LYCEUM-NORTHWESTERN UNIVERSITY

Dagupan City, Pangasinan

COLLEGE OF NURSING

CARE OF MOTHER, CHILD AND ADOLESCENT (WELL CLIENTS)- NCM 107

Study Guide
Related Learning Experience
I. Overview

This guide focuses the unitive and procreative health. It provides procedures to
help in maintaining good reproductive health and ensures better chances of survival during
pregnancy and taking care of the child. Moreover, you will learn how important nursing care
in terms of mother and child safety.

II. Module Learning Outcomes

After completing this study guide, you will be able to:

1. Integrate concepts, theories and principles of sciences and humanities in the formulation and
application of appropriate nursing care during childbearing and childrearing years.
2. Apply maternal and child nursing concept and principles holistically and comprehensively.
3. Identify 2020 National Health Goals as an important guide to understanding the health of the
nation and goals that nurses can help the nation achieve.
4. Describe the professional roles of nurses in maternal and child health nursing.
5. Use critical thinking to identify areas of nursing care that could benefit from application of
evidence-based practice.
6. Assess mother’s health status with the use of specific methods and tools to address existing
health needs.
7. Assess mother and child’s health status with the use of specific methods and tools to address
existing health needs
8. Assess mother and child’s health status with the use of specific methods and tools to address
existing health needs.
9. Adhere to ethico-moral considerations when providing safe, and quality maternal and child
nursing care based on the Philippine Nursing Law and other legal, regulatory and institutional
requirements.
10. Protect maternal and child rights based on “Patient’s Bill of Rights and Obligations”
11. Formulate nursing diagnosis/es focusing on health promotion and disease prevention related
to mother’s health.
12. Plan and implement safe and quality nursing interventions addressing health needs affecting
women during pregnancy.
13. Conduct individual/group/health education activities based on the priority learning needs of
other.
14. Evaluate with the client the health outcomes of nurse-client working relationship.
15. Institute appropriate corrective actions to prevent or minimize harm arising from adverse
effects.
16. Manage resources (human, physical, financial, time) efficiently and effectively).
17. Use appropriate technology to support the delivery of care to the mother.
18. Adhere to protocols and principles of confidentiality in safekeeping and releasing of records
and other information.
19. Collaborate client care as a member of a health care team in the implementation of programs
and services for mothers.
20. Ensure a working relationship with individual and family based on trust, respect and shared
decision-making using appropriate communication/interpersonal techniques/strategies.

III. Key Concepts

1. Framework for Maternal and Child Health Nursing

2. Reproductive and Sexual Health
Page 1 of 49
 3. Nursing Care of the Mother and the Fetus during Prenatal Period
4. Nursing Care of Mother and the Fetus during Intrapartum Period
5. Nursing Care of Mother and the Fetus during Postpartum Period

IV. Content/ Lectures/ Readings/ Learning Resources

Week 1
Lesson 1: Assessment
Components of Health History
Lesson 2: EDC (Expected Dated of Confinement)
[Link]

Lesson 3: AOG Age of Gestation Computation

Week 2
Lesson 4: Breast Care
Lesson 5: Leopold’s Maneuver
[Link]
Chapter 15
Week 3
Lesson 6: Fetal Heart Tone Monitoring
[Link]
Lesson 7: Pelvic size
[Link]
Lesson 8: Laboratory Assessment

Lesson 9: Monitoring progress of Labor

[Link]
Lesson 10: Catheterization
[Link]
[Link]

Week 4
Lesson 11: Assisting and Handling Normal Delivery
[Link]
Lesson 12: Crede’s Maneuver/ Ritgen’s Maneuver
[Link]
Lesson 13: Episiorrhapy Care
Lesson 14: Perineal Care
[Link]

Week 5
Lesson 15: Post partal Evaluation
Lesson 16: Identifying Lochias
Lesson 17: Newborn Care

Week 6
Lesson 18: APGAR Scoring
Lesson 19: Breastfeeding
[Link]
[Link]

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 Lesson
1
Assessment
Piggyb
ack
Components of Health History
Intrave
nous
1. Demographic data (name, age, address, gender, marital status, educational level, occupation,
Oxytoci
religion and health insurance information)
n
2. Chief concern: is the reason why a woman visits the health care setting. This is related to
Admini
thestratio
fact that she is or thinks she is pregnant.
3. Presentn health history

4. Past health history: woman’s past medical history including diseases that may cause
potential difficulty during pregnancy (e.g. heart disease, hypertension, diabetes, kidney
disease, thyroid disease, urinary tract infection, varicosities, tuberculosis, asthma, STIs
including Hepatitis B and C, herpes and HIV, childhood diseases and immunizations)

5. Family health history: illnesses that occur among woman’s relatives (hereditary diseases
like cardiovascular and renal disease, blood disorders cognitive impairment and congenital
anomalies or diseases inherited genetically)
6. Gynecologic history:
A. Menstrual history: age of menarche, length of menstrual cycle, duration and amount of
menstrual flow, any accompanying discomforts and menstrual pain.

 Menarche: is the first menstrual period

 Menopause: cessation of menstrual cycles
 Amenorrhea: absence of menstruation
 Dysmenorrhea: painful menstruation
 Menorrhagia: abnormally heavy menstrual flows
 Metrorrhagia: bleeding between menstrual periods
 Oligomenorrhea: scanty or very light menstruation

B. Perineal and Breast Self-Examination

 Perineal self-examination: inspecting the external genitalia monthly for
signs of infection or lesions
 Breast self-examination: monthly self-care routine

C. Past surgery: involves previous surgery on the reproductive tract which may
influence the ability of a woman to conceive and give birth

D. Reproductive planning

E. Sexual history
**Note: Abdominal examination is included

7. Obstetric history: includes previous pregnancy (when? type of delivery? outcome of birth?),
previous miscarriage or therapeutic abortions.

Classifying pregnancy status (OB Score)

GTPAL or GTPALM: provides information on woman’s history of pregnancy

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G: the number of times a woman has been pregnant, including the present pregnancy (Gravida
status)

P: the number of children over the age of viability that a woman has previously delivered (Para
status)

T: the number of full-term infants born at 37 weeks or after

P: the number of preterm infants born before 37 weeks

A: the number of spontaneous miscarriage or abortion

L: the number of living children

Definition of terms related to pregnancy:

Term Definition

Para Number of pregnancies that have reached viability, regardless of whether

the infants were born alive.

Gravida Woman who is or has been pregnant.

Primigravida Woman who is pregnant for the first time.

Primipara Woman who has given birth to one child past age of viability.

Multigravida Woman who has been pregnant previously.

Multipara Woman who has carried two or more pregnancies to viability.

Nulligravida Woman who has never been and is not currently pregnant.

Viability The ability of the fetus to survive in extra-uterine condition (20 weeks
gestation)
 Age of fetus ≥ 20-24 weeks
 Weighs at least 500g
 Length ≥ 18cm
Term pregnancy A pregnancy of 38 – 42 weeks

Preterm pregnancy It occurs before the end of 37 weeks of gestation

Postterm pregnancy A pregnancy that exceeds from 42 weeks

(Postmature or
postdate)
Datism
Abortion is the medical term for any interruption of pregnancy before a fetus is
viable

Miscarriage Early: Termination of pregnancy before 16th week

Late: Termination of pregnancy between 16th -24th weeks

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Naegele’s is a method used for calculating the estimated Expected Date of Delivery/Expected
Date of Confinement (EDD/EDC) based on Last Menstrual Period (LMP)

8. Psychosocial aspect- social support system

9. Laboratory result (CBC, Blood group and RH Factor, HCG, urinalysis, ultrasound)

10. Current medication or treatment

11. Functional health history/History of daily activity: information regarding

woman’s current nutrition, elimination, sleep, activity or exercise, personal habits, lifestyle,
recreation, and interpersonal interactions

12. Physical examination

A. Assessment of Body Systems
B. Height/Weight and Vital Signs:

Calculation of Body Mass Index:

BMI (Body Mass Index) = (weight per kg) / (Height per meter) ²

TOTAL WEIGHT GAIN DURING PREGNANCY (Body Mass Index – BMI)

*Institute of medicine (IOM) and National Research Council (NRC), 2009
(weight per kg/Height per meter2) Range of Total Weight Gain (lb) Single
Fetus
Underweight: BMI is less than 18.5 28-40
Normal weight: BMI is 18.5 to 24.9 25-25
Overweight: BMI is 25 to 29.9 15-25
Obese: BMI is 30 or more 11-20

Note:

Weight gain during 1st trimester: 0.8kg (1.5 lbs) per month ; 0.4 kg (1 lb) per week during the
last two trimesters (minimum weight gain 4.5 lbs, 12 lbs and 12 lbs for the trimester)

Normal weight gain during pregnancy is 11.3-15.8 kg (25 – 35 lbs)

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 Lesson
2 EDC (Expected Dated of Confinement)

Example: Mrs Vila visits

her physician today
because of uncomfortable
feelings like morning
discomfort and body malaise.
The Nurse took vital signs and
asked her some question:

Nurse: When was your last

menstrual period?
Mrs Vila: April 11, 2021.

Compute for the EDC.

Example: A patient was rushed in the emergency

room complaining of minimal vaginal bleeding and
she stated that she is pregnant. As interviewed her
LMP is January 6, 2021. Compute for the EDC.

Example: LMP- August 14, 2021

LMP- March 27, 2021
LMP- December 25, 2020

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 Lesson
3 AOG Age of Gestation Computation

Abdominal examination

General Guidelines:
 Empty bladder
 Measure fundal height (measure growth of fetus)
 Provide privacy
 Use inspection and palpation
 Documentation

Inspection:
Inspect the woman’s abdomen for its shape. This can indicate fetal size and lie, the amount
of amniotic fluid and sometimes fetal movement may be noticed. Obvious scars will be seen
and this information may be significant

Gestational age Fundal height

40 weeks 1-2 finger widths below subcostal arch

(Normally, due to settling of the fetus into the midpelvis, known as
Lightening)
36 weeks Usually touches the xiphoid process

32 weeks Between umbilicus and xiphoid process

28 weeks 3 finger widths above umbilicus

24 weeks Just above the level of umbilicus

20 or 22 weeks At the level of umbilicus

16 weeks Between symphysis pubis and umbilicus

12 weeks Just above the symphysis pubis

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 Bartholomew’s Rule

Estimating Gestational Age from Fundal Height Measurement

Description:
Fundal height is measured in centimeters from the pubic symphysis to the top most
portion of the uterus

Purpose: To determine if the baby is growing normally at each stage of the pregnancy.
Normally, the height of the uterus will match the gestational age

How to measure fundal height

 Place a tape measure on the mother’s abdomen, holding the 0 (zero) part of the measuring
tape at the top of the pubic bone
 Follow the curve of her abdomen, and hold the tape measure at the top of her uterus
(Fundus feels like firm, circular or rounded regular)
 Write down the number of centimeters (cm) from the top of the pubic bone to the top of the
uterus.

McDonald’s Rule:

Fundal height (cm) X 8/7 = AOG in weeks

Fundal height (cm) X 2/7 = AOG in months

Manual computation Age of Gestation- LMP: January 8, 2021

Clinic visit: September 6, 2021

Jan 23
Feb 28
Mar 31
Apr 30
May 31
Jun 30
Jul 31
Aug 31
Sep 7
181 days
181/ 7= 25.85(calculator)
181/7= 25 weeks and 7 days ( manual division)

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 Lesson Breast Care
4

Breast examination

General Guidelines:
 Perform hand hygiene
 Prepare necessary supplies/ materials needed.

 Explain the procedure to the client.

 Provide optimal privacy

 Use inspection and palpation

 The patient should be undressed from her waist up with arms at her sides.
 Maintain a warm and relaxing environment, with good lighting

 Documentation

General Appearance:

1. Inspect for the breasts, areolas and nipples.

Breasts:

Assess for the

 Size and symmetry

 Characteristics of the skin (color, thickening, peau d’orange, edema, superficial
venous pattern of the breasts)
 Presence of dimpling, nipple or skin puckering

Observe the breasts while woman’s hands are over her head and presses her hands on her hips.
Normally, the breasts hang evenly.

Breast asymmetry involves having a breast with a different shape or size than the other. Screening
of breast cancer or mammogram may indicate asymmetrical size or density of the breast.

(Note: it is common to have a slight asymmetry in size; usually the left breast is slightly
smaller than the right breast)

Areolas

 Observe the size, shape, symmetry, color and lesions

Nipples

 Note the symmetry, size, shape, appearance and direction to which the nipples point
(protruded, flat or inverted), presence of any rashes or sores and nipple discharge or
bleeding

2. Palpate for the breasts.

Assist the client in supine position
Rationale: This position will flatten the breast tissue and displace it medially

Put pillow under the side of the breasts to be palpated and raise her arm over her head.
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Palpate the entire breast using the first three finger pads, in a gentle circular motion. Note for any
masses or lumps (location, size, shape, consistency, tenderness and mobility) or presence of
tenderness, swelling, and increase in warmth

Note: Patterns of palpation can be vertical strip, spokes-on-a-wheel or concentric circles.

Gently squeeze the nipple. Check for any induration or subareolar mass. Using the thumb and
forefinger, gently depress the nipple tissue into the wall behind the areola. Note for any discharge

Note: Milky discharge may be due to hypothyroidism, prolactinoma, drugs.

Bloody discharge may be due to papilloma, Paget’s disease

3. Inspect and palpate for the axillae

Inspect the skin for rashes and any signs of infection.
The patient’s forearm is rested across the examiner’s forearm.
(An alternative is to ask the patient to rest their hand on the examiner’s shoulder)
Rationale: The patient’s muscles are loose and relaxed

4. Palpate for the left axilla using your right hand and reaching your fingers high into the axilla.
Anterior (posterior surface of anterior axillary fold)
Medial (on the chest wall)
Lateral (against the humerus)
Posterior (anterior surface of posterior axillary fold)
Note for the texture: smooth without edema
5. Palpate for the right axilla using your left hand and reaching your fingers high into the axilla.

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 Lesson
5 Abdominal Assessment

Leopold’s Maneuver

Leopold’s Maneuvers are a systematic method of observation and palpation to determine fetal
position, presentation, lie and attitude. The maneuvers are important because they help determine
the position and presentation of the fetus, which in conjunction with correct assessment of the
shape of the maternal pelvis can indicate whether the delivery is going to be complicated, or
whether a Cesarean section is necessary.

Keen observation of abdomen should give data about:

1. Longest diameter in appearance (longest diameter (axis) is the length of the fetus)
2. Location of apparent fetal movement (the location of the activity most likely reflects the
position of the feet)

PREPARATION

1. CARDINAL RULE: instruct woman to empty bladder first. This will promote
comfort and allows for more productive palpation because fetal contour will not be
obscured by a distended bladder.
2. Place woman in dorsal recumbent position, supine knee flexed to relax
abdominal muscles. Place a small pillow under the head for comfort.
3. Drape properly to maintain privacy.
4. Explain procedures to gain patient’s cooperation
5. Warm hands first by rubbing them together before placing them over the woman’s
abdomen to aid comfort. Cold hands may stimulate uterine contractions.
6. Use the palm for palpation, not fingers.
7. During the first three maneuvers, stand facing the patients. For the last
maneuver, stand facing the patient’s feet

FIRST MANEUVER:

Fundal Grip: what fetal pole or part occupies the fundus?

 Palpation of the fundal area to determine which fetal part is in the uterine fundus
 To determine the presenting part of presentation (part of the fetus lying over the

Page 11 of 49
 inlet)

Procedures

1. Nurse stand at the side of the bed, facing the patient

2. Using both hands, feel for the fetal par lying in the fundus

Findings

The nurse-midwife should ascertain what is lying at the fundus by feeling the upper abdomen
(fundus) with tips of both hands. generally, she will find there is a mass, which will either be the
head or the buttocks (breech) of the fetus. The nurse-midwife must decide which pole of the fetus; it
is by observing three points:

 Relative consistency- the head is harder/firmer than the breech

 Shape- if the head, it will be round and hard, and the transverse groove of the
neck may be felt. The breech has no groove and usually feels more angular.
 Mobility- the head will move independently of the trunk; but the breech
moves only in conjunction with the body.

If the nurse-midwife feels the head, the fetus is in breech presentation; if the nurse-midwife
feels the buttocks, it means the fetus is in vertex presentation.

SECOND MANEUVER: Umbilical Grip: Which side is the fetal back?

To locate/identify the fetal back in relation to the right and left sides of the mother
To determine the fetal position (the relationship of the presenting part to one of the
quadrants of the mother’s pelvis)

Procedures
1. The nurse-midwife places the palmar surfaces of both hands on either side of the abdomen
2. With left palm stationary on the left side of the abdomen to steady the uterus, the right
palpates the right side of the uterus on a circular motion from top to lower segment of the
uterus applying gentle but deep pressure to palpate the fetal outline and small fetal parts
3. The nurse-midwife the reverses her hands

Findings
Small fetal parts (knee and elbows) feel nodular with numerous angular nodulations.
Fetal back feels smooth, hard, like a resistant surface

THIRD MANEUVER: Pawlik’s Grip: What fetal part lies above the pelvic inlet?

 Determine if the presenting part has entered the pelvis (engagement of presenting
part)
 To find the head at the pelvis and to determine the mobility of the presenting part

Procedures
1. The nurse-midwife stands at the side of the bed, facing the patient
2. It should be conducted by gently grasping the lower portion of the abdomen, just above
the symphysis pubis, between the thumb and the two fingers of one hand and then
pressing together slightly and make gentle movements from side to side

Findings
If the presenting part moves, round, ballotable and easily displaces it is not yet engaged. If
the presenting part not movable felts as relatively fixed, knoblike part, it is engaged.
If it is firm, it must be the head. If soft, it could be breech

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FOURTH MANEUVER: Pelvic Grip: Which side is the cephalic prominence?

Cephalic prominence is a part of the fetal head that prevents the deep descent with one
hand
To determines the degree of fetal head flexion or extension
To determine the attitude or habitus (degree of flexion of the fetal body, head and
extremities, or the relationship of fetal parts to each other)
To determine the fetal descent
Should only be done if fetus is in cephalic presentation. Information about the infant’s
anteroposterior position may also be gained from this final maneuver

Procedures
1. The nurse-midwife faces the feet of the patient
2. Place one hand each on either side of the lower pole of the uterus
3. Palpate the fetal head by pressing downward about 2 inches above the inguinal ligament
4. Use both hands

Findings
If descended deeply, only a small portion of the fetal head will be palpated.
If cephalic prominence or brow or the baby is on the same side of the small fetal parts, the
head is flexed.
If the cephalic prominence is on the same side of the fetal back, the head is extended.

Things needed:

Tape measure
Blanket (to provide privacy)
Stethoscope
Clipboard (documentation

Leopold’s Maneuver Rationale

Preparation To relieve the patient’s anxiety and enhance
1. Explain the procedure and instruct the cooperation. To promote comfort and allows for
mother to void to empty her bladder. more productive palpation because fetal contour
will not be obscured by distended bladder.
2. Wash your hands using warm water. To aid comfort and cold hands may stimulate
Drape properly. uterine contraction. To provide privacy.

3. Position the client in a dorsal To relax abdominal muscles

recumbent position, supine with knees
slightly flexed.
Procedure
First maneuver: (Fundal grip)
1. Stand at the foot part of the client, To determine whether the fetal head or breech.
facing her and place hands above the When palpating, a head feels firmer than a breech.
abdomen just below the xyphoid A head is round and hard; the breech is less well
process. defined. A head moves independently of the body;
2. Gently move your hands downward the breech moves only in conjunction with the
and Page33 palpate the superior body.
surface of the fundus

Second maneuver: (Umbilical grip)

1. Face the client, hold the left-hand To determine the location of the fetal back. One
stationary of the uterus while you palpate hand will feel a smooth, hard, resistant surface (the
with the right hand on the opposite side back), while on the opposite side, a number of

Page 13 of 49
of the uterus from top to bottom. Repeat angular nodulations (the knees and elbows of the
palpation using the opposite side. fetus) will be felt.

Third maneuver: (Pawlik’s grip)

1. Gently grasp the lower portion of the To determine if the presenting part has entered the
abdomen just above the symphysis pelvis (engagement of presenting part)
pubis between the thumb and fingers
and try to press the thumb and
fingers together.

2. Determine any movement and If the presenting part moves, round, ballotable and
whether the part feels firm or soft. easily displaces it is not yet engaged. If the
presenting part not movable felts as relatively fixed,
knoblike part, it is engaged.

If it is firm, it must be the head. If soft, it could be

breech.

Fourth maneuver: (Pelvic grip)

1. Place fingers on both sides of the To determines the degree of fetal head flexion or
uterus approximately 2 inches about extension.
the inguinal pressing downwards and
inward in the direction of the birth
canal.

2. Allow the fingers to be carried To determine the attitude or habitus (degree of

downward to determine the fetal flexion of the fetal body, head and extremities, or
attitude and degree of fetal extension the relationship of fetal parts to each other).
into the pelvis.

To determine the fetal descent

Page 14 of 49
 Lesson
6 Fetal Heart Tone Monitoring

FETAL HEART TONE MONITORING

Fetal Heart Tone/Rate

 Fetal well-being or fetal health is best measured by evaluating fetal heart tones (FHT).

 A normal fetal heart tone (FHT) usually ranges from 120 to 160 beats per minute (bpm) in

the in utero period. Mild bradycardia is considered to be 100 to 119 BPM (beats per
minute). Marked bradycardia is considered as 99 or fewer BPM. Marked tachycardia is
considered to be 180 BPM or higher. This is only a guide; some authorities will use
different parameters for diagnosis; be familiar with what is used at your facility to diagnose
these conditions.

 This method of testing fetal well-being can be used commencing with the 18th to 20th

week of pregnancy. A fetoscope is used for counting the rate. In some cases, ultrasonic
equipment may be used to detect fetal heart tones, as early as the 10th week of gestation.
However, most nurses will use the standard fetoscope for heart tones.

When to check FHT

 Typically, FHT drops somewhat with the onset of uterine contraction but recovers promptly as the
contraction ends. Changes in FHT that are most likely to be ominous always are detectable
immediately after a contraction. It is therefore imperative to auscultate FHT immediately after a
contraction.

 Fetal distress is suspected if FHT immediately after a contraction is repeatedly below 120/minute
and fetal distress very likely exists if FHT is less than 100/minute even though there is recovery to
a normal rate before the next contraction.

Frequency of FHT Auscultation

 Normal labor, first stage: at least every 30 minutes, immediately after a contraction.

 High-risk pregnancy/labor: every 15 minutes in an acceptable alternative to continuous electronic

monitoring.

Page 15 of 49
 Procedure Rationale
[Link] use the Doppler:
 Place the ultrasonic gel on the diaphragm Gel is use to maintain contact with the maternal
 The diaphragm should be warmed prior to abdomen and enhances conduction of sound.
the using the Doppler
. Place the Doppler diaphragm on the You are most likely to hear the FHR in this area.
woman’s abdomen halfway between the
umbilicus and symphysis pubis and in the
midline. Listen carefully for the sound of
the heartbeat.
[Link] the woman’s pulse against the fetal If the rates are the same, you are probably
sounds you hearing the maternal pulse and not FHR.
hear. If the rates are the same, reposition the
Doppler
and try again.
3. If the rates are not similar, count the FHR Note that the FHR has a double rhythm and
for 1 full only one sound is counted.
minute.
4. If you do not locate the FHR, move the
Doppler laterally.
5. Auscultate the FHR between, during, and for This detects abnormal heart rate.
30 to 60 seconds following a uterine contraction
(UC).
1. Frequency recommendations: This evaluation provides the opportunity to
 Low risk women: Every 30 minutes assess the fetal status and response to labor.
during the first stage, and every 15
minutes in the second stage.
 High risk women: Every 15 minutes
during the first stage, and every 5
minutes in the second stage.
7. Documentation Document that the procedure was explained to
the woman and that she verbalized
understanding. The location of the FHR, FHR
baseline, changes in FHR that occur with
contractions, and presence of accelerations or
decelerations should be included. Other
characteristics should include variability,
maternal position, type of device used, uterine
activity, maternal pulse, and nursing
interventions that were performed.

8. To use fetoscope
 The bell should be warmed prior to
using the fetoscope.
Page 16 of 49
9. Place the fetoscope earpieces in your ears and
the device support against your forehead; use
the handpiece to position the bell of the
fetoscope on the mother’s abdomen.
10. Place the diaphragm halfway between the You are most likely hear the FHR in this area.
umbilicus and symphysis and in the midline.

11. Without touching the fetoscope, listen

carefully to the
FHR.
12. Frequency recommendations:
 Low risk women: Every 30 minutes during This evaluation provides the opportunity to
the first stage, and every 15 minutes in the assess the fetal status and response to labor.
second stage.
 High risk women: Every 15 minutes during
the first stage, and every 5 minutes in the
second stage.
13. Documentation Document that the procedure was explained to
the woman and that she verbalized
understanding. The location of the FHR, FHR
baseline, changes in FHR that occur with
contractions, and presence of accelerations or
decelerations should be included. Other
characteristics should include variability,
maternal position, type of device used, uterine
activity, maternal pulse, and nursing
interventions that were performed
14. To use Stethoscope
 Explain the procedure to the mother. Tell the mother that you will check the fetus by
listening to its heartbeat. Explain that frequent
check of the FHT is routine.

15. Perform the Leopold’s maneuvers. To detect the area of fetal back – best site for
locating the FHT.

16. With the bell of the stethoscope placed over

the area of fetal back, count FHT for 1 whole
minute.

17. Observe care in holding the stethoscope over Keep fingers odd bell. Make sure that friction
the mother’s abdomen. noises from the fingers or abdominal surface do
not distort the sounds.

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18. Differentiate FHT from other sounds:

 FHT: distinct in sound, resembling the ticking

of a watch
placed under a pillow; rapid with rate of 120-
160/minute. To check if it is really FHT and not maternal
 Maternal soufflé: from uterine arteries soufflé, carefully listen to the FHT using a well-
pulsation; functioning stethoscope and at the same check
described as soft, blowing with “sh” sound the the maternal pulse.
rate The identification of maternal soufflé does not
which resembles that of maternal pulse. guarantee fetal life.
 Funic Souffle or cord whistle: soft, whistling
sound The identification of funic soufflé indicates fetal
occurring at the same rate as the FHT. life.
 Maternal peristalsis may also be heard
because a woman
in labor is usually hungry.
19. Encourage the mother and father (if present To promote bonding between the fetus and the
during labor) to listen, too to the FHT. father, allow him to listen to the FHT.

20. Record accordingly.

21. Report abnormalities of FHT. a. Late Decelerations: FHT decreases where the
range of drop maybe within normal and the
decelerations occur after the onset of contraction
(usually after acme) and persists beyond
completion of contraction. This is an ominous
sign of fetal hypoxia caused by uteroplacental
insufficiency.

b. Variable Deceleration: FHT decreases at any

point during or between contractions where the
range of drop in FHT is large and extends below
normal. This is another ominous sign of
umbilical cord compression.  For both late
decelerations and variable decelerations, the
healthcare provider should act fast: repose the
mother to her left side, give oxygen and summon
the physician

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 Lesson
7 Pelvic size

Pelvic size

They largely based these pelvis types on the shape of the pelvic inlet, which is the upper area of the
pelvic cavity. During vaginal childbirth, the baby passes through the birth canal, which runs
through your pelvic cavity. The pelvic inlet is at beginning of the birth canal.

The four different pelvis shapes are:

 Gynecoid. This is the most common type of pelvis in females and is generally considered to
be the typical female pelvis. Its overall shape is round, shallow, and open.

 Android. This type of pelvis bears more resemblance to the male pelvis. It’s narrower than
the gynecoid pelvis and is shaped more like a heart or a wedge.

 Anthropoid. An anthropoid pelvis is narrow and deep. Its shape is similar to an upright egg
or oval.

 Platypelloid. The platypelloid pelvis is also called a flat pelvis. This is the least common type.
It’s wide but shallow, and it resembles an egg or oval lying on its side.

Remember that these pelvis shapes are more like guidelines as opposed to rules. Pelvis shape can
vary greatly among females around the world.

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 Lesson
8
Laboratory Assessment

Laboratory Assessment

1. Urinalysis: is a laboratory test used to detect proteinuria, glycosuria, nitrites and pyuria

2. Blood Serum Studies:

a. Complete Blood Count (CBC):

Red Blood Cells (RBCs) including Hemoglobin (Hgb) and Hematocrit (Hct) - determine the
presence of anemia
White Blood Cells (WBCs) - determine presence of infection
Platelet count – estimates clotting ability
b. A genetic screen: used for common diseases inherited ethnically
Example:
African-American women– Sickle-cell disease and Glucose-6-phosphate dehydrogenase
(G6PD)
Asian and Mediterranean women – B-thalassemia
Jewish – Tay-Sach’s disease
Caucasian women – Cystic fibrosis
c. Serologic test for syphilis (VDRL or rapid plasma reagin test)
d. Blood typing (including Rh Factor): used to detect possible occurrence of ABO and Rh
isoimmunization.
It is also necessary for incidences when the woman is experiencing bleeding and needs
blood transfusion

e. Maternal serum alpha-fetoprotein (MSAFP) and pregnancy associated plasma protein A. it is

done between 16 and 18 weeks
An elevated alpha-fetoprotein level indicates neural tube defects (e.g.
myelomeningocele) and a decrease level indicates chromosomal anomaly (e.g.
Trisomy 21)
Ultrasound or amniocenthesis will be ordered to further assess fetal disorder

f. Indirect Coombs test

it determines whether Rh antibodies are present in an Rh-negative woman.
If an Rh (-) woman’s titer is not increased, Rhogam will be administered at 28 weeks of
pregnancy, following procedures which can cause possible bleeding (amniocenthesisi) and
within 72 hours after delivery

g. Serum antibody titers for rubella, hepatitis B (HBsAg), hepatitis C, varicella (chickenpox),
and HPV
determine if a woman is protected against the diseases
HBsAg may be repeated at 36 weeks
Antibodies for chickenpox may also assessed
Vaccines be offered postpartum period
h. HIV screening
 High risk criteria:
 Using IV drugs
 Engaged in multiple sex partners
 IV drug abusers
 Hemophiliacs, who had received blood transfusion

Page 20 of 49
  Screening test: enzyme-linked immunosorbent assay (ELISA)
 Confirmatory test: Western blot
 Therapeutic treatment: Zidovudine (AZT)

3. Mantoux Test (Tuberculosis Screening)

results within 48-72 hours

Induration (redenned, raised, hardened area)
Interpretation:
Induration at least 10 cm in diameter = (+)
This means that the person has been either exposed to TB or has TB
Induration 5cm is considered (+) for immunocompromised person
Chest X-ray is recommended if there is (+)

Diagnostic tests

1. Ultrasound - determines the:

a. Gestational age
b. Fetal position
c. Multiple pregnancy
d. Placental location
e. Growth retardation
f. Estimated date of delivery

Note: Sonogram can be scheduled at:

 7 – 11 weeks to confirm length of pregnancy and fetal growth
 Between 16 and 20 weeks’ gestation to verify fetal structures and gender

2. Chorionic villi sampling

a. Determines some genetic aberrations (chromosomes or DNA analysis)

b. Instruct the patient to drink water to fill the bladder to aid in the attainment of the
desired position of the uterus.
c. Post CVS, advice the woman to report occurrence of chills or fever
d. Explain that risks include:
- spontaneous abortion
- infection
- hematoma
- intrauterine death

3. Amniocentesis

 Is a medical procedure used in prenatal diagnosis of chromosomal abnormalities, fetal

infections, and determination of fetal sex.

 Amniotic fluid is to be withdrawn through the abdominal wall for analysis at 15th-20th week
of gestation

 If done: 14 – 16 weeks (assess chromosomal aberration or other disorders

 If done after 35 weeks (assess fetal lung maturity)

 Complications: placental, cord and bladder puncture.
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4. Percutaneous Umbilical Blood Sampling (PUBS) or Cordocentesis
The removal of blood from the umbilical cord of the fetus at about 17 weeks of gestation
using amniocenthesis

5. Fetal imaging
Magnetic resonance imaging and ultrasonography are used to assess the general size and
structural disorders of the internal organs, spine and limbs

6. Fetoscopy

It is used t confirm ultrasound results, to remove skin cells for DNA analysis or to perform
surgery for a congenital disorder.
A fiber optic fetoscope is inserted through a small incision in the abdomen of mother. It goes
to the uterus and membranes for visualization of fetus for gross disorders, using local
anesthesia

7. Newborn screening

A routine screening test that uses a few drops of newborn’s blood to identify conditions that
can affect a child’s long-term health or survival. It includes genetic, endocrine (e.g.
hypothyroidism), and metabolic disorders (e.g. phenylketonuria), may also determine hearing
loss and critical congenital heart defects
Heel prick analysis is done 24 – 48 hours after birth

Page 22 of 49
 Lesson
9 Monitoring progress of Labor

Signs of True Labor

A. Uterine Contractions – the surest sign that labor has begun is the initiation of effective,
productive uterine
contractions.

1. Pain in uterine contractions results from:

a. Contraction of uterine muscles when in an ischemic state
b. Pressure on nerve ganglia in the cervix and lower uterine
segment
c. Stretching of ligaments adjacent to the uterus and in the pelvic
joints
d. Stretching and displacement of the tissues of the vulva and
perineum

2. Phases of uterine contractions

a. Increment – first phase during which the intensity of
contraction increases; also known as crescendo
b. Acme – the height of the uterine contraction; also known as
apex
c. Decrement – last phase during which intensity of contraction
decreases; also known as decrescendo

Differences Between False and True Labor Pains

FALSE LABOR PAINS TRUE LABOR PAINS

1. Remain irregular 1. May be slightly irregular at first but become
2. Generally confined to the abdomen regular and predictable in a matter of hours.
3. No increase in duration, frequency, and 2. First felt in the lower back and sweep
intensity around to the abdomen in a girdle-like
4. Often disappears if the woman ambulates fashion
5. Absent cervical changes 3. Increase in duration, frequency, and
intensity
4. Continue no matter what the woman’s level
of activity is.
5. Accompanied by cervical effacement &
dilatation

A. Effacement – shortening and thinning of the cervical canal from 1-2 cm. to one in which
no canal as distinct from the uterus exists. It is expressed in percentage.
B. Dilatation – enlargement of the external cervical os to 10 cm. primarily because of uterine
contractions and, secondarily, because of pressure of the presenting part and the BOW.

C. Uterine Changes – the uterus is gradually differentiated into 2 distinct portions:

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

Length of Normal Labor

Primis Multis
First Stage 12 ½ hours 7 hours, 20 minutes
Second Stage 80 minutes 30 minutes
Third Stage 10 minutes 10 minutes
Total 14 hours 8 hours

Stages of Labor

A. First Stage (Stage of Dilatation) – begins with true labor pains and ends with complete
dilatation of the cervix.

Phases:
a. Latent – early time in labor
 Cervical dilatation is minimal because effacement is occurring
 Cervix dilates 3-4 cm. only
 Contractions are of short duration and occur regularly 5-10 minutes apart
(during which
time the pregnant woman may seek admission to the hospital)
 Mother is excited, with some degree of apprehension but still with ability
to
communicated
 Takes up 8 of the 12-hour first stage

b. Active/accelerated
 Cervical dilatation reaches 4-8 cm.
 Rapid increase in duration, frequency. and intensity of contractions
 Mother fears losing control of herself

B. Second Stage (stage of Expulsion) – begins with complete dilatation of the cervix and ends
with delivery of the baby.

Types of Presentation

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

B. Breech – buttocks are the presenting parts

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

II. HORIZONTAL – Transverse lie – Shoulder presentation

Page 25 of 49
 Lesson
10 Catheterization

Catheterization

[Link]
[Link]

is the introduction of a catheter through the urethra into the bladder for the purpose of
withdrawing urine.

Purposes

• To relieve urinary retention

• To obtain a sterile urine specimen from a woman
• To measure the amount of residual urine in the bladder
• To obtain a urine specimen when a specimen cannot secure satisfactory by other means
• To empty bladder before and during surgery and before certain diagnostic examinations

Necessary Equipment for Catheterization

• Catheters are graded on the French scale according to the size of the lumen.
• For the female adult, No. 14 and No. 16 French catheters are usually used. Small catheters
are generally not necessary and the size of the lumen is also so small that it increases the
length of time necessary for emptying the bladder.
• Larger catheter distends the urethra and tends to increase the discomfort of the procedure.
• For male adult, No.18 and No. 20 French catheters usually used, but if this appears to be too
large, smaller catheter should be used.
No. 8 and No. 10 French catheters are commonly used for children

Page 26 of 49
Materials needed:

Indweling Foley Catheter

Urine Bag
Sterile Gloves
10 cc syringe
KY jelly
Distilled water for injection
Cotton Ball with betadine solution

Preparation of the Patient

Page 27 of 49
1. Adequate exploration. On some instances, catheterization is the last resort, use other
techniques first for drawing out the urine before proceeding to catheterization.

2. Position. Dorsal recumbent for the female and supine for the male using a firm mattress or
treatment table, Sim’s or lateral position can be an alternate for the female patient
3. Provision for privacy

• A catheter to remain in place for the following purposes:

1. The gradual decompression of an over distended bladder
2. For intermittent bladder drainage
3. For continuous bladder drainage
• An indwelling catheter has a balloon which is inflated after the catheter is inserted into the
bladder. Because the inflated balloon is larger than the opening to the urethra, the catheter
is retained in the bladder.

Procedure for Insertion

1. Inflate the balloon with the prefilled syringe before inserting the catheter to check for balloon
patency. Aspirate the fluid back into the syringe when it is determined that the balloon is
patent.
2. Hold the catheter with one hand and inflate the balloon according to the manufacturer’s
instructions, as soon as the catheter is in the bladder and urine has begun to drain from the
bladder. Usually 5 ml to 10 ml of sterile water is used

Page 28 of 49
3. If the patient complains of pain after the balloon is inflated, allow it to empty and replace the
catheter with another one. The balloon is probably located in the urethra and is causing discomfort
owing to distention of the urethra
4. Exert slight tension on the catheter after the balloon is inflated to assure its proper placement in
the bladder

5. Connect the catheter to the drainage tubing and drainage bag if not already connected
6. Tape the catheter along the anterior aspect of the thigh for a female patient. Be sure there

is no tension on the catheter when it is taped to the patient

7. Hang the drainage bag on the frame of the bed below the level of the bladder

Caring for the Patient with an Indwelling Catheter

1. Be sure to wash hands before and after caring for a patient with an indwelling catheter
2. Clean the perineal area thoroughly, especially around the meatus, twice a day and after each
bowel movement. This helps prevent organisms for entering the bladder
3. Use soap or detergent and water to clean the perineal area and rinse the area well
4. Make sure that the patient maintains a generous fluid intake. This helps
prevent infection and irrigates the catheter naturally by increasing urinary output
5. Encourage the patient to be up and about as ordered

6. Record the patient’s intake and output

7. Note the volume and character of urine and record observations carefully
8. Teach the patient the importance of personal hygiene, especially the importance of

careful cleaning after having bowel movement and thorough washing of hands

frequently
9. Report any signs of infection promptly. These include a burning sensation and irritation

at the meatus, cloudy urine, a strong odor to the urine, an elevated temperature and chills

[Link] to change indwelling catheters only as necessary. The usual length of time between catheter
changes varies and can be anywhere from 5 days to 2 weeks. The less often a catheter is changed,
the less the likelihood than an infection will develop

Removing the Indwelling Catheter and Aftercare of the Patient

1. Be sure the balloon is deflated before attempting to remove the catheter. This may be done by
inserting a syringe into the balloon valve or by cutting the balloon valve
2. Have the patient take several deep breaths to help him relax while gently removing the
catheter. Wrap the catheter in a towel or disposable, waterproof drape
3. Clean the area at the meatus thoroughly with antiseptic swabs after the catheter is removed
4. [Link] to it that the patient’s fluid intake is generous and record the patient’s intake and
output. Instruct the patient to void into the bedpan or urinal
5. [Link] the urine carefully for any signs of abnormality
Page 29 of 49
6. [Link] and report any usual signs such as discomfort, a burning sensation when
voiding, bleeding and changes in vital signs, especially the patient’s temperature. Be alert to
any signs of infection and report them promptly

Page 30 of 49
Lesson
11 Assisting and Handling Normal Delivery

Assisting and Handling Normal Delivery

[Link]

1. Mechanisms of Labor/ Fetal Position Changes: (ED FIRE ERE)

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

C. Third Stage (Placental Stage) – begins with the delivery of the baby and ends
with the delivery of the placenta.

Signs of placental separation:

a. Uterus becoming round and firm again, rising high to the level of the
umbilicus
(Calkin’s sign) – the earliest sign of placental separation
b. Sudden gush of blood from the vagina
c. Lengthening of the cord from the vagina

2 Types of placental delivery:

a. Schultz – if placenta separates first at its center and last at its edges, it tends
to fold on itself like an umbrella and presents the fetal surface which is shiny. 80% of
placentas separate in this manner (“Shiny” for Schultz)

b. Duncan – if placenta separates first at its edges, it slides along the uterine
surface and presents with the maternal surface which is raw, red, beefy, irregular, and
“dirty”. Only about 20% of placentas separate this way. (” Dirty” of Duncan)
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 D. Fourth Stage – first 1 – 2 hours after delivery which is said to be the most
critical stage for the mother because of unstable vital signs.

Purpose
To identify the instrument that is commonly used in the labor room

Equipment
• Sterile gloves
• Sterile gauze
• Suture
• Delivery room set of instruments

Mayo scissor: use to cut the umbilical cord and

perineum

Kelly clamp (curve): use to

clamp the cord toward the baby

Kelly clamp (straight): use to clamp the cord

toward the placenta

Rubber suction bulb – for suctioning of oral and

nasal secretions of the baby

Needle holder: use to hold the

needle during episiorrhaphy. Its
tip is shorter than Kelly clamp

Page 32 of 49
 Sponge holder: use to hold sterile gauze during
suturing Tissue forceps:
handheld instrument use to
grasp tissue and sterile objects
during suturing and operation

Mayo Table:

Lactation-suppressing agents – estrogen-androgen preparation given within the first hours

postpartum to prevent breastmilk production in mothers who will not (or cannot) breastfeed. E.g.,
diethylstilbestrol, TACE or deladumone. These drugs tend to increase uterine bleeding and retard
menstrual return.

Rooming-in concept – mother and baby are together while in the hospital. The concept of a family,
therefore, is felt at the very beginning because parents have the baby with them, thus providing
opportunities for developing a positive relationship between parents and newborn. Eye-to-eye
contact is immediately established, releasing maternal caretaking responses.

Page 33 of 49
 Lesson
12 Crede’s Maneuver/ Ritgen’s Maneuver

The delivery of the fetal head should be managed by Ritgens maneuver, i.e. lifting the fetal chin anteriorly, using
the fingers of one hand placed between the anus and the coccyx, and thereby extending the fetal neck, whereas
the other hand should be placed on the fetal occiput to control the pace of the expulsion of the fetal head.
Please watch the clip: [Link]

Page 34 of 49
 Lesson
13 Episiorrhapy Care

Episiotomy is a surgical incision of perineum that will prevent perineal laceration or tears and
release pressure over fetal head. It enlarges the outlet during vaginal delivery
Episiorrhapy is the suture repair of an episiotomy

Types of episiotomy:
• Mediolateral episiotomy is an inch-long diagonal cut from the vulva toward the hipbone
• Midline episiotomy is a straight cut from the vulva toward the anus.

Note: In midline episiotomy, blood loss, pain, and scarring are lesser. However, there's a
higher risk of cuts in the anal muscles.

Episiotomy care:
• Keep the episiotomy site clean to avoid infection.
• Use a sitz bath often to reduce the swelling at the site of the episiotomy.
• Avoid foods that may cause constipation.
• Apply prescribed ointments and medicines to the episiotomy site to promote healing

Page 35 of 49
 Lesson
14 Perineal Care

PERINEAL CARE

[Link]

Introduction:

It is also defined as perineal-genital care. The perineal area is condusive to the growth of
pathogenic organisms because it is warm, moist and it is not well-ventilated. Since there are
many orifices example, urinary meatus, vaginal orifice and the anus situated in this area, the
pathogenic organisms can enter into the body. Thoroughly cleanliness is essential to prevent
bad odor to promote comfort.

Definition:
Perineal care involves washing the external genitalia and surrounding with soap and water
or with water alone or in combination with any commercially prepared peri-wash.

Purpose:

 To maintain cleanliness and comfort.  To promote healing of suture line.  To instruct the
mother about perineal self-care.

Principle:

 To clean the perineum from the cleanest to the less clean area.  Follow Standard
Precautions.  Maintain patient’s privacy.

1. Explain procedure to the woman & maintain privacy.

2. Ensure woman's bladder is empty.
3. Assemble equipments:
a. Sterile gloves.
b. Macintosh or towel
c. Paper bag.
d. Sterile Perineal Pad.
e. Dressing set
f. Sterile cotton swabs in bowl
g. Antiseptic solution
h. Bedpan (if required)

4. Position the mother in dorsal recumbent position.

Page 36 of 49
 Perineal Care
Procedure Rationale
1. Wash hands and wear gloves. Ensures that standard precautions are
followed.
2. Place Macintosh or towel under mother’s To protect the bed
hips.
3. Remove soiled pad from front to back. Reduces chances of transmitting organisms to
urinary meatus.
4. Observe color, amount and odor
5. Wrap soiled pad & throw it in paper bag.
6. Test the temperature of the antiseptic
solution and pour over vulva.
7. Use dressing set & swabs for cleaning
according to the following direction:.
8. Mons pubis from the level of clitoris upward
to the lower abdomen in a zigzag line
9. Both thighs from medial to lateral in a zigzag
line.
10. Labia majora (both side) from upward to Wiping from up to down reduces the chance of
downward in a single motion.. transmitting fecal organisms to urinary meatus
11. Labia minora (both side) from upward to Wiping from up to down reduces the chance of
downward in a single motion.. transmitting fecal organisms to urinary meatus
12. The introitus from upward to downward in Wiping from up to down reduces the chance of
a single motion. transmitting fecal organisms to urinary meatus.
13. Anus downward in a single motion. Wiping from up to down reduces the chance of
transmitting fecal organisms to urinary meatus.
14. Dry the perineum using the same technique
and put sterile perineal pad from up to down
without touching the surface close to the
woman.
15. Rearrange bed, clothes & make the women
comfortable
16. Remove screen & equipment from bed side
and wash hands.
17. Record and report the date & time of
procedure, discharge, genitalia condition and
any abnormalities.

Page 37 of 49
 Lesson
15 Post Partum Evaluation

Assessment after expulsion of the baby

a. Fundus – should be checked every 15 minutes for 1 hour then every 30
minutes for the next 4

hours. Fundus should be firm, in the midline and, during the first 12 hours
postpartum, is a little above the umbilicus. First nursing action for a non-contracted
uterus: massage.

b. Lochia – should be moderate in amount. Immediately after delivery, a

perineal pad can be completely saturated after 30 minutes.

c. Bladder – a full bladder is evidenced by a fundus which is to the right of the

midline, dark-red bleeding with some clots.
d. Perineum – is normally tender, discolored, and edematous. It should be
clean, with intact sutures

e. Blood pressure and pulse rate – may be slightly increased from excitement
and effort of delivery but normalize within one hour.

Page 38 of 49
 Lesson
Identifying Lochias
16

Lochia

-uterine flow, consisting of blood, fragments of decidua, white blood cells, mucus, and
some bacteria following childbirth

Lochia alba

-colorless or white vaginal discharge occurring about the 10th postpartal day

Lochia rubra
- vaginal discharge consisting almost entirely of blood with only small particles of

decidua and mucus, occurring from days 1 to 3 of the postpartal period

Lochia serosa

-pink or brownish vaginal discharge beginning at about the 4th postpartal day

Page 39 of 49
 Lesson
17 Newborn Care

ESSENTIAL NEWBORN CARE

The ENC Protocol is a step-by-step guide for health workers and medical practitioners issued by the
Department of Health for implementation under AO 2009-0025 dated December 1, 2009.

OBJECTIVES OF ENC

Aims to ensure health workers have the skills and knowledge to provide appropriate care at
the most vulnerable period in a baby’s life. (WHO, Essential Newborn Care, 2010)

DEFINITION OF TERMS

1. Attachment - is the mode of contact between the baby's mouth and the mother's breast
during the act of breastfeeding
.
2. Kangaroo Mother Care - a universally available and biologically sound method of care for all
newborns, but in particular for premature babies, with three components:
a) skintoskin contact,
b) exclusive breastfeeding and
c) support to the mother-infant

3. Newborn Resuscitation - a series of actions taken to establish normal breathing in a newborn

with depressed vital signs

4. Positioning - means how the mother holds her baby to ensure proper attachment to each other.
5. Positive pressure ventilation - is the most important aspect of newborn resuscitation for ensuring

adequate ventilation of the lungs, oxygenation of vital organs such

as heart and brain, and initiation of spontaneous breathing.

Pregnancy, Childbirth, Postpartum and Newborn Care (PCPNC): A Guide for Essential practice in
Philippine setting - an Essential Care Practice Guideline adapted from the World Health
Organization by the Department of Health. It provides evidence based recommendations to guide
healthcare professionals in the management of women during pregnancy, childbirth and
postpartum, post-abortion, and newborns during their first week of life
6. Skin-to-skin contact - is placing the naked newborn prone on the mother's bare chest. It is
considered a critical component for successful breastfeeding initiation.
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7. Small baby - a newborn weighing from between 1,500 g to 2,499 g
8. Vernix Caseosa – Protective barrier to E. coli and Group B Strep

ESSENTIAL IMMEDIATE NEWBORN CARE PRACTICES

1. Time Band: AT PERINEAL BULGING – prepare for delivery

a. Check the temperature of the delivery room (25-28oC), free of air drafts
b. Notify the appropriate staff
c. Arrange the needed supplies in linear fashion: 2 CLEAN DRY TOWELS
CORD TIES
SYRINGES & NEEDLES
CORD CLAMPS
RESUSCITATION EQUIPTMENT
TETRACYCLINE
OINTMENT
RAZOR BLADE
d. Check resuscitation equipment
e. Wash hands with clean water and soap
f. Double glove just before the delivery

2. Time Band: IMMEDIATE THOROUGH DRYING - Within 1-30 seconds

a. Call out the time of birth
b. Dry the newborn thoroughly for at least 30 seconds
c. Wipe the eyes, face, head, front and back, arms and legs
d. Remove the wet cloth
e. Do a quick check for breathing and while drying
f. NOTES: during the 1st second
Do not ventilate unless the baby is floppy/limp and not breathing
Do not suction unless the mouth/nose are blocked with secretions and other
materials

3. Time Band: CORD CARE - 1-3mins

a. Remove the first set of gloves
b. After the umbilical pulsation have stopped, clamp the cord using a sterile plastic
clamp or tie at 2 cm
from the umbilical base
c. Clamp again at 5 cm from the base
d. Cut the cord to the plastic clamp
e. Notes:
Do not milk the cord towards the baby
After the 1st clamp, you may strip the cord of blood before applying the 2nd
clamp
Cut the cord close to the plastic clamp so that there is no need for a second
trim
Do not apply any substance unto the cord

[Link] Band: UNANG YAKAP / BREASTFEEDING - within 90 mins – is conducted to

ensure early breastfeeding initiation and roaming-in. The earlier the baby breastfeeds,
the lesser the risk of death.
Page 41 of 49
 a. Leave the newborn in skin-to-skin contact

b. Observe for feeding cues, including tonguing, licking and rooting

c. Point these out to the mother and encourage her to nudge the newborn towards the
breast

NON-IMMEDIATE INTERVENTIONS

These interventions are usually given within 6 hours after birth, and should never be made
to compete with the time-bound interventions.

1. Give Vitamin K prophylaxis

- Inject a single dose of Vitamin K 1 mg 1M (if parents decline intramuscular
injections, offer oral vitamin
K as a 2nd line).
2. Inject Hepatitis and BCG vaccinations
-Inject hepatitis B vaccine IM and BCG intradermal

3. Examine the newborn. Check for birth injuries, malformations or defects

-Weigh the newborn and record.

-Look for possible birth injury and/or malformations.
-Refer for special treatment and/or evaluation if available.
-If the newborn has feeding difficulties because of the injury/malformation, help the
mother to breastfeed. If not successful, teach her alternative feeding methods.

3. Cord Care
-Wash hands.
-Fold diaper below stump. Keep cord stump loosely covered with clean clothes.
-If stump is soiled, wash it with clean water and soap. Dry it thoroughly with clean
cloth.
-Explain to the mother that she should seek care if the umbilicus is red or draining
pus.
-Teach the mother to treat local umbilical infection three times a day:

Early Washing
-hinders crawling reflex
-can lead to hypothermia, infection, coagulation, defect, acidosis, delayed fetal to NB
circulatory adjustment, hyaline membrane disease, brain hemorrhage

Page 42 of 49
 Lesson
18
APGAR Scoring

APGAR Scoring

Assessment of the newborn immediately starts the moment he or she is delivered, and there are a
lot of standard assessments used to evaluate them rapidly.

The Apgar scoring is done during the first 1 minute and 5 minutes of life. The heart rate,
respiratory rate, muscle tone, reflex irritability, and the color are evaluated in an infant. Apgar score
is the baseline for all future observations.

• Each parameter can have the highest score of two and the lowest is 0.
• The scores of the five parameters are added to determine the status of the infant.
• Apgar scoring
• 0-3 points: the baby is serious danger and need immediate resuscitation.
• 4-6 points: the baby’s condition is guarded and may need more extensive clearing of the
airway and supplementary oxygen.
• 7-10 points: are considered good and in the best possible health.

The physical assessment includes an exam of the following physical characteristics:

• Skin texture. Skin may be sticky, smooth, or peeling.
• Lanugo. This is the soft downy hair on a baby's body. It's absent in premature babies. It's
present in full-term babies, but not in babies born late.
• Plantar creases. These are the creases on the soles of the feet. They range from absent to
covering the entire foot.
• Breast. The thickness and size of the breast tissue and the areola (the darkened area around
each nipple) are assessed.
• Eyes and ears. Eyelids are checked to see if they are open or fused shut (more likely in a
premature baby). The amount of cartilage and stiffness of the ear tissue are also noted.

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• Male genitals. The presence of testes and the look of the scrotum, from smooth to wrinkled,
is verified.
• Female genitals. The appearance and size of the clitoris and the labia are noted.

Ballard score is commonly used to determine gestational age

• Scores are given for 6 physical and 6 nerve and muscle development (neuromuscular) signs
of maturity. The scores for each may range from -1 to 5.
• The scores are added together to determine the baby’s gestational age. The total score may
range from -10 to 50.
• Premature babies have low scores. Babies born late have high scores.
• The neuromuscular assessment includes an exam of the following:
• Posture. How the baby holds his or her arms and legs.
• Square window. How far the baby's hands can be flexed toward the wrist.
• Arm recoil. How well the baby's arms spring back to a flexed position.
• Popliteal angle. How well the baby's knees bend and straighten.
• Scarf sign. How far the elbows can be moved across the baby's chest.
• Heel to ear. How close the baby's feet can be moved to the ears.

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 Lesson
19
Breastfeeding

Skin-to-skin Contact

- general perception is purely for mother-baby bonding

-other benefits:
B – reastfeeding success
L – ymphoid tissue system stimulation
E – xposure to maternal flora
S – ugar (protection from hypoglycemia)
T – hermoregulation

- Early skin-to-skin contact

-If breathing or crying:
Position prone on mother’s chest or abdomen
Cover the NB with dry linen for back and bonnet for head

-Temperature check
Room: 25-28 C
Baby: 36.5-37.5 C

Breastfeeding

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 -Is the feeding a neonate/infant with breast milk directly from female human breasts (i.e.
lactation) not from a
baby bottle or other container.
-One of the most effective ways to ensure child health and survival. However, nearly 2 out of
3 infants are not
exclusively breastfed for the recommended 6 months – a rate that has not improved in 2
decades. (WHO)
- Breast milk is the ideal food for infants. It is safe, clean and contains antibodies which help
protect against
many common childhood illnesses. Provides all the energy and nutrients that the infant
needs for the first
months of life, continues to provide up to half or more of a child’s nutritional needs during
the second half of
the first year, and up to one third during the second year of life

How Long to Breastfeed

-Newborns can nurse for 5 – 10 minute per breast; every 2 -3 hours. This comes to about 10 – 12
feedings per day. In
the beginning, there is only Colostrum, and there’s not very much of it, so be ready to
feed often but for short
durations.
- One month or more: as baby gets older, his stomach will get larger. He will nurse less frequently
but for a longer
duration at each feeding session. For example, he may nurse 20 – 40 minute per breast.
-By 6 months, baby may breastfeed for 20 – 40 minutes per breast; 3 – 5 times per day

Types and Composition of Human Breast Milk

- COLOSTRUM or Early Milk is produced in the late stage of pregnancy until 4 days after delivery;
and is rich in
antibodies
- TRANSITIONAL Milk produced from day 4 – 10 is lower in protein in comparison to Colostrum.
- MATURE Milk is produced from approximately ten days after delivery up until the termination of
the breastfeeding.

Benefits of Breastfeeding to Infants

- Protection against gastrointestinal infections and gastrointestinal development
- Helps in development of immune system
- Helps in cognitive development of the infant
- Infants who are breastfed have reduced risk of infection compared to formula fed infants.
- Breastfed infants have reduced risk of obesity later in life compared to formula fed infants.
- Reduced risk of sudden infant death syndrome, Hodgkin’s lymphoma, Leukemia and Type 1
Diabetes
- Lower risk of infectious e.g. Otitis media, Lower respiratory tract infection, Diarrheal diseases,
Allergies, Eczema,
Meningitis and inflammatory bowel diseases.
- Breastfed children perform better on intelligence tests

Benefits of Breastfeeding to Mothers

-Reduced risk of breast and ovarian cancers
- Enhance early maternal – infant bond
- Aids involution of the uterus
-Long term breastfeeding helps in loss of the excess weight acquired during pregnancy
- Documented long term effect of breastfeeding includes reduced risk of breast, ovarian and
endometrial cancers.

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Socio-Economic Benefits of Breastfeeding
- Income savings
-Reduced risk of infections and diseases hence reduced hospital visits and attendant medical cost
-Mothers are more economically productive since they will spend less time caring for a sick child

Breastfeeding Position

Cradle Hold

 Most common position used by mothers

 Infant’s head is supported in the elbow, the back and buttock is supported by the arm and
lifted to the breast

Football Hold Position

 The infant’s is placed under the arm, like holding a football

 Baby’s body is supported with the forearm and the head is supported with the hand
 Good position after operative procedures

Side Lying Position

 The mother lies on her side propping up her head and shoulder with pillows
 The infant is also lying down facing the mother
 Good position after Caesarean section
 Allows the new mother some rest
 Most mothers are scared of crushing the baby

Cross Cradle Hold Position

 Mother holds the baby crosswise in the crook of the arm opposite the breast where the
infant is to be fed
 The baby’s trunk and head are supported with the forearm and palm
 The other hand is placed beneath the breast in a Ushaped to guide the baby’s mouth to
your breast

Australian Hold Position

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  This is also called the saddle hold
 Usually used for older infants
 Not commonly used by mothers
 Best used in older infants with runny nose, ear infection

Barriers to Effective Breastfeeding

 Lack of confidence in mother

 Belief that breast milk is not sufficient
 Lack of adequate support system
 History of previous breast surgery
 Breast engorgement, cracked and sore nipples
 Retractile nipples
 Embarrassment by mother
 Jealousy by siblings
 Chronic illness in mother; psychosis, cancer

Contraindication to Breastfeeding

 Active Tuberculosis
 HIV, HLTV 1 & 11 infections (Adult T-cell lymphoma virus)
 Herpes lesions on mother’s breast
 Infant with inborn error of metabolism; galactosemia, phenylketonuria
 Mothers on certain medications; anticancer therapy, radioactive isotope

Barriers to Bonding

 A bottle places a physical barrier between mom and baby

 Less skin to skin contact
 Less eye contact
 The hormonal connection between the breastfeeding mother and baby cannot be
experienced by the bottle feeding mother

Other Options if Breastfeeding is Not Possible

 Use a breast pump (electric/manual)

 Cup or bowl feeding
 Spoon feeding
 Eyedropper or feeding syringe
 Get milk from donation bank

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 V. Learning Activities
Weekly submission: 2 Nursing Care Plan
2 Drug Study
VI. Assessment/ Evaluation
Submit your answer in the submission bin in Google Classroom entitled “Submission Bin
for Assessment/ Evaluation.

A. References

Flagg, JoAnne and Pillitteri, Adele. 2018. Maternal & Child Health Nursing. 8 th edition. Lippincott
Williams & Wilkins

Internet sources:
[Link]; [Link]
[Link]

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