on adolescent-friendly and non-invasive methods
• Support for digital integration and telehealth follow-up
8. Challenges
• High cost and limited availability in rural areas
• Cultural barriers to male contraceptive use
• Need for awareness and counseling on new methods
• Training gaps among healthcare provider
9. Role of Nurses in Promoting New Methods
• Provide up-to-date information on available options
• Educate on correct usage, benefits, and side effects
• Dispel myths and misconceptions
• Encourage male involvement
• Support informed choice and autonom
10. Diagram/Table Suggestions
• Comparison chart: Traditional vs. New methods
• Timeline of contraceptive innovation
• Flowchart: How Vasalgel works in male contraception
11. Possible Outcome Questions
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Two Marks
1. What is Vasalgel?
2. Name any two recent contraceptive innovations used in India.
Five Marks
1. List and explain any four new trends in contraception.
2. Describe the role of nurses in promoting recent contraceptive methods.
Ten Marks
1. Discuss the recent trends and research developments in contraception and
their impact on reproductive health.
2. Explain the innovations introduced in India to expand contraceptive
access and acceptability.
Family Planning Counseling using Balanced Counseling Strategy (BCS)
1. Introduction
• Balanced Counseling Strategy (BCS) is a client-centered, evidence-
based approach for family planning counseling.
• Developed by Population Council, BCS helps providers guide clients in
selecting the most appropriate contraceptive method based on
individual needs, medical eligibility, and preferences.
• Focuses on informed choice, respect, confidentiality, and active client
involvement
2. Objectives of BCS
• Assist clients in making an informed and voluntary decision.
• Improve quality of family planning services.
• Promote correct and consistent use of contraceptive methods.
• Respect clients’ reproductive rights, values, and choices.
3. Phases of Balanced Counseling Strategy
Phase Activities Involved

Pre-Counseling Greet the client, ensure privacy, build rapport, and assess
Phase needs

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Phase Activities Involved

Provide information on all methods using job aids; assist

Counseling Phase
in method selection

Post-Counseling Confirm understanding, provide method, schedule follow-

Phase up, and record details
4. Steps of Balanced Counseling Strategy (Simplified)
Step Key Actions

1. Greet and build trust Use respectful tone, ensure privacy

Ask about goals (spacing, limiting), medical

2. Identify client needs
history, partner involvement

3. Rule out contraindicated

Use WHO MEC wheel/checklist
methods

Use visual/job aids; explain effectiveness, side

4. Present method options
effects, usage

5. Support informed choice Clarify doubts, allow the client to decide

6. Provide method or
Provide method if available, refer if not
referral

7. Counsel on use and

Usage instructions, warning signs, return date
follow-up

8. Document and close Record choice, provide contact info for support
5. Key Principles of BCS
• Client autonomy: The client chooses the method.
• Privacy and confidentiality: Counseling should be private.
• Respectful communication: Avoid bias or judgment.
• Tailored approach: Based on age, marital status, health condition, parity,
etc.
• Use of job aids: E.g., method cards, counseling checklist, decision tree
6. Counseling Tools in BCS

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Tool Purpose

Visual aids showing features of each

Method Cards
contraceptive method

WHO Medical Eligibility Helps rule out unsafe methods for clients with
Criteria (MEC) specific health conditions

Client Recording Form For documentation and follow-up planning

A flowchart to guide clients in selecting suitable

Decision-making Tree
options
7. Benefits of Using BCS
• Improves client satisfaction and method continuation
• Reduces provider bias
• Ensures accurate, consistent information
• Helps identify the most appropriate method
• Strengthens client-provider communicatio
8. Nurse’s Role in BCS
• Create a non-judgmental, welcoming atmosphere
• Actively listen to client concerns
• Provide accurate, method-neutral information
• Use BCS job aids to support shared decision-making
• Ensure proper documentation and follow-u
9. Diagram Suggestions
• Flowchart of BCS steps
• Table comparing client-centered vs. traditional counseling
• Sample decision tree based on client needs and MEC
10. Possible Outcome Questions
Two Marks
1. What is the full form of BCS?
2. Name two tools used in the Balanced Counseling Strategy.
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Five Marks
1. Explain the steps involved in the Balanced Counseling Strategy.
2. Describe the nurse’s role in family planning counseling using BCS.
Ten Marks
1. Discuss the Balanced Counseling Strategy in family planning services.
2. Explain the importance and steps of BCS in improving contraceptive use
among women of reproductive age.
Legal and Rights Aspects of Family Planning (FP)
1. Introduction
• Family planning (FP) is not just a health service but a fundamental
human right.
• Recognized by global organizations like the United Nations (UN) and
World Health Organization (WHO).
• Ensures individuals and couples can freely decide if, when, and how
many children to have.
2. Legal Framework for Family Planning in India
Law/Policy Description

Emphasizes voluntary and informed choice

National Population Policy, 2000
in FP

Medical Termination of Allows abortion under specific conditions;

Pregnancy (MTP) Act, 1971 related to reproductive rights

Right to Privacy (SC Judgment, Recognizes reproductive choices under the

2017) right to privacy (Article 21)

Prohibition of Child Marriage Prevents early marriage, supports

Act, 2006 adolescent reproductive rights

Reproductive and Child Health Provides comprehensive reproductive

(RCH) Program health services, including FP
3. Key Reproductive Rights (as per WHO & ICPD)
• Right to information: Accurate, unbiased, and timely education on FP

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• Right to access: Availability and affordability of all contraceptive

methods
• Right to choose freely: Without coercion or pressure from providers or
family
• Right to privacy and confidentiality
• Right to non-discrimination: Regardless of gender, caste, religion, age,
or marital status
• Right to safety: FP services must be safe, medically approved, and with
informed consen
4. Informed Consent in Family Planning
• Essential before providing any contraceptive method, especially:
o Sterilization (permanent methods)
o Insertion of IUCD
o Use of injectable contraceptives
• Must be:
o Voluntary
o Fully informed (risks, benefits, alternatives)
o Documented
• For minors, parental or guardian consent is usually required
5. Rights of Special Groups
Group FP Rights Specifics

Access to FP services, counseling, privacy; prevention of

Adolescents
early pregnancy

Equal rights to access contraceptives without judgment

Unmarried women
or denial

Persons with Right to reproductive autonomy; services must be

disabilities accessible and respectful

Men Equal responsibility and rights in FP decision-making

6. Ethical Issues in Family Planning

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• Coercion (e.g., forced sterilization) is unethical and illegal

• FP services must respect autonomy and dignity
• Informed decision-making is critical – no method should be imposed
• No discrimination based on number of children, gender of children, or
marital status
7. National Guidelines and Supreme Court Rulings
• Supreme Court Guidelines on Female Sterilization (2016):
o Ban on sterilization camps
o Ensure proper facilities, consent, and follow-up
• Government of India FP Guidelines:
o Provider must explain all available options
o Ensure method-neutral counseling
8. Global Perspective
• UN Declaration of Human Rights (1948): Reproductive choice is a
human right
• ICPD – Cairo, 1994: Reproductive rights = basic human rights
• SDG 3.7 (Sustainable Development Goal): Universal access to FP by
203
9. Role of Nurses in Upholding Rights
• Provide non-judgmental, client-centered counseling
• Maintain confidentiality
• Ensure voluntary consent
• Educate clients on all available methods
• Protect clients from coercion, discrimination, or misinformation
10. Diagram/Table Suggestions
• Table: Legal acts supporting reproductive rights
• Chart: Key components of reproductive rights
• Flowchart: Steps to ensure informed and voluntary FP decision

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11. Possible Outcome Questions

Two Marks
1. Mention any two reproductive rights related to family planning.
2. What is the importance of informed consent in family planning?
Five Marks
1. Write the legal and ethical aspects of family planning.
2. Describe the role of the nurse in protecting reproductive rights.
Ten Marks
1. Discuss the legal framework and reproductive rights related to family
planning in India.
2. Explain the ethical principles and human rights approach to family
planning services.
Human Rights Aspects of Family Planning (FP) – Focus on Adolescents
1. Introduction
• Adolescents (10–19 years) are a vulnerable group with specific
reproductive health needs.
• Family planning is a fundamental human right, including the right to
access FP services without discrimination or coercion.
• Recognized by international frameworks like:
o WHO
o UNICEF
o ICPD (1994)
o UN Declaration of Human Rights
2. Key Human Rights in Family Planning for Adolescents
Right Explanation

Access to comprehensive reproductive health care,

Right to Health
including FP

Accurate, age-appropriate, and confidential

Right to Information
information on sexual health

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Right Explanation

Decide freely and responsibly on matters related to

Right to Autonomy
sexuality and reproduction

Right to Privacy Confidential services without judgment or disclosure

Right to Non- Regardless of age, gender, marital status, religion, or

Discrimination disability

Right to Informed Choose or refuse a method after receiving complete,

Consent unbiased information
3. Challenges Faced by Adolescents in Accessing FP
• Stigma and judgment from providers and society
• Lack of awareness about contraceptive options
• Parental consent requirements in some areas
• Gender inequality and lack of decision-making power
• Poor access to youth-friendly services
4. International Guidelines Supporting Adolescent FP Rights
Agency Key Guidance

Recommends adolescent-friendly FP services and age-appropriate

WHO
counseling

Supports adolescent reproductive rights through education and

UNFPA
empowerment programs

ICPD 1994 Declares adolescents have the same reproductive rights as adults

SDG Goal
Ensure universal access to reproductive health services by 2030
3.7
5. Legal Provisions in India Related to Adolescent Reproductive Rights
Law/Policy Relevance to FP

National Adolescent Health Provides FP education, counseling, and

Strategy (RKSK) services to adolescents

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Law/Policy Relevance to FP

Protects female adolescents from gender-

PC-PNDT Act (1994)
based discrimination

Prohibition of Child Marriage Prevents early marriage and teenage

Act, 2006 pregnancy

POSCO Act (2012) Protects adolescents from sexual abuse

6. Nurse’s Role in Protecting Adolescent FP Rights
• Provide non-judgmental counseling
• Ensure confidentiality and privacy
• Promote awareness and education about contraceptive options
• Respect adolescent's right to autonomy
• Refer to youth-friendly clinics when needed
• Advocate for gender equity and empowerment
7. Strategies to Improve FP Access for Adolescents
• Establish adolescent-friendly health clinics (AFHCs)
• Integrate sexuality education in schools
• Train providers in youth-sensitive communication
• Use peer educators and digital platforms
• Remove barriers to access (e.g., mandatory parental consent)
8. Diagram/Table Suggestions
• Table of adolescent reproductive rights
• Flowchart: Rights-based approach in adolescent FP services
• Pyramid: Levels of adolescent FP care (Awareness → Access → Support)
9. Possible Outcome Questions
Two Marks
1. Mention any two human rights related to family planning for adolescents.
2. Name any two legal acts that support adolescent reproductive rights in
India.

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Five Marks
1. Write five challenges faced by adolescents in accessing FP services.
2. Describe the role of a nurse in protecting adolescent reproductive rights.
Ten Marks
1. Discuss the human rights-based approach to family planning for
adolescents.
2. Explain the barriers and solutions to providing FP services for
adolescents in India.
Youth-Friendly Services – SRHR Services, Policies, and Provider Attitudes
(Review)
1. Introduction
• Youth-Friendly Services (YFS) are health services designed to be
accessible, acceptable, equitable, appropriate, and effective for young
people (aged 10–24 years).
• These services support Sexual and Reproductive Health and Rights
(SRHR) of adolescents and youth, helping them make informed
decisions about their health.
2. What is SRHR?
• Sexual and Reproductive Health and Rights (SRHR) include:
o Right to make decisions about one’s own body and sexuality
o Access to family planning
o Prevention and treatment of STIs including HIV
o Maternal health care (antenatal, delivery, postnatal)
o Menstrual health management
o Safe abortion (where legal)
3. Characteristics of Youth-Friendly SRHR Services
Features Description

Accessible Services are affordable, available at convenient times/locations

Acceptable Respectful, confidential, and non-judgmental environment

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Features Description

Equitable Available to all youth, regardless of gender, caste, or background

Appropriate Culturally relevant, meets specific youth needs

Effective Based on evidence and provided by trained staff

4. SRHR Services for Youth – What They Include
• Family planning counseling and services
• Information and education on safe sex, puberty, and menstruation
• Prevention and treatment of sexually transmitted infections (STIs)
• HIV testing and counseling
• Safe abortion (where legal) and post-abortion care
• Mental health and gender-based violence (GBV) support
• Pre-marital and post-marital reproductive education
5. National and Global Policies Supporting SRHR for Youth
Policy/Program Relevance

Rashtriya Kishor Swasthya India’s adolescent health program –

Karyakram (RKSK) includes FP, nutrition, mental health

Focus on informed choice, delaying age at

National Population Policy (2000)
marriage

Adolescent Reproductive and Strengthens adolescent-friendly clinics in

Sexual Health (ARSH) India

ICPD (1994) Declares SRHR as a basic human right

Ensure universal access to SRH services

SDG 3.7
by 2030
6. Barriers Faced by Youth in Accessing SRHR Services
• Lack of awareness and education
• Stigma and fear of judgment by providers
• Gender inequality and social norms

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• Lack of privacy or confidentiality

• Poor availability of youth-friendly facilities in rural/underserved areas
7. Attitude of Nurses and Midwives in Providing Youth-Friendly Services
Positive Attitudes Negative Attitudes

Non-judgmental and empathetic Judgmental or moralistic views on

communication premarital sex

Ensuring privacy and confidentiality Breaching confidentiality

Supporting adolescent autonomy and Forcing decisions based on provider

choice beliefs

Youth-tailored counseling and

Inadequate knowledge or training
education
8. Importance of Provider Sensitization and Training
• Nurses and midwives must be trained to:
o Respect adolescents’ rights
o Provide accurate, age-appropriate information
o Avoid personal bias or cultural judgment
o Ensure confidentiality and trust
o Handle sensitive topics like contraception, STIs, menstruation, etc.
9. Nurse's Role in Youth SRHR Services
• Create a safe space for open conversation
• Build rapport and trust with adolescent clients
• Educate on reproductive health and rights
• Encourage parental involvement, if appropriate
• Refer to specialized services if needed (mental health, legal aid)
10. Diagram/Table Suggestions
• Table: Components of SRHR services for youth
• Venn diagram: Overlap of Youth-Friendly Services and SRHR
• Flowchart: Steps for youth-centered SRH counseling
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11. Possible Outcome Questions

Two Marks
1. Mention any two SRHR services for youth.
2. List two qualities of youth-friendly health services.
Five Marks
1. Describe the barriers faced by adolescents in accessing SRHR services.
2. Explain the role of nurses in providing youth-friendly SRHR services.
Ten Marks
1. Discuss youth-friendly health services and the role of nurses/midwives in
promoting SRHR among adolescents.
2. Review the impact of health policies on adolescent SRHR services in
India.
Importance of Follow-Up and Recommended Timing in Postnatal Care
1. Introduction
• Follow-up care is a critical part of comprehensive postnatal care.
• It ensures the physical and emotional recovery of the mother, promotes
healthy infant development, and provides an opportunity to identify and
manage complications early.
2. Importance of Postnatal Follow-Up
Aspect Importance

Monitor uterine involution, lochia, blood pressure,

Maternal health
perineal healing

Ensure feeding adequacy, monitor jaundice, weight

Newborn health
gain, screening

Early identification of baby blues or postpartum

Emotional well-being
depression

Assess for issues like nipple soreness, mastitis, or poor

Breastfeeding support
latching

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Aspect Importance

Contraceptive Discuss family planning options suitable for the

counseling mother

Teach about hygiene, diet, newborn care, and warning

Health education
signs
3. Recommended Timing of Follow-Up Visits (As per WHO & MoHFW
India)
Timing of Visit Purpose of Visit

Immediate postnatal assessment of both mother and

Within 24 hours
newborn

Day 3 (48–72 Check for bleeding, infection, feeding problems, early signs
hours) of neonatal jaundice

Monitor maternal healing, newborn weight gain, feeding

Day 7–14
adequacy

6 weeks Final physical checkup, mental health screening, family

postpartum planning advice
4. Maternal Assessments During Follow-Up
• Vital signs (BP, temperature, pulse, RR)
• Uterine involution and lochia
• Breast condition (engorgement, nipple condition)
• Perineal/wound healing
• Signs of infection
• Bladder and bowel function
• Emotional and mental health evaluati
5. Newborn Assessments During Follow-Up
• Weight gain and growth tracking
• Jaundice, cord healing
• Breastfeeding/latching effectiveness
• Reflexes and developmental milestones
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• Immunization status
• Screening for congenital anomalies (if not done
6. Nurse’s Role in Follow-Up Care
• Schedule and remind about follow-up visits
• Conduct thorough postnatal assessments
• Provide emotional support and postpartum education
• Identify any danger signs in mother or newborn
• Offer counseling on nutrition, hygiene, contraception
• Refer to specialists if needed (psychiatrist, pediatrician, gynecologist)
7. Tools Used in Follow-Up
• Mother and child protection (MCP) card
• Postnatal care checklist
• Growth monitoring chart for newborn
• BP apparatus, thermometer, weighing scale
8. Possible Complications Detected During Follow-Up
• Postpartum hemorrhage
• Puerperal infection
• Mastitis or breast abscess
• Delayed uterine involution
• Postpartum depression
• Neonatal jaundice or sepsis
9. Diagram/Table Suggestions
• Timeline chart of recommended postnatal visits
• Table: Comparison of maternal and newborn assessments
• Checklist of postpartum danger signs to assess during follow-up
10. Possible Outcome Questions
Two Marks

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1. When should the first postnatal follow-up visit be done?

2. Mention any two maternal assessments done during follow-up.
Five Marks
1. Explain the importance of follow-up visits in the postnatal period.
2. Write a note on maternal and newborn assessments during the 6-week
follow-up.
Ten Marks
1. Discuss the importance of follow-up care in the postnatal period along
with recommended timing and nurse’s role.
Gender-Related Issues in Sexual and Reproductive Health (SRH)
Gender-Based Violence (GBV): Physical, Sexual Abuse, Laws, and Role of
Nurse/Midwife
1. Introduction to Gender and SRH
• Gender refers to socially constructed roles and behaviors considered
appropriate for men and women.
• Sexual and Reproductive Health (SRH) is heavily influenced by gender
norms, roles, and inequality.
• Women and girls often face limited access to SRH services due to
gender discrimination, violence, and lack of autonomy.
2. What is Gender-Based Violence (GBV)?
• GBV is any harmful act directed at individuals based on their gender.
• It includes physical, sexual, psychological, and economic abuse, often
resulting from power imbalance and gender inequality.
3. Types of Gender-Based Violence in SRH Context
Type of GBV Examples

Beating, slapping, kicking, pushing during pregnancy or

Physical violence
labor

Sexual violence Rape, coerced sex, denial of contraception, marital rape

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Type of GBV Examples

Psychological
Threats, humiliation, isolation from family/friends
abuse

Controlling finances, denial of basic needs like nutrition or

Economic abuse
medical care

Female genital mutilation (FGM), child marriage, honor

Harmful practices
killings
4. Impact of GBV on SRH
• Physical effects: Injury, chronic pain, STIs including HIV, unplanned
pregnancy
• Reproductive health issues: Unsafe abortion, pregnancy complications,
miscarriage
• Mental health impact: Depression, anxiety, PTSD, suicidal thoughts
• Obstetric complications: Preterm labor, low birth weight, stillbirth
5. Laws and Policies Addressing GBV in India
Law/Act Purpose

Protection of Women from

Legal protection from domestic violence
Domestic Violence Act (PWDVA),
(physical, sexual, emotional, economic)
2005

Indian Penal Code Sections (375,

Deals with sexual assault and rape
376, etc.)

The Criminal Law (Amendment) Expands definition of sexual violence,

Act, 2013 (Nirbhaya Act) ensures stricter punishment

POSCO Act, 2012 Protects children from sexual offences

Allows abortion in cases of sexual

Medical Termination of Pregnancy
assault, rape, or risk to mental/physical
(MTP) Act
health

The Sexual Harassment of Women Protection of women in formal/informal

at Workplace Act, 2013 workspaces

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6. Role of Nurse and Midwife in GBV Prevention and Care

A. Identification and Screening
• Screen clients sensitively and confidentially for signs of abuse
• Use standardized tools or questionnaires for screening (e.g., HITS tool)
• Look for physical injuries, fearfulness, inconsistent stories
B. Provide Immediate Care and Support
• Offer first aid and manage injuries
• Provide emergency contraception or STI treatment if needed
• Refer for psychological counseling or mental health support
• Ensure privacy and non-judgmental environment
C. Legal and Reporting Responsibilities
• Inform survivor about legal rights and available services
• Report cases as per institutional and legal protocols
• Help in filling medico-legal forms (MLR) if required
• Assist in forensic evidence collection (if trained and applicable)
D. Advocacy and Education
• Educate patients and families about women’s rights and gender
equality
• Participate in community awareness programs
• Advocate for safe spaces in health facilities for women and girls
7. Nurse’s Responsibilities in GBV Care Pathway
Stage Action

Assessment Gentle questioning, privacy, empathetic communication

Care & Support Medical care, emotional support, documentation

Referral To counselors, shelter homes, legal aid centers

Follow-Up Ensure continued care and check for safety of the client

Documentation Accurate, confidential, non-biased notes with client consent

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8. Diagram/Table Suggestions
• Flowchart: GBV Screening to Referral Process
• Table: Comparison of various laws protecting women against GBV
• Venn diagram: Overlap between gender issues and SRH outcomes
9. Possible Outcome Questions
Two Marks
1. Define gender-based violence.
2. Mention any two laws that protect women from violence.
Five Marks
1. List the types of gender-based violence and explain their impact on SRH.
2. Describe the role of a nurse/midwife in handling GBV cases.
Ten Marks
1. Discuss gender-based violence in the context of SRH and explain the role
of a nurse in managing such cases.
2. Describe legal provisions in India for GBV and how a nurse contributes
to their implementation.
Special Courts for Abused People
1. Introduction
• Survivors of gender-based violence (GBV) and sexual abuse often face
challenges in accessing justice due to delays, insensitive handling, and
lack of privacy in regular courts.
• Special courts have been established to provide speedy, sensitive, and
victim-friendly legal redress for abused individuals, particularly women
and children
2. Purpose of Special Courts
• To ensure justice without delay in cases of sexual assault, child abuse,
domestic violence, and other gender-based crimes.
• To protect the rights and dignity of survivors throughout the legal
process.
• To ensure privacy and confidentiality during trials.

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3. Types of Special Courts in India

Special Court Key Focus

Deals exclusively with cases under Protection of

POCSO Courts
Children from Sexual Offences Act, 2012

Fast Track Special Established for speedy trial of rape and sexual
Courts (FTSCs) assault cases

Handle cases related to domestic violence, custody,

Family Courts
divorce, etc.

Mahila (Women’s) Focus on crimes against women, including

Courts harassment, assault, dowry

Juvenile Justice Handle offenses committed by juveniles, including

Boards victims under age 18
4. Legal Provisions for Special Courts
• Protection of Children from Sexual Offences (POCSO) Act, 2012:
o Mandates creation of exclusive POCSO courts in every district.
o Trials must be child-friendly, completed within 1 year.
• Criminal Law (Amendment) Act, 2013 (Nirbhaya Act):
o Establishes Fast Track Courts to address crimes against women.
o Trials to be completed in 2 months for certain offenses.
• Domestic Violence Act, 2005:
o Provides for Magistrate Courts to handle domestic violence
complaints.
o Includes Protection Officers to support survivors in court.
5. Features of Special Courts
• In-camera proceedings (closed to the public)
• Use of video conferencing if survivor is unable to attend physically
• Presence of trained counselors/social workers
• Victim support desks in court premises

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• Protection from intimidation or re-traumatization

• Time-bound trials for swift justice
6. Role of Nurse/Midwife in Supporting Survivors in Special Courts
• Legal documentation: Accurate and detailed recording of injuries and
findings (Medico-legal reports – MLR)
• Health certificate and testimony: May be called to testify in court
• Support and referral: Guide the survivor to legal aid, counselors, shelter
homes
• Education and empowerment: Inform women about their legal rights
and available services
• Maintaining confidentiality and respect
7. Challenges in Implementation
• Lack of adequate number of special courts in rural areas
• Delays due to high case loads despite “fast-track” status
• Need for sensitization training for police and judiciary
• Limited awareness among survivors about these courts
8. Diagram/Table Suggestions
• Table: Types of special courts and their jurisdiction
• Flowchart: Legal process from complaint to trial in special courts
• Timeline: Expected duration for trials in fast-track courts
9. Possible Outcome Questions
Two Marks
1. Name any one act that mandates the establishment of special courts.
2. What is the full form of POCSO?
Five Marks
1. Describe the purpose and features of POCSO special courts.
2. Explain the role of nurses/midwives in supporting GBV survivors in legal
proceedings.
Ten Marks
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1. Discuss the importance of special courts for GBV survivors. Describe

types of special courts and the legal provisions under which they operate.
Gender-Sensitive Health Services Including Family Planning
1. Introduction to Gender-Sensitive Health Services
• Gender-sensitive health services recognize and address the different
health needs of individuals based on their gender roles, social
expectations, and biological differences.
• It ensures equity in health care access, delivery, and outcomes, especially
for women and marginalized genders.
2. Principles of Gender-Sensitive Health Services
• Respect for gender diversity (male, female, transgender, non-binary)
• Equality in access and care regardless of gender
• Non-judgmental and confidential environment
• Empowerment of women and girls to make informed health decisions
• Inclusion of men and boys in reproductive and sexual health education
3. Components of Gender-Sensitive Services
Area Examples

Infrastructure Separate waiting areas, toilets for all genders

Staff training Sensitization to gender bias, respectful communication

Ensuring confidentiality, use of curtains/screens during

Privacy and dignity
procedures

Information
Culturally appropriate, gender-inclusive content
materials

Health records Gender options beyond male/female

Feedback Complaint boxes, exit interviews with gender-sensitive

mechanism questions
4. Gender Sensitivity in Family Planning (FP)
• Recognizes that men and women have different needs, roles, and
responsibilities in FP.

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• Empowers both partners to make informed reproductive choices.

• Prevents coercion and ensures voluntary acceptance of FP methods.
5. Key Gender-Sensitive Approaches in FP
Approach Description

Couple counseling Encouraging joint decision-making in FP

Educating and involving men in contraception and

Inclusion of men
reproductive responsibilities

Youth-friendly
Tailored counseling for adolescent boys and girls
services

Choice and consent Providing full range of options with informed consent

Respect for cultural Sensitivity to religious or cultural beliefs while

context promoting best practices
6. Barriers to Gender-Sensitive Services
• Cultural norms and gender stereotypes
• Lack of trained and sensitive health staff
• Limited access to services in rural/remote areas
• Fear of stigma or discrimination (especially for LGBTQ+ individuals
7. Role of Nurse/Midwife in Gender-Sensitive Care
• Assessment: Recognize gender-specific health needs
• Communication: Use respectful, inclusive, and non-biased language
• Counseling: Provide equitable, individualized information on FP and
SRH
• Advocacy: Promote policy changes and community awareness on gender
equity
• Referral and coordination: Link clients to social/legal support services
when needed
8. Government and WHO Recommendations
• MoHFW (India) promotes:

Shaping the Future of Indian Healthcare Bright medico 548 | Page

 Trusted Medical Related Course Notes & Study Material at [Link]

o ASHA-led family planning counseling

o Distribution of contraceptives in rural areas
o Focused interventions for adolescents and newly married couples
• WHO recommends:
o Gender equity in FP program design
o Inclusion of men and boys in SRH strategies
o Rights-based approach to contraception
9. Diagram/Table Suggestions
• Table: Gender-sensitive features vs Traditional health services
• Flowchart: Gender-sensitive FP counseling steps
• Pie chart: Unmet need for contraception among women by gender-related
barriers
10. Possible Outcome Questions
Two Marks
1. Define gender-sensitive health services.
2. Mention one gender-sensitive feature in family planning services.
Five Marks
1. Write a short note on gender sensitivity in family planning.
2. Describe the role of a nurse in providing gender-sensitive reproductive
health care.
Ten Marks
1. Discuss gender-sensitive health services with a special focus on family
planning.
2. Explain how gender-related barriers affect access to SRH services and
how health workers can address them.

Shaping the Future of Indian Healthcare Bright medico 549 | Page