Maternal

and Child
Nursing I

Submitted by:

Reyes, Miguel Grecco G.

Ruiz, Carmela V.

Salvo, Dianne Rose P.

Tabuzo, Maurice Larraine G.

BSN2-5
Essential Newborn Care (ENC)/ Unang Yakap

How was the ENC Protocol developed?

The ENC Protocol was developed the Newborn Care Technical
Working Group (TWG) that conducted a systematic search and
critical appraisal of foreign and local medical and allied
health literature on practices in the immediate newborn period.
An evidence-based draft was then developed and reviewed by the
Department of Health (DOH), United Nations Children’s Fund
(UNICEF), United Nations Population Fund (UNFPA), the Philippine
Obstetrical and Gynecological Society (POGS), the Philippine
Society of Newborn Medicine (PSNbM, a subspecialty society of
the Philippine Pediatric Society, PPS), other health
professional organizations/associations, Save the Children, the
academe and other stakeholders.
What are the four (4) time-bound interventions involved in ENC?

At the heart of the protocol are four (4) time-bound

interventions:
1. Immediate and thorough drying,
2. Early skin-to-skin contact followed by,
3. Properly-timed clamping and cutting of the cord after 1 to
3 minutes, and
4. Non-separation of the newborn from the mother for early
breastfeeding initiation and rooming-in.
What do these four (4) time-bound interventions do to the
newborn?

1. Immediate and thorough drying of the newborn prevents

hypothermia which is extremely important to newborn
survival
2. Keeping the mother and baby in uninterrupted skin-to-skin
contact prevents hypothermia, hypoglycemia and sepsis,
increases colonization with protective bacterial flora and
improved breastfeeding initiation and exclusivity
3. Properly timed cord clamping and cutting until the
umbilical cord pulsation stops decreases anemia in one out
of every seven term babies and one out of every three
preterm babies. It also prevents brain (intraventricular)
hemorrhage in one of two preterm babies.
4. Breastfeeding initiation within the first hour of life
prevents an estimated 19.1% of all neonatal deaths.

What has the government done to ensure implementation of the

Essential Newborn Care Protocol?
 The signing of the Administrative Order 2009-0025 last Dec.
1, 2009 institutionalizes policies and guidelines for government
and private health facilities to adopt the essential newborn
care protocol. Advocacy and dissemination for a have been done
since its launch. Scale-up implementation in all health
facilities and social marketing are both in the pipeline to
ensure that the policy is implemented all over the country.
What is the relationship of the ENC Protocol with regard to the
Maternal, Newborn and Child Health Nutrition (MNCHN) Strategy?
The Maternal, Newborn, Child Health and Nutrition (MNCHN)
Strategy is in line with the DOH Administrative Order 2008-0029
that seeks to rapidly reduce maternal and newborn morbidity and
mortality. Foremost to this is the provision of Basic and
Comprehensive Emergency Obstetric and Newborn Care (BEmONC and
CEmONC) capability of health facilities to meet the UN MDGs 4
and 5. Newborn care has been incorporated in the provision of
these service capabilities. The Administrative Order 2009-0025
formalized the adoption of policies and guidelines on essential
newborn care.
What is the relationship of the ENC Protocol with regard to the
Mother-Baby Friendly Hospital Initiative (MBFHI), Infant and
Young Child Feeding Strategy, and the Republic Act 10028?

The ENC Protocol seeks to provide a firm foundation for an

environment that complies with the “Ten (10) Steps to Successful
Breastfeeding” of the Mother-Baby Friendly Hospital Initiative
(MBFHI), breastfeeding initiation crucial to the IYCF WHO global
strategy and in the implementation of the R.A. 10028.
What newborn care practices in the delivery room should no
longer be continued?
The following practices should never be done anymore to the
newborn:

 Manipulation such as routine suctioning of secretions if

the baby is crying and breathing normally. Doing so may
cause trauma or introduce infection.
 Putting the newborn on a cold or wet surface.
 Wiping or removal of vernix caseosa if present
 Foot printing
 Bathing earlier than 6 hours of life
 Unnecessary separation of the newborn primarily for
weighing, anthropometric measurements, intramuscular
 administration of vitamin K, Hepatitis B vaccine and BCG
vaccine
 Transferring of the newborn to the nursery or neonatal
intensive care unit without any indication
Who are involved in Essential Newborn Care Protocol?
Healthcare professionals, either in government or in
private facilities, involved in maternal and newborn care not
limited to obstetrician-gynecologists,
pediatricians/neonatologists, nurses, midwives, but also the
hospital administration officials, anesthesiologists, hospital
infection control officers, hospital PhilHealth/Quality
officers, clinical nutritionists, clinical pharmacists, nursing
attendants, health promotion and information officers.
At the community level, the local government up to the
barangay officials, together with their health workers,
nutrition scholars, community health teams and volunteers,
mothers’ groups are likewise enjoined to ensure proper
information is disseminated to pregnant women and women of the
reproductive age group.
Why is there a need for Essential Newborn Care Protocol?

The wide variations in newborn care practices in health

facilities, both government and private, and also the proper
sequence or order of newborn care services need to be
standardized based on current evidences that show reduction in
neonatal mortality and morbidity. This is to achieve the United
Nations Millennium Development Goal 4 of Reducing Under 5 Child
Mortality (through reduction of neonatal deaths).
STAGES OF LABOR
Labor is traditionally divided into three stages: a first
stage of dilatation, which begins with the initiation of true
labor contractions and ends when the cervix is fully dilated; a
second stage, extending from the time of full dilatation until
the infant is born; and a third or placental stage, lasting from
the time the infant is born until after the delivery of the
placenta. The first 1 to 4 hours after birth of the placenta is
sometimes termed the “fourth stage” to emphasize the importance
of the close maternal observation needed at this time. These
designations are helpful in planning nursing interventions to
ensure the safety of both a woman and her fetus.
FIRST STAGE
Three separate divisions mark the first stage of labor: the
latent, the active, and the transition phase.
Latent Phase

The latent or preparatory phase begins at the onset of

regularly perceived uterine contractions and ends when rapid
cervical dilatation begins. Contractions during this phase are
mild and short, lasting 20 to 40 seconds. Cervical effacement
occurs, and the cervix dilates from 0 to 3 cm. The phase lasts
approximately 6 hours in a nullipara and 4.5 hours in a
multipara. A woman who enters labor with a “nonripe” cervix will
have a longer than usual latent phase. Although women should not
be denied analgesia at this point, analgesia given too early may
prolong this phase. Measuring the length of the latent phase is
important because a reason for a prolonged latent phase is
cephalopelvic disproportion (a disproportion between the fetal
head and pelvis) that could require a cesarean birth
In a woman who is psychologically prepared for labor and
who does not tense at each tightening sensation in her abdomen,
latent phase contractions cause only minimal discomfort. A woman
can (and should) continue to walk about and make preparations
for birth, such as doing lastminute packing for her stay at the
hospital or birthing center, preparing older children for her
departure and the upcoming birth, or giving instructions to the
person who will take care of them while she is away. In a birth
setting, allow her to continue to be active (Greulich & Tarrant,
2007). Encourage her to continue or begin alternative methods of
pain relief such as aromatherapy or distraction (Smith et al.,
2007).
Active Phase

During the active phase of labor, cervical dilatation

occurs more rapidly, increasing from 4 to 7 cm. Contractions
grow stronger, lasting 40 to 60 seconds, and occur approximately
every 3 to 5 minutes. This phase lasts approximately 3 hours in
a nullipara and 2 hours in a multipara. Show (increased vaginal
secretions) and perhaps spontaneous rupture of the membranes may
occur during this time. This phase can be a difficult time for a
woman because contractions grow strong, last longer, and begin
to cause true discomfort. It is also an exciting time, because
something dramatic is suddenly happening. It can be a
frightening time as a woman realizes labor is truly progressing
and her life is about to change forever.
The active stage of labor in a Friedman graph can be
subdivided into the following periods: acceleration (4 to 5 cm)
and maximum slope (5 to 9 cm). During the period of maximum
slope, cervical dilatation proceeds at its most rapid pace,
averaging 3.5 cm per hour in nulliparas and 5 to 9 cm per hour
in multiparas. Encourage women to remain active participants in
labor by assuming what position is most comfortable for them
during this time (Albers, 2007)
Transition Phase

During the transition phase, contractions reach their peak

of intensity, occurring every 2 to 3 minutes with duration of 60
to 90 seconds and causing maximum cervical dilatation of 8 to 10
cm. If the membranes have not previously ruptured or been
ruptured by amniotomy, they will rupture as a rule at full
dilatation (10 cm). If it has not previously occurred, show
occurs as the last of the mucus plug from the cervix is
released. By the end of this phase, both full dilatation (10 cm)
and complete cervical effacement (obliteration of the cervix)
have occurred.
During this phase, a woman may experience intense
discomfort, so strong that it is accompanied by nausea and
vomiting. Because of the intensity and duration of the
contractions, a woman may also experience a feeling of loss of
control, anxiety, panic, or irritability. Sensations may be so
intense it may seem as though labor has taken charge of her. A
few minutes before, she enjoyed having her forehead wiped with a
cool cloth. Now she may knock a husband’s hand away. A moment
before, she enjoyed having her partner rub her back. Now she may
resist being touched and push that person away. Her focus is
entirely inward on the task of birthing her baby.
The peak of the transition phase can be identified by a
slight slowing in the rate of cervical dilatation when 9 cm is
reached (termed deceleration on a labor graph). As a woman
reaches the end of this stage at 10 cm of dilatation, a new
sensation (i.e., an irresistible urge to push) occurs.
SECOND STAGE

The second stage of labor is the period from full

dilatation and cervical effacement to birth of the infant; with
uncomplicated birth, this stage takes about 1 hour (Archie,
2007). A woman feels contractions change from the characteristic
crescendo–decrescendo pattern to an overwhelming, uncontrollable
urge to push or bear down with each contraction as if to move
her bowels. She may experience momentary nausea or vomiting
because pressure is no longer exerted on her stomach as the
fetus descends into the pelvis. She pushes with such force that
she perspires and the blood vessels in her neck may become
distended.
As the fetal head touches the internal side of the
perineum, the perineum begins to bulge and appears tense. The
anus may become everted, and stool may be expelled. As the fetal
head pushes against the perineum, the vaginal introitus opens
and the fetal scalp appears at the opening to the vagina. At
first, the opening is slitlike, then becomes oval, and then
circular. The circle enlarges from the size of a dime, then a
quarter, then a half-dollar. This is called crowning.

It takes a few contractions of this new type for a woman to

realize everything is still all right, just different, and to
appreciate that it feels good, not frightening, to push with
contractions. In fact, the need to push becomes so intense that
she cannot stop herself. She barely hears the conversation in
the room around her. All of her energy, her thoughts, her being
are directed toward giving birth. As she pushes, using her
abdominal muscles to aid the involuntary uterine contractions,
the fetus is pushed out of the birth canal.
THIRD STAGE
The third stage of labor, the placental stage, begins with
the birth of the infant and ends with the delivery of the
placenta. Two separate phases are involved: placental separation
and placental expulsion.
After the birth of an infant, a uterus can be palpated as a
firm, round mass just inferior to the level of the umbilicus.
After a few minutes of rest, uterine contractions begin again,
and the organ assumes a discoid shape. It retains this new shape
until the placenta has separated, approximately 5 minutes after
the birth of the infant.
Placental Separation
As the uterus contracts down on an almost empty interior, there
is such a disproportion between the placenta and the contracting
wall of the uterus that folding and separation of the placenta
occur. Active bleeding on the maternal surface of the placenta
begins with separation; this bleeding helps to separate the
placenta still farther by pushing it away from its attachment
site. As separation is completed, the placenta sinks to the
lower uterine segment or the upper vagina.
The following signs indicate that the placenta has loosened
and is ready to deliver:

 Lengthening of the umbilical cord

 Sudden gush of vaginal blood
 Change in the shape of the uterus
 Firm contraction of the uterus
 Appearance of the placenta at the vaginal opening
If the placenta separates first at its center and last at
its edges, it tends to fold onto itself like an umbrella and
presents at the vaginal opening with the fetal surface
evident. Appearing shiny and glistening from the fetal
membranes, this is called a Schultze presentation.
Approximately 80% of placentas separate and present in this
way. If, however, the placenta separates first at its edges, it
slides along the uterine surface and presents at the vagina
with the maternal surface evident. It looks raw, red, and
irregular, with the ridges or cotyledons that separate blood
collection spaces showing; this is called a Duncan
presentation. A simple trick of remembering the presentations
is associating “shiny” with Schultze (the fetal membrane
surface) and “dirty” with Duncan (the irregular maternal
surface)
Bleeding occurs as part of the normal consequence of
placental separation, before the uterus contracts sufficiently
to seal maternal sinuses. The normal blood loss is 300 to 500
mL.
Placental Expulsion

After separation, the placenta is delivered either by the

natural bearing-down effort of the mother or by gentle pressure
on the contracted uterine fundus by a physician or nursemidwife
(Credé’s maneuver). Pressure must never be applied to a uterus
in a noncontracted state, because doing so may cause the uterus
to evert and hemorrhage. This is a grave complication of birth,
because the maternal blood sinuses are open and gross hemorrhage
could occur (Poggi, 2007). If the placenta does not deliver
spontaneously, it can be removed manually. With delivery of the
placenta, the third stage of labor is complete.
For most health care providers in the United States, a
placenta has little importance or meaning after its work of
oxygenation is done and it is delivered. For many women,
however, the placenta has continuing importance. For this
reason, women may ask if they can take it home with them. In
several Asian and Native American cultures, women bury the
placenta to ensure that the child will continue to be healthy.
In some parts of China, the placenta is cooked and eaten to
ensure the continued health of the mother. Ask parents whether
saving the placenta is important to them before it is destroyed.
Be certain when supplying placentas to women to take home with
them that you respect standard infection precautions and
hospital policy.
In major health centers, women may be asked to donate their
newborn’s placenta so blood can be removed and banked to be
available for bone marrow or stem cell transplantation (Scott,
2007). Placental membranes can be salvaged to be used as
temporary coverings for burns.

PLACENTA (PREVIA/ABRUPTION)
Placenta previa
Placenta previa is a condition in which the placenta is attached
close to or covering the cervix (opening of the uterus).
Placenta previa occurs in about one in every 200 live births.
There are three types of placenta previa:

 Total placenta previa. The placenta completely covers the

cervix.
 Partial placenta previa. The placenta is partially over the
cervix.
 Marginal placenta previa. The placenta is near the edge of
the cervix.
Causes of Placenta Previa

The cause of placenta previa is unknown, but it is associated

with certain conditions including the following:

 Women who have scarring of the uterine wall from previous

pregnancies
 Women who have fibroids or other abnormalities of the
uterus
 Women who have had previous uterine surgeries or cesarean
deliveries
 Older mothers (over age 35)
 African-American or other minority race mothers
 Cigarette smoking
 Placenta previa in a previous pregnancy
 Being pregnant with a male fetus
Placental Abruption

Placental abruption is the premature separation of a placenta

from its implantation in the uterus. Within the placenta are
many blood vessels that allow the transfer of nutrients to the
fetus from the mother. If the placenta begins to detach during
pregnancy, there is bleeding from these vessels. The larger the
area that detaches, the greater the amount of bleeding.
Placental abruption occurs about once in every 100 births. It is
also called abruptio placenta.
Causes of Placental Abruption

Other than direct trauma to the uterus such as in a motor

vehicle accident, the cause of placental abruption is unknown.
It is, however, associated with certain conditions, including
the following:

 Previous pregnancy with placental abruption

 Hypertension (high blood pressure)
 Cigarette smoking
 Multiple pregnancy
 Sickle cell anemia
How is placental abruption diagnosed?
The diagnosis
of placental
abruption
is usually
made by the
symptoms, and the amount of bleeding and pain. Ultrasound may
also be used to show the location of the bleeding and to check
the fetus. There are three grades of placental abruption,
including the following:

 Grade 1. Small amount of vaginal bleeding and some uterine

contractions, no signs of fetal distress or low blood
pressure in the mother.

 Grade 2. Mild to moderate amount of bleeding, uterine

contractions, the fetal heart rate may shows signs of
distress.

 Grade 3. Moderate to severe bleeding or concealed (hidden)

bleeding, uterine contractions that do not relax (called
tetany), abdominal pain, low blood pressure, fetal death.
Sometimes placental abruption is not diagnosed until after
delivery, when an area of clotted blood is found behind the
placenta.
MECHANISMS (CARDINAL MOVEMENTS) OF LABOR
Passage of a fetus through the birth canal involves several
different position changes to keep the smallest diameter of the
fetal head (in cephalic presentations) always presenting to the
smallest diameter of the pelvis. These position changes are
termed the cardinal movements of labor: descent, flexion,
internal rotation, extension, external rotation, and expulsion.
Descent

- Descent is the downward movement of the biparietal diameter

of the fetal head to within the pelvic inlet. Full descent
occurs when the fetal head extrudes beyond the dilated
cervix and touches the posterior vaginal floor. Descent
 occurs because of pressure on the fetus by the uterine
fundus. The pressure of the fetal head on the sacral nerves
at the pelvic floor causes the mother to experience a
pushing sensation. Full descent may be aided by abdominal
muscle contraction as the woman pushes.
Flexion

- As descent occurs and the fetal head reaches the pelvic

floor, the head bends forward onto the chest, making the
smallest anteroposterior diameter (the suboccipitobregmatic
diameter) present to the birth canal. Flexion is also aided
by abdominal muscle contraction during pushing.
Internal Rotation

- During descent, the head enters the pelvis with the fetal
anteroposterior head diameter (suboccipitobregmatic,
occipitomental, or occipitofrontal, depending on the amount
of flexion) in a diagonal or transverse position. The head
flexes as it touches the pelvic floor, and the occiput
rotates to bring the head into the best relationship to the
outlet of the pelvis (the anteroposterior diameter is now
in the anteroposterior plane of the pelvis). This movement
brings the shoulders, coming next, into the optimal
position to enter the inlet, putting the widest diameter of
the shoulders (a transverse one) in line with the wide
transverse diameter of the inlet.
Extension

- As the occiput is born, the back of the neck stops beneath

the pubic arch and acts as a pivot for the rest of the
head. The head extends, and the foremost parts of the head,
the face and chin, are born.
PREGNANCY (1st, 2nd, and 3rd TRIMESTERS)
First Trimester
The first trimester lasts for the first 12 weeks of the
pregnancy and is crucial for the baby's development. At
conception, the egg and sperm combine to form a zygote, which
will implant in the uterine wall.

 The zygote becomes an embryo as the cells divide and grow.

All of the major organs and structures begin to form.
 At 4–5 weeks, the embryo is only 0.04 inches long but will
grow to around 3 inches long by the end of the first
 trimester. The embryo is now looking a lot more like a
human baby.
 The fetus's heart rate can be heard as early as 8 weeks on
a doppler in the doctor's office, but more likely closer to
12 weeks. During the eighth week the eyelids remain closed
to protect its eyes. The fetus can also make a fist at this
stage. Also, external genitalia will have formed and may be
visible during an ultrasound, meaning that a doctor can
tell someone whether the fetus is male or female.
 A woman will experience many changes during the first
trimester, too. Many women will start to feel morning
sickness, or nausea and vomiting due to pregnancy, at 6–8
weeks.
 Despite its name, this nausea does not just occur in the
morning. Some pregnant women get sick at night, while
others are sick all day.
 A pregnant woman might also feel very tired and notice that
she is more emotional than usual due to hormonal changes.
 Many also report experiencing food cravings or aversions
during early pregnancy, alongside a stronger sense of
smell. Breast tenderness is also very common.
Second Trinester
The second trimester lasts between week 13 and 26 of
pregnancy. The fetus will go through a lot of changes during
this time and grow from approximately 4–5 inches long to around
12 inches long. During the second trimester, the fetus will also
go from weighing about 3 ounces to weighing 1 pound (lb) or
more. In addition to the major structures and organs, other
important parts of the body will also form during the second
trimester, including:

 the skeleton
 muscle tissue
 skin
 eyebrows
 eyelashes
 fingernails and toenails
 blood cells
 taste buds
 footprints and fingerprints
 hair
If the fetus is male, the testes begin to drop into the scrotum.
If the fetus is female, the ovaries begin to form eggs. The
fetus now has regular sleeping and waking patterns. They can
also hear sounds from outside the womb, and they will begin to
practice swallowing, which is an important skill after delivery.
The woman will also likely begin to feel better. In most cases,
morning sickness and fatigue start to go away at the beginning
of the second trimester. Food cravings and aversions can
continue, however. A woman may notice that her belly is starting
to grow and that she is beginning to "look pregnant." She should
also start to feel the baby moving, which is called
"quickening." Braxton–Hicks contractions may start toward the
end of the second trimester.
A woman may also begin to experience other symptoms in the
second trimester, including:

 round ligament pain

 nipple changes, such as darkening
 stretch marks
Third Trimester

The third trimester lasts from week 27 until delivery,

which is usually around week 40. During this trimester, a
developing baby will grow from around 12 inches long and 1.5 lbs
in weight to about 18–20 inches long and 7–8 lbs in weight. Most
of the organs and body systems have formed by now, but they will
continue to grow and mature during the third trimester. The
fetus's lungs are not fully formed at the beginning of this
trimester, but they will be by the time of delivery. A growing
baby will start practicing breathing motions to help prepare for
life after birth. Kicks and rolls become stronger, and a
pregnant woman should feel the baby move regularly. A pregnant
woman may also begin to feel uncomfortable during this
trimester, as her belly starts to grow. Most women start to feel
Braxton–Hicks contractions getting stronger, and they may have
back pain from carrying a heavy belly.
Other symptoms that a pregnant woman may experience during the
third trimester include:

 heartburn
 swollen feet
 insomnia
 mood swings
 leakage of milk from the breasts
 other breast and nipple changes
 frequent urination
As the woman gets closer to the delivery, the baby should turn
in to a head-down position to make birth easier. Anxiety about
delivery and parenthood are also common toward the end of
pregnancy.
SIGNS OF PREGNANCY

PRESUMPTIVE SIGNS AND SYMPTOMS OF PREGNANCY

Presumptive signs and symptoms of pregnancy are those signs
and symptoms that are usually noted by the client, which impel
her to seek council. These signs and symptoms are not proof of
pregnancy but they will make the health provider and woman
suspicious of pregnancy.
1. AMENORRHEA (CESSATION OF MENSTRUATION)
- Amenorrhea is one of the earliest clues of pregnancy. The
majority of clients have no periodic bleeding after the
onset of pregnancy. However, at least 20 percent of
women have some slight, painless spotting during early
gestation for no apparent reason and a large majority of
these continue to term and have normal infants.
- Other causes for amenorrhea must be ruled out, such as:
a. Menopause.
b. Stress (severe emotional shock, tension, fear, or a
strong desire for pregnancy).
c. Chronic illness (tuberculosis, endocrine disorders, or
central nervous system abnormality).
d. Anemia.

2. NAUSEA AND VOMITING (MORNING SICKNESS)

- Usually occurs in early morning during the first weeks of
pregnancy.
- Usually spontaneous and subsides in 6 to 8 weeks or by the
twelfth to sixteenth week of pregnancy.
- Hyperemesis gravidarum. This is referred to as nausea and
vomiting that is severe and lasts beyond the fourth month
of pregnancy. It causes weight loss and upsets fluid and
electrolyte balance of the mother.
- Nausea and vomiting are unreliable signs of pregnancy since
they may result from
other conditions such as:
a. Gastrointestinal disorders (hiatal hernias, ulcers, and
appendicitis)
b. Infection (influenza and malaria)
c. Emotional stress, upset (anxiety and anorexia nervosa)
d. Indigestion
e.
3. FREQUENT URINATION:
- Frequent urination is caused by pressure of the expanding
uterus on the bladder.
- It subsides as pregnancy progresses and the uterus rises
out of the pelvic cavity.
- The uterus returns during the last weeks of pregnancy as
the head of the fetus presses against the bladder.
- Frequent urination is not a definite sign since other
factors can be apparent (such as tension, diabetes, urinary
tract infection, or tumors).
4. BREAST CHANGES
- In early pregnancy, changes start with a slight, temporary
enlargement of the breasts causing a sensation of weight,
fullness, and mild tingling.
- As pregnancy continues the patient may notice:
a. Darkening of the areola--the brown part around the
nipple.
b. Enlargement of Montgomery glands--the tiny nodules or
sebaceous glands within the areola.
c. Increased firmness or tenderness of the breasts.
d. More prominent and visible veins due to the increased
blood supply.
e. Presence of colostrum (thin yellowish fluid that is the
precursor of breast milk). This can be expressed during
the second trimester and may even leak out in the latter
part of the pregnancy.
- These breast changes can be more positive if the patient
has not recently delivered and is not presently
breastfeeding.
5. VAGINAL CHANGES
- CHADWICK'S SIGN: The vaginal walls have taken on a deeper
colour caused by the increased vascularity because of
increased hormones. It is noted at the sixth week when
associated with pregnancy. It may also be noted with a
rapidly growing uterine tumor or any cause of pelvic
congestion.
- LEUKORRHEA: This is an increase in the white or slightly
gray mucoid discharge that has a faint musty odour. It
is due to hyperplasia of vaginal epithelial cells of the
cervix because of increased hormone level from the
pregnancy. Leukorrhea is also present in vaginal
infections.
6. QUICKENING (FEELING OF LIFE)
- This is the first perception of fetal movement within the
uterus. It usually occurs toward the end of the fifth month
because of spasmodic flutter.
 a. A multigravida can feel quickening as early as 16 weeks.
b. A primigravida usually cannot feel quickening until after
18 weeks.
- Once quickening has been established, the patient should be
instructed to report any instance in which fetal movement
is absent for a 24-hour period.
- Fetal movement early in pregnancy is frequently thought to
be gas.

7. SKIN CHANGES
- Striae gravidarum (stretch marks). These are marks noted on
the abdomen and/or buttocks. Striae gravidarum may also be
classified as a probable sign of regnancy.
- These marks are caused by increased production or
sensitivity to adrenocortical hormones during pregnancy,
not just weight gain.
- These marks may be seen on a patient with Cushing's disease
or a patient with sudden weight gain.
8. LINEA NIGRA
- This is a black line in the midline of the abdomen that may
run from the sternum or umbilicus to the symphysis pubis.
- This appears on the primigravida by the third month and
keeps pace with the rising height of the fundus.
- The entire line may appear on the multigravida before the
third month.
- This may be a probable sign if the patient has never been
pregnant.
9. CHLOASMA
- This is called the "Mask of Pregnancy." It is a bronze type
of facial coloration seen more on dark-haired women. It is
seen after the sixteenth week of pregnancy.
10. FINGERNAILS
- Some patients note marked thinning and softening by the
sixth week.

11. FATIGUE
- This is a common complaint by most patients during the
first trimester. Fatigue may also be a result of anemia,
infection, emotional stress, or malignant disease.
12. POSITIVE HOME TEST
- These tests may not always be accurate; however, they can
be very effective if they are performed properly.
PROBABLE SIGNS OF PREGNANCY
Probable signs of pregnancy are those signs commonly noted by
the health providers upon examination of the client. These signs
include: uterine changes; abdominal changes; cervical changes;
basal body temperature; a positive pregnancy test and fetal
palpation.
1. UTERINE CHANGES
- Position: By the twelfth week, the uterus rises above the
symphysis pubis and it should reach the xiphoid process
by the 36th week of pregnancy. These guidelines are fairly
accurate only as long as pregnancy is normal and there are
no twins, tumors, or excessive amniotic fluid.
- Size: The uterine increases in width and length
approximately five times its normal size. Its weight
increases from 50 grams to 1,000 grams.
- Hegar’s Sign: This is softening of the lower uterine
segment just above the cervix. When the uterus is
compressed between examining fingers, the wall feels tissue
paper thin. The physician will use a bimanual maneuver
simultaneously (abdominal and vaginal) and will cause
the uterus to tilt forward. Hegar's sign is noted by the
sixth to eighth week of pregnancy.
- Ballotement: This is demonstrated during the bimanual
examination done at the 16th to 20th week. Ballottement is
when the lower uterine segment or the cervix is tapped by
the examiner's finger which is left in place during the
procedure. The fetus floats upwards, then sinks back and a
gentle tap is felt on the finger. This is not considered
diagnostic because it can be elicited in the presence of
ascites or ovarian cysts.

2. ABDOMINAL CHANGES
- This corresponds to changes that occur in the uterus. As
the uterus grows, the abdomen gets larger. Abdominal
enlargement alone is not a sign of pregnancy. Enlargement
may be due to uterine or ovarian tumors, or edema.

3. CERVICAL CHANGES
- Goodell’s Sign: The cervix is normally firm, like the
cartilage at the end of the nose. Goodell's sign occurs
when there is marked softening of the cervix. This is
present at the 6th week of pregnancy.
- Formation of mucous plug: This is due to hyperplasia of the
cervical glands as a result of increased hormones. It
serves to seal the cervix of the pregnant uterus and to
protect it from contamination by bacteria in the vagina.
 The mucous is expelled at the end of pregnancy near or at
the onset of labour.
- Braxton-Hicks Contractions: This involves painless uterine
contractions occurring throughout pregnancy. It usually
begins at about the 12th week of pregnancy and becomes
progressively stronger. These contractions will, generally,
cease with walking or other forms of exercise. Braxton-
Hick's contractions are distinct from contractions of true
labour by the fact that they do not cause the cervix to
dilate and can usually be stopped by walking.
- Basal Body Temperature: This is a good indication if the
patient has recorded her temperature over several previous
cycles. A persistent temperature elevation spanning the 3
weeks from ovulation is noted as an indicator of pregnancy.
Basal body temperature (BBT) is 97 percent accurate.
- Positive Pregnancy Test: This may be misread by doing it
too early or too late. Even if the test is positive, it
could be the result of ectopic pregnancy or a hydatidiform
mole (an abnormal growth of a fertilized ovum).
- Fetal Palpation: This is a probable sign in early
pregnancy. The physician can palpate the abdomen and
identify fetal parts. It is not always accurate.

POSITIVE SIGNS OF PREGNANCY

Positive signs of pregnancy are those signs that are definitely

confirmed as a pregnancy. They include fetal heart sounds,
ultrasound scanning of the fetus, palpation of the entire fetus,
palpation of fetal movements, x-ray, and actual delivery of an
infant.
A. Fetal Heart Sounds:
- The fetal heart begins beating by the 24th day following
conception. It is audible with a doppler by 10 weeks of
pregnancy and with a fetoscope after the 16th week (see
figure 1.4). It is not to be confused with uterine souffle
or the swish like tone from pulsating uterine arteries. The
normal fetal heart rate is 120 to 160 beats.

B. Ultrasound Scanning of Fetus”

- Pregnancy ultrasound is a method of imaging the fetus and
the female pelvic organs during pregnancy. The gestation
sac can be seen.
DANGER SIGNS OF PREGNANCY
Most women go through pregnancy with some uncomfortable symptoms
but no serious problems. Normal discomforts of pregnancy can
include nausea (especially in the first 3 months), heartburn, a
need to urinate often, backache, breast tenderness and swelling,
and tiredness.
There are some symptoms that may mean danger for you or the
baby. Being aware of these danger signs can help you know when
you may need special care from your healthcare provider.
Contact your healthcare provider right away if you have any of
the following symptoms before the 37th week of pregnancy:

- Pain, pressure, or cramping in your belly

- Contractions that happen more than 4 times an hour or are
less than 15 minutes apart
- Leaking of fluid from the vagina
Also call your provider right away if you have:

- Vaginal bleeding
- A lot of nausea and vomiting
- A temperature over 100°F (37.8°C)
- Very bad headache or a headache that lasts for several days
- New problems with your vision
- Less movement and kicking by the baby
- Sudden weight gain (3 to 5 pounds within 5 to 7 days) with
a lot of swelling of your feet, ankles, face, or hands
- Seizures
You should also call your provider if you have:

- Blood in your urine or burning and pain when you urinate

- Diarrhea that doesn’t go away
- Vaginal discharge with a bad odor, irritation, or itching
PROBLEMS MIGHT CAUSE THESE DANGER SIGNS

A number of different problems may cause these danger signs.

Some of the more common problems are described below.
Miscarriage
Cramping, contractions, and bleeding during the first 20
weeks of pregnancy can be a sign of a miscarriage and possible
loss of your baby. Other signs include bleeding or a gush of
fluid from your vagina. Sometimes a miscarriage can be avoided
with bed rest. If you do lose the baby, then you need to see
your healthcare provider to make sure that no tissue from your
pregnancy is left in your uterus. Tissue left in your uterus
could cause an infection.
Tubal pregnancy

Pain or pressure in your lower belly during the first 3

months of pregnancy could mean that the fertilized egg is
outside your uterus. This is called a tubal, or ectopic,
pregnancy. The pain may be worse on one side of your belly or
you may feel pain in your shoulder. You may also feel dizzy or
faint, or have nausea or vomiting. A baby cannot survive in an
ectopic pregnancy. Because an ectopic pregnancy can cause severe
internal bleeding and threatens the life of the mother, it must
be ended. If it is diagnosed very early in pregnancy, the
pregnancy may be ended with medicine. Otherwise, surgery must be
done to remove the pregnancy.
Severe morning sickness

If you have severe nausea and vomiting that doesn’t stop in

the first 3 months of pregnancy, you could lose weight and lose
too much fluid from your body. You and the baby may not get
enough nutrients. Your body’s chemicals may get off balance. You
may need to be treated in the hospital. Morning sickness usually
gets better after the first 3 months of pregnancy.
Preterm labor
Labor that starts between weeks 20 and 37 of a pregnancy is
called preterm labor. The signs of preterm labor may include:

- Cramps that come and go

- Pelvic pressure
- Low, dull backache
- More vaginal discharge or a change in its color
Infection

A temperature that is over 100°F (37.8°C) could be a sign

of infection or illness. A high temperature or infection can
lead to preterm labor. The infection may need to be treated with
antibiotics or other medicines.
Problems with the baby

Babies start to move early in pregnancy. Most women start

to feel the movements at about 20 weeks, or halfway through the
pregnancy. Each baby has its own pattern of movement. Be aware
of the pattern of your baby’s movements. Follow your healthcare
provider’s instructions for keeping track of your baby’s
movements and know when to tell your provider about possible
problems.
High blood pressure and preeclampsia

It’s important to see your healthcare provider regularly to

have your blood pressure checked. If you have high blood
pressure along with other symptoms, it’s called preeclampsia.
Symptoms of preeclampsia include:

- Headaches
- Swelling of your feet, ankles, face, or hands
- Pain in your upper belly
- Blurred vision
If preeclampsia is not treated or gets severe, it can cause
brain, liver, kidney, heart, or eye damage. Sometimes it causes
seizures.
Delivery of the baby may be the best treatment for
preeclampsia. If your baby has not developed enough, you may
need bed rest at home or in the hospital until your blood
pressure goes down or the baby is ready for delivery.
Problems with the placenta

The placenta is tissue inside the uterus that is attached

to the baby by the umbilical cord. It carries oxygen and food
from your blood to the baby’s blood. Vaginal bleeding during the
second half of pregnancy, with or without pain, may be a sign of
problems with the placenta. For example, the placenta may cover
the cervix, or it may separate from the wall of the uterus.
Vaginal bleeding from a problem with the placenta may be treated
with bed rest at home or in the hospital. In severe cases, the
baby may need to be delivered right away.
AGE OF GESTATION COMPUTATION

 Gestation by LMP is calculated from the first day of the

last menstrual period.
 Gestation by CRL is calculated: Weeks = 5.2876 + (0.1584 *
Crown_Rump_Length) - (0.0007 * Crown_Rump_Length2). This
will be gestation at time of ultrasound.
 Gestation by BPD is calculated using the formula: Days = 2
* BPD + 44.2. This will be gestation at time of ultrasound.
 Gestation by HC is calculated: Weeks = eTo(1.854 +
(0.010451 * Head_Circumference) - (0.000029919 *
Head_Circumference2) + 0.000000043156 *
 Head_Circumference3). This will be gestation at time of
ultrasound.
Estimated Date of Confinement (EDC)

The Estimated Date of Confinement (EDC), also known

as expected date of delivery/estimated due date (EDD) or
simply due date, is a term describing the estimated delivery
date for a pregnant woman. Normal pregnancies last between 37
and 42 weeks.

Due date estimation basically follows two steps:

 Determination of which time point is to be used as the

origin for gestational age. This starting point is the
woman's last normal menstrual period (LMP) or the
corresponding time as estimated by a more accurate method
if available.
 Adding the estimated gestational age at childbirth to the
above time point. Childbirth on average occurs at a
gestational age of 280 days (40 weeks), which is therefore
often used as a standard estimation for individual
pregnancies. However, alternative durations as well as more
individualized methods have also been suggested.
Naegele’s Rule

Naegele's rule is a standard way of calculating the due

date for a pregnancy when assuming a gestational age of 280 days
at childbirth. The rule estimates the expected date of delivery
(EDD) by adding a year, subtracting three months, and adding
seven days to the origin of gestational age. The result is
approximately 280 days (40 weeks) from the start of the last
menstrual period. Another method is by adding 9 months and 7
days to the first day of the last menstrual period.

 Example:
LMP = 8 May 2009
+1 year = 8 May 2010
−3 months = 8 February 2010
+7 days = 15 February 2010

Other suggested durations

  276 days for both ultrasound-estimated and LMP-estimated
gestational age in a US study of 1867 singleton live
births.
 281 days after LMP with a standard deviation of 13 days,
was the result of a population-based study of 427,581
singleton births in Sweden.
 281 days after LMP for first-time mothers and 280 days for
all others were the medians found by a 1995 American study
of 1,970 spontaneous births. Standard deviation was 7–9
days.
 282 days after LMP was recommended for cases where LMP is
the only known factor, in a study of 17,450 patients
combining LMP and ultrasound measurement techniques.
 A median of 288 days (274 days from the date of ovulation)
for first-time mothers and 283 days (269 days from the date
of ovulation) for mothers with at least one previous
pregnancy was found by a 1990 study of 114 white, private-
care patients with uncomplicated pregnancies and
spontaneous labor. The authors suggest that excluding
pregnancies involving complications (that often lead to
pre-term deliveries) accounts for the longer periods.

Leopold’s Maneuver

Leopold’s Maneuver is a systematic method of observation

and palpation to determine fetal position, presentation, lie and
attitude. It is preferably performed after 24 weeks gestation
when fetal outline can be palpated. It is named after the
gynecologist Christian Gerhard Leopold.
The examiner's skill and practice in performing the
maneuvers are the primary factor in whether the fetal lie is
correctly ascertained. Alternately, position can be determined
by ultrasound performed by a sonographer or physician.
Preparation:
1. Instruct woman to empty bladder first. This will promote
comfort and allows for more productive palpation because
fetal contour will not be obstructed by a distended
bladder.
2. Position the woman in a dorsal recumbent, supine with knees
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 patients’ cooperation.
 5. Warm hands first by rubbing them together. Cold hands may
stimulate uterine contractions.
6. Use the palm of the hands in palpating and not the fingers.
7. During the first three maneuvers, stand facing the client,
for the last maneuver stand facing the client’s feet.

Step 1.Fundal Group.

The top of the uterus (fundus) is felt (palpated) to establish
which end of the fetus (fetal pole) is in the upper part of the
uterus. If either the head or breech (buttocks) of the fetus are
in the fundus then the fetus is in vertical lie. Otherwise the
fetus is most likely in transverse lie.

Step 2.Umbilical Grip.

Firm pressure is applied to the sides of the abdomen to
establish the location of the spine and extremities (small
parts).

Step 3.Pawlik’s Grip.

Using the thumb and fingers of one hand the lower abdomen is
grasped just above the pubic symphysis to establish if the
presenting part is engaged. If not engaged a movable body part
will be felt. The presenting part is the part of the fetus that
is felt to be in closest proximity to the birth canal.

Step 4.Pelvic Grip.

Facing the maternal feet the tips of the fingers of each hand
are used to apply deep pressure in the direction of the axis of
the pelvic outlet. If the head presents, one hand is arrested
sooner than the other by a rounded body (the cephalic
prominence) while the other hand descends deeply into the
pelvis. If the cephalic prominence is on the same side as the
small parts, then the fetus is in vertex presentation. If the
cephalic prominence is on the same side as the back, then the
head is extended and the fetus is in face presentation.
GTPALM
- method that is commonly used for recording (using
symbols) a woman's pregnancy history
- provides a systematic, quick system to indicate not
only the number of pregnancies the
woman has had but also the outcomes, which can be
shown using a shorthand method

G - Gravida
T –Number of full-term infants born
(infants born at 37 weeks or after)
P –Number of preterm infants born (infants
born before 37 weeks)
A –Spontaneous miscarriages or therapeutic
abortions
L - Number of living children
M –Multiple Pregnancies

 Example #1:
A pregnant woman who has 4 living children all single
births, and who has had no preterm births and no abortions.

GTPALM: 5-4-0-0-4-0

 Example #2:
A woman who had term twins, then one preterm infant, and is
currently pregnant again.
 GTPALM: 3-2-1-0-3-1

 Example #3:
A pregnant woman who is a mother of a triplet, had one
child die from dengue.
GTPALM: 3-4-0-0-3-1

Breastfeeding RA 7600

AN ACT PROVIDING INCENTIVES TO ALL GOVERNMENT AND PRIVATE HEALTH

INSTITUTIONS WITH ROOMING-IN AND BREASTFEEDING PRACTICES AND FOR
OTHER PURPOSES.
This law is in promotion of the State policy to encourage
the practice of breastfeeding in the Philippines. It composes of
14 Sections divided into 4 chapters.
Chapter 1 states the rules and regulations which contain
standard procedures to be followed for rooming-in and
breastfeeding in all private and government health institutions.
Specific provisions are made for complicated births. The right
of the mother to breastfeed and the right of the infant to
receive breast milk is expressed, and mothers may only exercise
their right to bottle feed after being fully informed of the
benefits of breastfeeding and by expressing their intention to
formula feed in writing.
The regulations cover the establishment and operation of
human milk banksand the donation of human milk which is stated
in Chapter 2 of the act.
Provisions are stated in Chapter 3 of the act for the continuing
education and training of health personnel and the education and
counseling of parents.
Other provisions indicated in Chapter 4 states that the
only milk formula to be stocked in the hospital is to be kept in
a closed cabinet out of sight and used for only emergency
purposes upon issuance of a prescription. These prohibitions
extend to the use of pacifiers, the donation of samples of
formula, and the promotion of infant formulas in
hospitals. Government and private hospitalswill
receive financial incentives for compliance. Noncompliance will
place health personnel and institutions in danger of losing
their licenses and of being found guilty of a wrongdoing.

The Philippine Milk Code of 1986 or Executive Order 51

A LAW IMPOSING STRICT FORMULA MILK MARKETING IN THE PHILIPPINES

Marketing includes:
  product promotion
 distribution
 selling
 advertising
 product public relations
 information services
In short summary, E.O. 51 imposes:
1. NO MILK COMPANY SHOULD SUPPORT BREASTFEEDING ACTIVITIES
2. NO HEALTH AND NUTRITION WORKER SHOULD PROMOTE OR SELL
INFANT FORMULA AND OTHER MILK PRODUCTS AND BOTTLES
3. NO MATERIAL THAT PROMOTES BREASTMILK SUBSTITUTES SHOULD BE
VISIBLE IN ALL HEALTH AND NUTRITION FACILITIES
4. MILK COMPANIES SHOULD ENSURE ACCURATE INFORMATION ON THE
USE AND QUALITY OF THEIR PRODUCTS (INSTRUCTIONS, EXPIRATION
DATE, ETC.)
Comprehensive Newborn Screening (NBS) Program

 It was integrated as part of the country’s public health

delivery system with the enactment of the Republic Act no.
9288 otherwise known as Newborn Screening Act of 2004.
 The Department of Health (DOH) acts as the lead agency in
the implementation of the law and collaborates with other
National Government Agencies (NGA) and key stakeholders to
ensure early detection and management of several congenital
metabolic disorders, which if left untreated, may lead to
mental retardation and/or death.
 Early diagnosis and initiation of treatment, along with
appropriate long-term care help ensure normal growth and
development of the affected individual.
 It has been an integral part of routine newborn care in
most developed countries for five decades, either as a
health directive or mandated by law.
 It is also a service that has been available in the
Philippines since 1996.
 Under the DOH, NBS is part of the Child Development and
Disability Prevention Program at the Disease Prevention and
Control Bureau.

VISION

The National Comprehensive Newborn Screening System envisions

all Filipino children will be born healthy and well, with an
inherent right to life, endowed with human dignity; and Reaching
their full potential with the right opportunities and accessible
resources

MISSION

To ensure that all Filipino children will have access to and

avail of total quality care for the optimal growth and
development of their full potential.

GOAL

To reduce preventable deaths of all Filipino newborns due to

more common and rare congenital disorders through timely
screening and proper management

STRATEGIES ACTION POINTS AND HIGHLIGHTS

1. Ensuring Efficient Operations, Systems and Networks

Management

2. Expanding Package of Services and Delivery Network

3. Enhancing Health Promotion and Advocacy

4. Optimizing Health Information Management Systems for Expanded

Newborn Screening

5. Strengthen Monitoring and Evaluation

6. Establishing Sustainable Financing Scheme

IMPORTANCE OF NEWBORN SCREENING ACT

– Most babies with metabolic disorder look normal at birth.
– One will never know that the baby has the disorder until the
signs and symptoms are manifested. By this time, irreversible
consequences are already present.

WHEN IS IT DONE?
– Ideally done on the 48th to 72nd hour of life (first 2 to 3
days of life).
– May also be done 24 hours from birth since some disorders are
not detected if the test is done earlier than 24 hours from
birth.

PROCEDURE
• Using the heel prick method, a few drops of blood are taken
from the baby’s heel
• Blotted on a special absorbent filter card
• Blood is dried for 4 hours and sent to the Newborn Screening
Center

WHO MAY COLLECT THE SAMPLE FOR NEWBORN SCREENING

 trained physician
 nurse
 midwife
 medical technologist

WHERE IS THE NEWBORN SCREENING AVAILABLE?

• Available in participating Newborn Screening Facilities that
includes
– hospitals
– lying-in centers
– RHU’s
– health centers.
• If babies are delivered at home, the baby may be brought to
the nearest Newborn Screening Facility.

WHEN ARE NEWBORN SCREENING RESULTS AVAILABLE?

• Seven (7) working days from the time the newborn screening
samples are received parents should claim the results from their
physician, nurse, midwife or health worker.
• Any laboratory result indicating an increased risk of a
heritable disorder (i.e. positive screen) shall be immediately
released, within twenty-four (24) hours, so that confirmatory
testing can be immediately done.
• A positive screen means that the newborn must be referred at
once to a specialist for confirmatory testing and further
management.

DISORDERS TESTED FOR NEWBORN SCREENING

1. CH (Congenital Hypothyroidism) results from lack or absence
of thyroid hormone which is essential for the physical and
mental development of a child.
2. CAH (Congenital Adrenal Hyperplasia) is an endocrine
disorder that causes severe salt loss, dehydration and
abnormally high levels of male sex hormones in both boys
 and girls. If not detected and treated early, babies with
CAH may die within 7-14 days.
3. GAL (Galactosemia) is a condition in which babies are
unable to process galactose, the sugar present in milk.
Accumulation of excessive galactose in the body can cause
many problems, including liver damage, brain damage and
cataracts.
4. PKU (Phenylketonuria) is a rare condition in which the baby
cannot properly use one of the building blocks of protein
called phenylalanine. Excessive accumulation of
phenylalanine in the blood causes brain damage.
5. G6PD (Glucose-6-Phosphate Dehydrogenase) is a condition
where the body lacks the enzyme called G6PD. Babies with
this deficiency may have hemolytic anemia resulting from
exposure to oxidative substances found in drugs, foods and
chemicals.

POST PARTUM ASSESSMENT

The postpartum period covers the time period from birth
until approximately six to eight weeks after delivery. This is a
time of healing and rejuvenation as the mother’s body returns to
pre-pregnancy states. Healthcare professionals need to be aware
of the normal physiologic and psychological changes that take
place in women’s bodies and minds after delivery in order to
provide comprehensive care during this period. In addition to
patient and family teaching, one of the most significant
responsibilities of the postpartum nurse is to recognize
potential medical complications after delivery.
NORMAL POSTPARTUM ADAPTATIONS: PHYSIOLOGIC
Reproductive System

UTERUS

Immediately after delivering, women experience massive

shifting as the body returns to its pre-pregnant state. The
uterus begins a process known as involution immediately after
the delivery of the placenta. The uterus, with the assistance of
the uterine muscles, contracts the uterine vessels and impedes
blood flow. Large vessels at the site of placental attachment
thrombose to control bleeding.

A process known as exfoliation also occurs at this time.

Exfoliation is the sloughing off of dead tissue at the site
where the placenta is attached to the uterine wall. Exfoliation
leaves the site smooth and without scar tissue to allow for the
implantation of fertilized ova in subsequent pregnancies.

The uterus continues to contract after delivery, and its

size decreases rapidly as estrogen and progesterone levels
diminish. Immediately after delivery, the upper portion of the
uterus, known as the fundus, is midline and palpable halfway
between the symphysis pubis and the umbilicus. By approximately
one hour post delivery, the fundus is firm and at the level of
the umbilicus. The fundus continues to descend into the pelvis
at the rate of approximately one centimeter (finger-breadth) per
day and should be nonpalpable by two weeks postpartum.

Uterine involution can be impeded by anything that would

cause distention of the uterus, including an unusually large
(macrosomic) infant, multiple pregnancies, multiple births, or
excessive amniotic fluid.

Afterpains, or intermittent uterine contractions, are a

normal occurrence during the postpartum period. Afterpains are
caused by the release of the hormone oxytocin and the subsequent
relaxation and contraction of the uterine muscles. Afterpains
can be quite intense for postpartum women and are particularly
painful for women who have given birth previously (multiparous).
Women may also experience afterpains while breastfeeding as a
result of nipple stimulation and the subsequent release of
oxytocin. Afterpains are usually resolved by the end of the
first postpartum week and can be alleviated by relaxation
techniques and, if necessary, analgesics, including short-acting
nonsteroidal anti-inflammatory drugs (NSAIDs).

LOCHIA
After delivery, the endometrial surface of the uterus is
shed via the vagina. The shedding endometrium is known
as lochia. Lochia occurs in three successive stages that include
lochia rubra, lochia serosa, and lochia alba.
1. Lochia rubra
 Red/red-brown and is noted on postpartum days 1 to 3
 Heaviest during first 1 to 2 hours after delivery
 Initially bright red
 May contain small clots

2. Lochia serosa
 Pink to brown in color and occurs after day 3.
 Vaginal flow Should not contain clots and can last up to
27 days in some women
3. Lochia alba
 Yellow to white in color
 Typically by 10 days
 May continue on average to the 6th week postpartum
Estimating Lochial Flow
 Count number of pads being changed per hour.
 Pads can be weighed (1 g = 1 mL blood)
 Check fundal firmness
 Document per facility protocol

Lochial Flow
 Teach mother that she may see an increase in lochia on rising
due to pooling of fluids within the vagina
 Excessive lochia rubra early in postpartum may suggest
bleeding due to retained placental fragments
 Recurrence of bleeding in 7 to 10 days suggests bleeding from
placenta site but could also be normal sloughing.
 After 3 to 4 weeks, late bleeding may be caused by infection
or subinvolution
 Continued lochia serosa or alba suggests infection
(endometritis) and may also indicate fever, pain, or abdominal
tenderness
 Lochia will have an offensive odor if infection is present

CERVIX
As with all other reproductive organs and structures, the
cervix also changes as the body returns to a pre-pregnancy
state. After delivery, the cervix is edematous and may appear
bruised. The external os resembles a slit as compared to the
circular, dimpled opening prior to the first pregnancy. The
internal os closes almost completely within three to four months
of delivery (Berens, 2016).

VAGINA
The vaginal walls are smooth after delivery, and the
vaginal folds, known as rugae, do not return until approximately
3 weeks postpartum. The vagina itself will never return to the
pre-pregnant size but will decrease in size and return to a near
pre-pregnancy state as the postpartum period progresses. The
vagina usually appears edematous and may have small lacerations
incurred during the delivery.

Vaginal dryness and painful intercourse, known

as dyspareunia, may be noted during the postpartum period due to
decreased estrogen levels. Mucus production should return with
ovulation, and women are frequently encouraged to use water-
based lubricants (e.g., K-Y Jelly) with intercourse to ease
discomfort. Although most women may resume intercourse as early
as two weeks postpartum, many women may not be ready because of
fatigue, low sexual desire, pain, vaginal dryness or discharge,
religious/cultural practices, psychological factors, or possibly
postpartum blues or depression (Berens, 2016).

PERINEUM
This area between the posterior portion of the labia majora
and the anus stretches and thins during birth to accommodate
delivery of the infant. Lacerations of the perineum may occur
during delivery, or an episiotomy (surgical incision) may be
performed to accommodate the infant.
Lacerations of the perineum are identified as first-,
second-, third-, or fourth-degree. First-degree lacerations
extend through the skin and superficial layers of the perineum.
Second-degree lacerations extend through the perineal muscles,
while third-degree lacerations extend through the anal sphincter
muscles. Fourth-degree lacerations extend through the anal
sphincter muscles and the anterior rectal wall.

According to the National Hospital Discharge Survey, about

25% of all procedures performed on females were obstetrical.
Cesarean sections and repair of current obstetric lacerations
were the most frequent obstetrical procedures performed [in
2010]. In 2010, there were 1,291 repairs of current obstetrical
lacerations in the United States (CDC/NCHS, 2010).

Ideally, the perineum should be protected from trauma

during labor and birth. Aasheim and colleagues, through a review
of the literature, recommend the use of warm compresses on the
perineum to decrease the occurrence of perineal trauma. Perineal
massage prior to delivery was also found to reduce third- and
fourth-degree tears (Aasheim et al., 2010).

Regardless of the presence of lacerations or an episiotomy,

the perineum is generally edematous and often bruised
immediately following delivery. The muscle tone of this area is
weakened as a result of delivery and never completely returns to
the state it was prior to the first pregnancy.

EPISIOTOMY
An episiotomy to aid in the delivery of the infant should
be performed only when necessary. There is much debate regarding
the maternal benefits of episiotomies, and researchers continue
to denounce its usage, except under extenuating circumstances.
Since the 1996 World Health Organization recommendation for an
episiotomy rate of approximately 10%, rates of episiotomy have
generally been in decline. In the United States, the episiotomy
rate dropped from 17.3% to 11.6% from 2006 to 2012.
Source: Berkowitz & Foust-Wright, 2016.

BREASTS
After delivery there is a significant decrease in estrogen
and progesterone levels. Before milk production begins, the
breasts secrete colostrum, a thin, yellowish fluid that helps
maintain the blood glucose level in the breastfeeding infant.
Nipple stimulation by the infant causes the release of the
hormone oxytocin from the posterior pituitary gland, which
triggers the release of the hormone prolactin from the anterior
pituitary. Prolactin initiates milk production, and the breasts
become full (engorged), as well as warm and tender, between
postpartum days 3 and 4. Mothers often refer to this as having
their milk “come in.” There may be a slight elevation in body
temperature during this time.
Women who choose not to breastfeed will also experience
their milk coming in; however, lactation can be suppressed
through the use of a well-fitted bra. Nonbreastfeeding mothers
should also avoid any type of nipple stimulation or heat to the
breasts, such as warm or hot showers in which the water is
allowed to run continuously over the breasts. These mothers can
use ice packs or cool cabbage leaves to ease breast discomfort
until milk production ceases. It generally takes five to seven
days for the breasts to stop producing milk. Healthcare
providers may consider prescribing mild analgesics if a woman
has significant discomfort. Due to risks associated with the
medications, drug therapy is not recommended for suppression of
lactation (Berens, 2016).

Endocrine System

With the sharp decrease of estrogen and progesterone levels

following delivery of the placenta, lactation begins and
menstruation returns. Estrogen is a prolactin-inhibiting
hormone. When mothers choose to bottle-feed, prolactin levels
diminish and estrogen levels begin to rise. Menstruation returns
in approximately six to eight weeks for these women. However,
ovulation can return within four weeks.
When women breastfeed, prolactin levels increase as
breastfeeding continues. Therefore, menstruation does not return
until 12 weeks or later. Because ovulation can return prior to
menses, it is important for healthcare providers to discuss
family planning with patients during the early postpartum period
in order to prevent undesired pregnancies.

POSTPARTUM SHIVERING
Postpartum shivering is observed in 25% to 50% of women
after normal deliveries. Shivering usually starts within 30
minutes after delivery and lasts for up to 60 minutes. The cause
is not clear, but “several mechanisms have been proposed,
including fetal-maternal hemorrhage, micro-amniotic emboli,
bacteremia, maternal thermogenic reaction to a sudden thermal
imbalance due to the separation of the placenta, drop in body
temperature following labor, use of misoprostol, and an
anesthesia related etiology.”
Source: Berens, 2016.

Cardiovascular System

As the pregnant body prepares for blood loss at birth,

there is an increase in circulating blood volume during
pregnancy. Women may lose up to 500 mL of blood during a vaginal
delivery and between 800 and 1000 mL of blood during a cesarean
(C-section) delivery.
At delivery, there are fluid changes within the body to
accommodate postpartum blood loss and prevent hypovolemia. These
changes include:
 Elimination of the placenta, which diverts 500 to 750 mL of
blood flow into the maternal systemic circulation
 Rapid reduction of the size of the uterus, which puts more
blood in the systemic circulation
  Increase of blood flow to the vena cava from elimination of
compression by the gravid uterus
 Mobilization of body fluids accumulated during pregnancy
(Leifer, 2011)
The postpartum body removes excess fluid accumulated during
pregnancy by diuresis. Women may excrete up to 3000 mL of fluid
per day during the postpartum period. In addition, women
frequently experience excessive perspiration (diaphoresis),
which also releases accumulated fluid during the postpartum
period. Patients should be educated about increased urination
and perspiration during this period.
During the early postpartum period there is a loss of plasma
blood volume that is greater than that of red blood cells. Thus,
there is a temporary rise in hemoglobin and hematocrit levels.
It is difficult to measure hemoglobin and hematocrit levels
accurately at this time. However, these levels do return to
normal within four to six weeks (Murray & McKinney, 2014).

Due to the inflammation, pain, and the stress of

birth, neutrophils, a type of white blood cell, are increased
and are responsible for a marked increase in the white blood
cell count during the postpartum period. White blood cell counts
may increase to levels as high as 30,000/mm3 (Murray & McKinney,
2014). As a result of this normal increase in the white blood
cell count, it is important for healthcare providers to monitor
patients closely for indications of infection during the
postpartum period.
Fibrinogen is a protein that, along with other clotting factors,
is responsible for the clotting of blood. In addition to the
increase in circulating blood volume during pregnancy, plasma
fibrinogen levels increase and remain increased for several days
after delivery. Postpartum women have an increased risk of
developing blood clots. Therefore, early ambulation is
imperative.
Respiratory System
 During pregnancy, the diaphragm is slightly elevated as the
fetus nears term. This, along with other respiratory changes,
causes thoracic versus abdominal breathing in the third
trimester (Murray & McKinney, 2014). After delivery, the
diaphragm descends and postpartum women’s respirations normally
return to the prepregnant state.
Gastrointestinal System

Women are generally hungry and thirsty after delivery due

to the amount of energy expended during labor. Food and fluid
intake is usually restricted during labor, and many women may
not have eaten for a number of hours prior to delivery. The
diaphoresis that occurs during the postpartum period may also
lead to increased thirst. It is important for nurses to provide
nourishment and hydration upon delivery.

Many women experience constipation from the lack of fluid

and food intake during labor. Furthermore, bowel tone is
sluggish as a result of elevated progesterone levels during
pregnancy and is slow to resolve. Often women are hesitant to
have a bowel movement in the postpartum period due to pain in
the perineal area resulting from an episiotomy, lacerations, or
hemorrhoids. Some women are also fearful that they will rip
their stitches should they have a bowel movement. Healthcare
providers may prescribe stool softeners and/or laxatives to
treat constipation and provide perineal comfort during
defecation.
Urinary System

The bladder, urethra, and urinary meatus are edematous

after delivery as a result of the fetal head passing through the
birth canal. Bladder tone is diminished, and many women are
unable to feel the need to void despite the rapid diuresis that
occurs following delivery. In this situation, the bladder can
become distended and displace the uterus upward and to the side,
which prevents the uterine muscles from contracting properly and
can lead to a postpartum hemorrhage. Therefore, healthcare
providers must carefully monitor bladder distention, the
firmness of the fundus, and bleeding during the postpartum
period.

Postpartum women may have protein in their urine that can

be noted for the first few postpartum days. Proteinuria during
this time is considered benign unless there are signs of a
urinary tract infection or preeclampsia (Murray & McKinney,
2014).
Musculoskeletal System

As with all other body systems, the musculoskeletal system

undergoes changes during the postpartum period. Relaxin is the
hormone responsible for the relaxation of the pelvic ligaments
and joints during pregnancy. After delivery, relaxin levels
subside and the pelvic ligaments and joints return to their
prepregnant state. However, the joints of the feet remain
altered, and many women notice a permanent increase in shoe
size.
The abdominal wall is weakened and the muscle tone of the
abdomen is diminished after pregnancy. Some women have a
separation between the abdominal wall muscles, called diastasis
recti. This separation can be improved with certain abdominal
exercises performed during the postpartum period (Nahabedian &
Brooks, 2015).

Patients should be instructed to begin abdominal exercises

anytime following a vaginal delivery and after abdominal
tenderness resolves following a cesarean section, generally in
four weeks (Murray & McKinney, 2014). Patients should also be
instructed to avoid overexertion during the first few weeks
after delivery.
Integumentary System
 Melanocyte-stimulating hormone (MSH) is responsible for the
hyperpigmentation that occurs during pregnancy. MSH levels
rapidly decrease after delivery, and the skin changes that
occurred as a result of pregnancy revert to the prepregnant
state or are permanently altered. More specifically, the mask of
pregnancy (chloasma) usually disappears, while stretch marks
(striae gravidarum) and linea nigra fade but generally do not go
away. Hair loss may occur during the postpartum period but
usually resolves without the need for intervention. As
previously mentioned, diaphoresis is common during the
postpartum period, and patients should be informed that they may
need to change clothes and bed linens more frequently than
usual.

Immune System

Other than increased white blood cell count, there are few
changes in the immune system during the postpartum period.
However, it is important for Rh-negative patients of Rh-positive
babies to receive Rh immune globulin within 72 hours of delivery
to prevent maternal antibody production in response to the Rh-
positive antigen received from infants during pregnancy or
birth.

The rubella vaccine should also be administered to

postpartum patients who tested nonimmune or had a rubella titer
less than 1:10 prior to delivery. Patients should be informed
that the vaccination is given to prevent fetal anomalies in
subsequent pregnancies. Additionally, the rubella vaccine is a
live virus and is contraindicated during pregnancy. Therefore,
all women should be instructed to avoid becoming pregnant for
the four weeks following the administration of the vaccine (CDC,
2016).

NORMAL POSTPARTUM ADAPTATIONS: PSYCHOLOGICAL

The postpartum period is a time of immense change for the

new mother and her family. Roles and expectations often shift as
families adjust to their newest addition and women learn to
“become mothers” (Mercer, 2004).

Attachment

Bonding, sometimes referred to as attachment, between

mothers and infants is affected by a multitude of factors,
including socioeconomic status, family history, role models,
support systems, disturbed sleep, cultural factors, and birth
experiences. Nurses are encouraged to consider these variables
when assessing the attachment process between mothers and
infants. It is also important to note that women begin to show
attachment behaviors not only in the postpartum period but also
during pregnancy.

Healthcare providers have multiple opportunities to assess

how pregnant patients will likely bond with their infants after
delivery. Various tools, such as the Postpartum Bonding
Questionnaire, can be helpful in assessing bonding.

In maternal-newborn healthcare, attachment refers to the

emotional connection between a mother and her infant. This
attachment is reciprocal; both the mother and the infant exhibit
attachment behaviors. The infant responds to the mother by
cooing, grasping, smiling, and crying. However, these behaviors
are nondiscriminatory before approximately eight weeks. Nurses
can assess for attachment behaviors by observing the
interactions between mothers and their infants. Behaviors
exhibited by mothers that indicate positive attachment include:

 Touching
 Holding
 Kissing
  Cuddling
 Talking and singing
 Choosing the “en face” position (face-to-face,
approximately 8 inches apart)

Expressing pride in the infant

Postpartum assessment of attachment should begin immediately

after delivery and continue throughout the infant’s first year
of life. Most women positively attach to their newborn infants.
However, there are some who do not form attachments
appropriately. Malattachment behaviors vary and can include:

 Refusing to look at the infant

 Refusing to touch or hold the infant
 Refusing to name the infant
 Negative comments about the infant
 Refusing to respond or responding negatively to infant cues
(e.g., crying, smiling)

It is important to note that during the early postpartum

period many factors can affect attachment, including anesthesia
after a cesarean section, pain, or a traumatic birthing
experience. Healthcare providers should consider these factors
when assessing attachment. If malattachment is noted, providers
should immediately report the observation and continue to
monitor both the mother and infant.

Paternal/Domestic Partner Adjustment

The postpartum period is a time of great change within the

family unit. Just as postpartum women are required to adjust to
the new role of mother, fathers and domestic partners also face
a period of adjustment upon the arrival of the newborn. All
partners, if possible, should also be assessed for attachment
behaviors when interacting with their infants.

POSTPARTUM ASSESSMENT AND PATIENT EDUCATION

Primary responsibilities of nurses in postpartum settings

are to assess postpartum patients, provide care and teaching,
and if necessary, report any significant findings. Postpartum
nurses are essentially detectives searching for findings that
might lead to negative outcomes for patients if left unattended.
Thus, it is imperative for nurses to distinguish between normal
and abnormal findings and to have a clear understanding of the
nursing care necessary to promote patients’ health and well-
being.
Breasts

The breasts are assessed for:

 Signs of engorgement, including fullness, around postpartum
days 3 and 4
 Hot, red, painful, and edematous areas, which could
indicate mastitis
 Nipple condition and latch-on technique of mothers who are
breastfeeding
Breastfeeding women should wear a comfortable, well-fitted
support bra. Instructions can include gently rubbing colostrum
or breast milk into their nipples and allowing the nipples to
air dry after each feeding to “condition” the nipples. Mothers
can prevent drying by avoiding soap and washing the nipples with
only water.

It is also extremely important to teach patients

proper breastfeeding techniques to ensure a positive experience
for mothers and their infants. Teaching proper latch-on
techniques and how to break the infant’s suction after feeding
can have a positive and lasting effect on mothers’ breastfeeding
experiences. Otherwise, mothers may develop sore, cracked, and
sometimes bleeding nipples, which can discourage the
continuation of breastfeeding.

According to the Joanna Briggs Institute (2009), “Among the

options of applying warm-water compresses, breast milk, or
teabags, the placement of a warm-water compress was found to be
the most effective intervention in controlling nipple pain and
trauma.”
Patients who are not breastfeeding are instructed to wear a
well-fitting support bra and to avoid any type of nipple
stimulation until lactation is discontinued.
Uterus

The fundus is assessed for:

 By approximately one hour post delivery, the fundus is firm
and at the level of the umbilicus.
 The fundus continues to descend into the pelvis at the rate
of approximately 1 cm or finger-breadth per day and should
be nonpalpable by 14 days postpartum.
In addition, patients are assessed for uterine cramping and
treated for pain as needed.
Patients or a family member can be taught to assess the
firmness of the fundus and to provide massage in the event of a
boggy uterus or excessive bleeding. Patients are encouraged to
void before palpation of the uterine fundus because a full
bladder displaces the uterus and can lead to excessive bleeding.
Bowel Function

Assessment of the bowel is important in all postpartum patients.

It is especially vital for patients following C-sections. The
bowel is assessed for:
 Bowel sounds
 Return of bowel function
 Flatus
 Color and consistency of stool
Prescribed stool softeners or laxatives are administered as
needed to treat constipation and ease perineal discomfort during
defecation.

Patients should be instructed to ambulate soon after delivery.

Instruction also includes teaching the need to eat fruits,
vegetables, and other high-fiber foods daily. Postpartum
patients should consume at least 2,000 mL/day of fluid. While
patients may consider 2,000 mL a lot to drink in one day,
consumption can be spread out throughout the day.
Bladder

Assessment of urination and bladder function includes:

 Return of urination, which should occur within six to eight
hours of delivery
 For approximately 8 hours after delivery, amount of urine
at each void. Patients should void a minimum of 150 mL per
void; less than 150 mL per void could indicate urinary
retention due to decreased bladder tone post delivery (in
the absence of preeclampsia or other significant health
problems).
 Signs and symptoms of a urinary tract infection (UTI),
including frequent urination, bladder spasm, cloudy urine,
persistent urge to urinate, and pain with urination
The bladder should be nonpalpable above the symphysis pubis.
Patients are encouraged to drink adequate fluid each day
and to report signs and symptoms of a urinary tract infection,
including frequency, urgency, painful urination, and hematuria.
Lochia

Lochia is assessed during the postpartum period:

 Saturating one pad in less than an hour, a constant trickle
of lochia, or the presence of large (i.e., golf–ball sized)
blood clots is indicative of more serious complications
(e.g., retained placenta fragments, hemorrhage) and should
be investigated immediately. A significant amount of lochia
despite a firm fundus may indicate a laceration in the
birth canal, which should be addressed immediately.
 Foul-smelling lochia typically indicates an infection and
needs to be addressed as soon as possible.
 Lochia should progress from rubra to serosa to alba. Any
changes in this progression could be considered abnormal
and should be reported. Lochia rubra is present on days 1–
 3, lochia serosa on days 4–10, and lochia alba on days 11–
21.
It is important to note that patients who had a C-section will
typically have less lochia than patients who delivered
vaginally; however, some lochia should be present.
After discharge, patients should report any abnormal
progressions of lochia, excessive bleeding, foul-smelling
lochia, or large blood clots to their physician immediately.
Patients are instructed to avoid sexual activity until lochial
flow has ceased.
Episiotomy/Perineum

Redness is considered normal with episiotomies and lacerations;

however, if there is significant pain present, further
assessment is necessary. Furthermore, excessive edema can delay
wound healing. The use of ice packs during the immediate
postpartum period is generally indicated.

There should be an absence of discharge from the episiotomy

or laceration, and the wound edges should be well approximated.
Perineal pain must be assessed and treated. Nurses are
encouraged to assess the rectal area for hemorrhoids and, if
present, should instruct patients to discuss hemorrhoidal
treatments (e.g., witch hazel pads or other over-the-counter
hemorrhoid medications) with their certified nurse-midwife or
physician.

Various actions can aid in perineal healing. To avoid

infection, patients can pat from front to back and use a peri-
bottle for gentle cleansing of the perineum after a bowel
movement or urination. Many certified nurse-midwives and
physicians prescribe topical ointments and sprays to ease the
discomfort of a sore perineum. If one of these has been
prescribed, patients are instructed to use a sitz bath and then
apply the suggested topical agent for best results.
 Analgesics are often prescribed for pain. Patients are
generally instructed to apply ice packs to the perineum
immediately after delivery. Patients with lacerations and
episiotomies are informed that as sutures dissolve, the perineum
may itch and that this is normal in the absence of any other
perineal abnormalities. Patients are to avoid tampons and sexual
activity until the perineum has healed.
Performing Kegel exercises are an important component of
strengthening the perineal muscles after delivery and may be
begun as soon as it is comfortable to do so.
Lower Extremities

To assess for deep vein thrombosis (DVT), the lower

extremities are examined for the presence of hot, red, painful,
and/or edematous areas. An elevated temperature may also be
present.
The legs are assessed for adequate circulation by checking
the pedal pulses and noting temperature and color. In addition,
the lower extremities are assessed for edema. Pedal edema is
normally present for several days after delivery as fluids in
the body shift. However, lasting edema should be reported for
further assessment.

To improve circulation and prevent the development of

thrombi, patients are encouraged to ambulate shortly after
delivery. They are to avoid crossing the legs for long periods
of time and to keep the legs elevated while sitting. Many
certified nurse-midwives and physicians seek to combat the
development of thrombi by encouraging patients to wear TED hose
and/or sequential compression devices (SCDs) after delivery.

ASSESSING FOR DVT

In the past, postpartum nurses assessed for DVT by
eliciting a Homans’ sign (dorsiflexion of the foot). The
presence of pain when eliciting the Homans’ sign indicated the
probable presence of a DVT. It is, however, unreliable. Massage
of the legs should be avoided due to the possibility of
dislodging a clot.
Emotions

Emotions are an essential element of the postpartum

assessment. Postpartum women typically exhibit symptoms of the
“baby blues” or “postpartum blues,” demonstrated by tearfulness,
irritability, and sometimes insomnia. The postpartum blues are
caused by a multitude of factors, including hormonal
fluctuations, physical exhaustion, and maternal role adjustment.
This is a normal part of the postpartum experience.
If symptoms last longer than a few weeks or if the
postpartum patient becomes nonfunctional or expresses a desire
to harm herself or her infant, she should be instructed to
report this to her certified nurse-midwife or physician
immediately. Appropriate interventions should be implemented to
protect the mother and her infant; this behavior is indicative
of postpartum depression (discussed below under “Postpartum
Complications”).
Postpartum mothers and their families should be taught to
understand that the baby blues are a normal part of the
postpartum experience. Patients should rest regularly and allow
family members to care for them as needed. They should get
plenty of fresh air and gentle exercise. Nurses can acquaint
patients with groups for new mothers that provide the support of
others experiencing postpartum blues. Finally, postpartum
mothers and their families are taught the signs and symptoms of
postpartum depression.
OTHER ASSESSMENTS
Pain

During the postpartum period, it is very important that

healthcare providers continually assess a patient for pain,
taking into account the patient’s acceptable pain levels. They
should look for pain in all areas of the body, including the
head, chest, breast, back, limbs, abdomen, uterus, perineum, and
extremities. Positioning during labor may cause muscular
discomfort, and headaches can indicate preeclampsia. Inadequate
pain control can affect the patient’s care for her baby.
Patients should also be assessed for emotional pain and treated
accordingly.

Mild analgesics or narcotics may be prescribed. Providers

can also teach nonpharmacologic methods of pain relief to the
patient and her family. Some of these methods include the
application of hot or cold packs, massage, progressive
relaxation, and meditation.
Cesarean Section Issues

Women who deliver via C-section have some additional

assessment needs during the postpartum period, including
incision status, pain, respirations, and lung and bowel sounds.
C-section patients may have vertical or
horizontal incisions that will need to be assessed throughout
the postpartum period. The REEDA method (redness, edema,
ecchymosis, discharge, and approximation) can be used to assess
these incisions. Incisions should be well approximated and
without signs and symptoms of infection, including significant
redness, edema, and drainage. There should be minimal to no
drainage from the incision. If minimal drainage is present, it
should not have a foul odor.
It is important to teach patients to examine their incision
each day with a mirror or have a family member monitor the
incision for them. Patients are instructed to immediately report
any abnormal findings, such as hematomas, abnormal drainage,
odors, or significant pain, to their healthcare provider.
Providers should also monitor pain levels in patients who
experienced a C-section. To manage pain during the initial
postoperative period, these patients generally have a single
morphine or opioid dose as spinal or epidural anesthesia or a
continuous intravenous infusion of pain medication via a
patient-controlled anesthesia (PCA) pump. Alternatively or
additionally, patients may take NSAIDs and/or oral or parenteral
opioids (Grant, 2016).
When patients receive narcotics for pain relief, there is a
possibility of respiratory depression. Therefore,
monitoring respirations is imperative. If a patient exhibits
respirations below 12 breaths per minute, immediate intervention
is necessary. The anesthesiologist or other physician (per
hospital policy) should be notified immediately, oxygen
administered, pulse oximetry levels monitored, and the head of
the bed elevated. Naloxone hydrochloride (Narcan), a narcotic
antagonist, should be available for administration per hospital
policy or as ordered.
Assessment of patients delivering via C-section also
includes auscultation of lung sounds because respiratory
depression and prolonged periods of immobility may cause
secretions to accumulate in the lungs, leading to further
complications. Patients are taught to turn, cough, and deep-
breathe while splinting the incision and to use an incentive
spirometer to aid in clearing the lungs. Bowel sounds and the
presence of flatus are assessed regularly to ensure proper GI
functioning prior to discharge.
Intimate Partner Violence

In addition to the typical assessments deemed necessary

during the postpartum period, it is vital to assess for signs
and symptoms of intimate partner violence (IPV), formerly known
as domestic violence. IPV touches the lives of countless
families around the world, and healthcare providers can help to
remedy this problem.
According to the National Intimate Partner and Sexual
Violence Survey (CDC, 2014), an estimated 19% of women in the
United States have been raped and an estimated 44% of women have
experienced other forms of sexual violence during their
lifetimes. The American Nurses Association (ANA) Position
Statement on Violence Against Women (2000) indicates that the
ANA supports the “assessment of women in healthcare institutions
and community settings [for IPV].”
Abusive behaviors are often exacerbated during pregnancy
and after delivery. Therefore, the maternal-child nurse has a
special opportunity to assess and assist women suffering from
IPV. It is essential that nurses have a clear understanding of
the tools and techniques necessary to assess this population
during the postpartum period and are knowledgeable about
community services related to IPV.

SIGNS AND SYMPTOMS

Intimate partner violence is abuse that occurs between two
people who are in a close or intimate relationship. It can
manifest as physical, verbal/emotional, or sexual abuse, or as
threatened abuse. Symptoms of IPV include:
 Chronic pain
 Migraine
 Depression
 Anxiety
 Bruises at various stages of healing
 Bruises resembling cords or belts
 Pelvic inflammatory disease (PID)
 Urinary tract infection (UTI)
An abusive partner may exhibit hostile or demanding behavior or
may refuse to leave the patient’s side. Abusers may also answer
for the patient and find ways to alienate the patient from her
family and friends.

ASSESSMENT
In assessing patients for IPV, nurses should provide a
private space for the assessment and ensure confidentiality.
Since IPV occurs between husband and wife, boyfriend and
girlfriend, domestic partners, and other family members, nurses
should avoid questions such as “Do you feel safe at home?” or
“Is anyone abusive to you?” in the presence of others, including
family members and friends.
 Furthermore, it is essential that nurses ask questions in a
nonjudgmental manner because victims of IPV are often afraid and
may feel ashamed. It is important to use open-ended questions
such as “Can you tell me more about this?” and to avoid
judgmental questions like “Why don’t you just leave?” or “Why do
you continue to go back?” It is essential for nurses to assess
patients in an unhurried and supportive manner that will provide
a safe space for them to talk about any violence.
Various tools are available to screen and assess patients
for IPV, and many healthcare organizations have agreed to follow
the ANA recommendation of screening all patients who enter
healthcare facilities for IPV. The CDC has published Intimate
Partner Violence and Sexual Violence Victimization Assessment
Instruments for Use in Healthcare Settings, which lists and
evaluates IPV screening tools that can be used by healthcare
providers to assess patients for IPV (Basile et al., 2007). With
the assistance of such tools, nurses are able to refer patients
to the appropriate resources within healthcare facilities and
the community.

POSTPARTUM COMPLICATIONS

Despite the normalcy of childbirth, complications may arise

that will have detrimental effects on the postpartum patient.
These include postpartum hemorrhage, thrombophlebitis,
infections (including mastitis, endometritis, and urinary tract
infections), and postpartum depression. Healthcare professionals
working with postpartum patients must have a clear understanding
of these complications, including the symptoms, nursing
interventions, and treatment.
Postpartum Hemorrhage (PPH)

Postpartum hemorrhage is one of the leading causes of death

among postpartum women. PPH refers to a blood loss of at least
500 mL after a vaginal birth and at least 1000 mL after a C-
section. Postpartum hemorrhage is categorized as early or
late. Early refers to a hemorrhage occurring within the first 24
hours after birth, while late refers to a hemorrhage occurring
24 hours to 12 weeks after delivery. Early postpartum hemorrhage
affects 1% to 5% of deliveries and late hemorrhage 0.2% to 2% of
deliveries (Belfort, 2016).

RISK FACTORS
Every postpartum woman has the potential to hemorrhage after
delivery. However, some patients have attributes that place them
at higher risk for postpartum hemorrhage. These risk factors
include:
 High parity
 Uterine overdistension (e.g., multiple gestation,
polyhydramnios, macrosomia)
 Obesity
 Previous postpartum hemorrhage
 Uterine infection
 Hypertensive disorders
 Prolonged or precipitous labor
 Labor induction
 Vacuum or forceps delivery
 Lacerations
 Intrauterine fetal demise
 Placenta previa
 Use of certain medications (e.g., magnesium sulfate)
 Mechanical factors, such as a full bladder
 Retained placenta/membranes
(Belfort, 2016)

CAUSES AND INTERVENTIONS

Early postpartum hemorrhage is often caused by uterine
atony. With uterine atony, there is a failure of the uterine
muscles to contract properly, thereby inhibiting the healing of
blood vessels at the site of placental attachment. The blood
vessels continue to bleed until the uterine muscles contract.
Signs of uterine atony include a boggy uterus, a fundus that is
higher than expected upon palpation, and excessive lochia.
 If the fundus is not firm (boggy), there are several nursing
interventions that can alleviate the problem:
1. Massage the uterine fundus.
2. Encourage the patient to void, or catheterize as needed.
3. Administer prescribed medications, such as oxytocin
(Pitocin), ergonovine, methylergonovine (Methergine),
misoprostol (Cytotec), or carboprost tromethamine
(Hemabate), to assist the uterus in contracting.
(Methergine can cause an elevation in blood pressure and
should not be used with hypertensive women.)
The nurse must report a PPH immediately and prepare for the
insertion of a large-bore intravenous catheter, if one is not
already present, and the administration of intravenous fluids
and oxygen. A large-bore intravenous catheter is inserted to
allow possible administration of blood products. The nurse
should assess continually for bleeding, changes in vital signs,
and oxygen saturation. The patient’s legs may also be elevated.
Patients and their families will need nursing support during a
PPH, as it can be quite a disconcerting experience.
Early postpartum hemorrhage can also be caused by damage to
the birth canal during labor and birth. If an early PPH is due
to trauma to the birth canal, such as a hematoma, an extension
of a perineal incision, or an improperly sutured laceration,
patients may exhibit one or more of the following symptoms:
 Contracted uterus with excessive lochia
 Bright red lochia
 Constant trickle of blood from the vagina
 Severe pain (possibly from a hematoma)
 Shock
In the case of an early PPH caused by damage to the birth
canal, surgical repair is usually necessary. In the case of
hematoma formation, surgical incision, evacuation of blood
clots, and ligation of the bleeding blood vessel may be
necessary. However, in the case of a small hematoma, observation
and application of ice may be all that is necessary (Murray &
McKinney, 2014).
 postpartum hemorrhage is often caused by diffuse uterine
atony or subinvolution of the uterus(uterus not returning to its
normal size) caused by retained placental fragments and/or
infection that prevent the uterus from contracting. In the case
of retained placental fragments, clots develop around the
retained fragments and hemorrhaging can occur days later when
the clots are shed. The certified nurse-midwife or physician is
responsible for examining the placenta after delivery and
ensuring that it is intact; therefore, a late PPH is usually
preventable. Women with placenta accreta (an abnormally deep
attachment of the placenta) or when providers attempt to extract
the placenta prior to uterine wall separation are at higher risk
for a late PPH.
Assessment and manual expression of placental fragments by the
physician or nurse-midwife can often alleviate the problem;
however, surgical intervention, such as a dilation and
evacuation (D&E), may be necessary. With subinvolution and a
late PPH, fundal massage, in addition to medications (Pitocin,
misoprostol) and the previously mentioned interventions for
early PPH, may be used to minimize bleeding.

HYPOVOLEMIC SHOCK
A sequelae of PPH is hypovolemic shock. Under normal
circumstances, postpartum women are able to withstand blood loss
during the postpartum period as a result of increased blood
volume during pregnancy. However, in the presence of a PPH,
hypovolemic shock can occur and cause severe organ damage and
even death if untreated.
Often mild tachycardia, palpitations, and lightheadedness are
the first signs and symptoms of hypovolemic shock. The blood
pressure usually decreases and the respiratory rate increases.
Weakness and sweating with a further increase in heart rate
(100–120 beats/min) can indicate more severe blood loss.
Patients may also become restless, confused, and pale with
worsening tachycardia (120–140 beats/min) as blood loss starts
to affect the brain. Later stages show lethargy, air hunger,
anuria, collapse, and more extreme tachycardia (>140
beats/min) (Belfort, 2016). Hypovolemic shock can be stopped by
stopping blood loss.
These patients will also require oxygen (usually 8–10 L via face
mask), IV fluids, and possibly blood products. This is a very
serious situation, and nurses must be prepared to assist in this
life-threatening emergency.
Thrombophlebitis

Women can suffer from thrombophlebitis as a result of venous

stasis and the normal hypercoagulability state of the postpartum
period. Thrombophlebitis is an inflammation of the blood vessel
wall in which a blood clot forms and causes problems in the
superficial or deep veins of the lower extremities or pelvis.
All postpartum women are at risk. However, certain risk factors
predispose some women to developing thrombophlebitis. These risk
factors include:
 Cesarean delivery
 Preeclampsia
 Hemorrhage
 Infection
(Berens, 2016)
The blood clot that develops in thrombophlebitis can lead to a
life-threatening pulmonary embolism as a result of the clot
detaching from the vein wall and blocking the pulmonary artery.
The major signs of pulmonary embolism include dyspnea and chest
pain.
In monitoring postpartum patients for the development or
presence of thrombophlebitis, nurses assess for the presence of
hot, red, painful, or edematous areas on the lower extremities
or groin area. An elevated temperature may also be present. As
previously mentioned, it is currently contraindicated to assess
for a thrombophlebitis by eliciting a Homan’s sign.
to treat thrombophlebitis depend on the severity of the
thrombosis. Usually, for superficial thrombosis, analgesics, bed
rest, and elevation of the affected limb is enough to alleviate
the problem. However, in the presence of a DVT, anticoagulants
may be necessary. In addition to use of compression stockings
and warm, moist heat applications, patients are instructed to
keep their legs elevated and uncrossed. These patients are
typically allowed to ambulate only after symptoms subside.
Infections

infections are infections accompanied by a temperature of

38 °C or higher on two separate occasions during the first 10
days postpartum, exclusive of the first 24 hours (when low-grade
fever is common and self-limited) (Berens, 2016). Postpartum
patients are carefully monitored for signs and symptoms of
infection during this period. Common infections that may occur
during the postpartum period include mastitis, endometritis,
wound infections, and urinary tract infections.

MASTITIS
Mastitis is a localized painful infection of the breast, which
can progress to an abscess if not treated properly. It typically
presents as a red, painful, firm, swollen area of one breast
with a fever >38.3 °C. The patient may also complain of myalgia,
chills, malaise, and flu-like symptoms (Dixon, 2016). Mastitis
often occurs in the setting of the following breastfeeding
problems, which typically lead to prolonged engorgement or poor
drainage:
 Partial blockage of milk duct (reduced drainage results in
stagnant milk distal to the obstruction)
 Pressure on the breast (e.g., tight brassiere or car
seatbelt)
 Oversupply of milk
 Infrequent feedings
 Nipple excoriation or cracking
 Rapid weaning
 Illness in mother or baby
 Maternal stress or excessive fatigue
  Maternal malnutrition
(Dixon, 2016)
Mastitis is less likely to occur with complete emptying of the
breast and good breastfeeding technique. Thus, it is crucial
that postpartum nurses teach breastfeeding patients proper
latch-on technique and that they stress regular breastfeeding
and allowing the breast to empty completely. Breastfeeding
patients are also encouraged to avoid missing feedings and
allowing the breast to become engorged.
Treatment for mastitis typically involves antibiotic therapy and
regular breastfeeding or pumping the breast. Nurses can
encourage these patients to apply cold or warm compresses to
ease discomfort and to take analgesics as needed. Mastitis
usually resolves quickly as long as patients continue to
breastfeed or pump regularly.

ENDOMETRITIS
Endometritis is an infection of the uterus characterized by
postpartum fever, midline lower abdominal pain, and uterine
tenderness. Also purulent lochia, chills, headache, malaise,
and/or anorexia may be present (Chen, 2016). The following
factors predispose women to developing endometritis:
 Cesarean delivery (especially after the onset of labor)
 Chorioamnionitis
 Prolonged labor
 Prolonged rupture of membranes
 Multiple cervical examinations
 Internal fetal or uterine monitoring
 Large amount of meconium in amniotic fluid
 Manual removal of the placenta
 Low socioeconomic status
 Maternal diabetes mellitus or severe anemia
 Preterm birth
 Operative vaginal delivery
 Postterm pregnancy
 HIV infection
  Colonization with group B streptococcus
 Nasal carriage of Staphylococcus aureus
 Heavy vaginal colonization by Streptococcus
agalactiae or Escherichia coli
(Chen, 2016)
Endometritis is usually treated with broad-spectrum
intravenous antibiotics and rest. Blood cultures to identify the
causative organism of endometritis are done if the patient does
not respond to empiric therapy. White blood cell (WBC) counts
are monitored. However, it is important to remember that the
white blood cell count is normally elevated after delivery for a
short period; continued monitoring of the WBC count is required
in identifying endometritis and is likely to show a left shift
and increasing number of neutrophils.

WOUNDS
Wound infections are infections that occur at wound sites.
Commonly affected wound sites during the postpartum period
include the perineum, where lacerations and episiotomies occur,
and C-section incisions. As with all infections, every patient
is at risk.
Postpartum patients with wound infections typically have
wounds that exhibit redness, warmth, poor wound approximation,
tenderness, and pain. If untreated, these patients may develop a
fever and other symptoms of an infection, such as malaise. Blood
cultures may be obtained to isolate the causative organism.
Antibiotics will typically be administered, and drainage of the
wound may be necessary.
Patients are taught about proper handwashing and encouraged to
maintain adequate fluid intake and increased protein intake to
assist in wound healing. Wound infections can be intensely
painful, especially in the perineum. Therefore, the nurse
assists these patients in managing pain through the use of
analgesics and positioning.

URINARY TRACT INFECTIONS (UTIs)

 Urinary tract infections are common during the postpartum
period. A woman’s urethra and bladder are often traumatized
during labor and birth due to intermittent or continuous
catheterizations and the pressure of the infant as it passes
through the birth canal. Additionally, the bladder and urethra
lose tone after delivery, making the retention of urine and
urinary stasis common. The risk of developing a UTI is high.
Women may also develop a UTI due to epidural anesthesia or
vaginal procedures (Berens, 2016).
Patients with urinary tract infections often complain of
frequent, urgent, and/or painful urination with suprapubic pain.
A low-grade fever and hematuria may also be present. Urinary
tract infections are treated with antibiotics, but it is
important that these patients drink adequate fluids to flush
bacteria out of the system.
HEMORRHOIDS AND INCONTINENCE
Hemorrhoids are common in late pregnancy (7.8%) and may
also develop during pushing, especially with large babies and
traumatic delivery. In the postpartum period, 35% of women
experienced anal lesions, with 20% having thrombosed external
hemorrhoids and 15% having anal fissures. Symptomatic
hemorrhoids may be treated with local anesthetics, topical
astringents/protectants, bulk-forming laxatives, stool
softeners, topical corticosteroids, or topical vasoactive
agents.
Urinary and anal incontinence is also common in the first
postpartum year. In a study of more than 1,500 women, 47%
reported urinary incontinence and 17% reported anal incontinence
in the first 12 months after delivery. The presence of urinary
incontinence at 3 months is a risk factor for long-term urinary
incontinence at 12 years, according to a longitudinal cohort
study.
Source: Berens, 2016.
Postpartum Depression

Postpartum depression is a serious and debilitating

depression that affects many women throughout the world.
Postpartum depression occurs in 8% to 15% of women after
delivery.
Symptoms are generally noted within the first three months
but may occur up to a year after delivery. Symptoms typically
include changes in sleep, energy, appetite, weight, and libido.
Other symptoms include lack of energy to the point of not
getting out of bed for hours; but this should be distinguished
from the normal lack of energy that results from sleep
deprivation of caring for an infant. Additional symptoms include
anxiety and panic attacks; irritability and anger; feeling
inadequate, overwhelmed, or unable to care for the baby; and
feelings of shame, guilt, and having failed as a mother (Roy-
Byrne, 2016).
Adverse outcomes of postpartum depression can include impaired
bonding, impaired infant and child development, marital discord,
suicide, and infanticide (Roy-Byrne, 2016).
It is the responsibility of nurses to assess postpartum
patients for signs and symptoms of postpartum depression.
Various assessment tools are available, including the Edinburgh
Postnatal Depression Scale (EPDS) and the Postpartum Depression
Screening Scale (PDSS). These tools are quick and provide a
simple way to assess patients while at the hospital, at home
during postpartum home visits, and during postpartum follow-up
visits. These tools can also be used to assess mothers at
pediatric follow-up visits.
After screening and assessment, women who are at risk for
developing (or who are suffering from) postpartum depression can
be referred to the appropriate healthcare professional for
follow-up and treatment. According to Murray & McKinney (2014),
“Depression responds best to a combination of psychotherapy,
social support, and medication.”
 Postpartum depression is usually treated with counseling
and medication. Nurses can support these patients in the healing
process at follow-up appointments and during home visits.
Driscoll (2006)recommends that nurses help mothers and their
families understand postpartum depression and assist them in
exploring the spiritual aspects of their suffering as an aid in
the healing process. Additionally, nurses should encourage these
patients to get adequate nutrition, rest, relaxation, and
exercise.

DISCHARGE INSTRUCTIONS

Postpartum patients and their families are instructed to call

the healthcare provider if the patient experiences any of the
following:
 Fever
 Foul-smelling lochia
 Large blood clots (golf ball–sized or bigger) or bleeding
that saturates a pad in one hour
 Discharge, erythema, or severe pain from incisions or
stitched areas
 Hot, red, painful areas on the breasts or legs
 Bleeding and/or severe pain in the nipples or breasts
 Severe headaches and/or blurred vision
 Chest pain and/or dyspnea without exertion
 Frequent, painful urination
 Signs of depression

POST PARTUM FAMILY PLANNING

Postpartum family planning is the initiation and use of

family planning methods in the first six weeks following
delivery. The aim is to prevent unintended pregnancy,
particularly soon after childbirth, when another pregnancy could
be harmful to the health of the mother or breastfeeding baby.
Best choice: non- Alternative choice: Less preferable:
combined oestrogen-
hormonal methods progestin-only progestin methods
methods
 Lactation  Progestin-only  Combined oral
menorrhea method pills contraceptive
(LAM) pills (COCs)
 Injectables
 Diaphragm (DMPA, NET-EN)  Monthly
injectables
 Male and female  Implants
(Mesigyna,
condoms (Jadelle,
Cyclofem).
Implanon).
 Spermicides
 IUCD
 Male and female
sterilisation
 Natural Family
Planning (NFP).

Effective breastfeeding should be encouraged for the benefit of

the mother, and the health of the infant. Here are three general
guidelines you should follow.

 Encourage women to exclusively breastfeed for the first six

months.
 Ensure their chosen contraceptive method will not adversely
affect breastfeeding or the health of the infant.
 Be certain that breastfeeding is not discontinued in order to
start a contraceptive method.
For breastfeeding women, non-hormonal methods are the best
choice and can safely be used. They do not interfere with a
woman’s ability to breastfeed, or the quality and quantity of
breastmilk and there is no adverse effect on infant growth and
development. From your previous sessions in this module, you
have learnt that non-hormonal methods include lactation
amenorrhoea method (LAM), male or female condoms, spermicides,
diaphragms, IUCDs, male or female voluntary surgical
contraception (VSC), and natural family planning methods.

Progestin-only oral contraceptive methods are the next best

choice, and are considered a suitable method for breastfeeding
women six weeks after childbirth. This method has been shown not
to affect breastmilk secretion and breastfeeding or infant
growth and development. Options include progestin-only
injectables, progestin-only pills, and implants put under the
skin.

It is recommended that progestin-only methods be provided

after the first six weeks postpartum. However, some find it more
convenient to begin these methods immediately after delivery,
since no adverse effects on the infant or breastfeeding have
been observed.

Combined oral contraceptives are less frequently

recommended for breastfeeding mothers, because they are known to
decrease breastmilk secretion by inhibiting the secretion of
prolactin. However, it is an option if the mother is no longer
breastfeeding, or breastfeeding less frequently six months after
childbirth. These methods include combined oral contraceptives
and combined injectable contraceptives (Mesigyna and Cyclofem)

POST PARTUM FAMILY PLANNING

While family planning (FP) is important throughout an

individual’s and couple’s reproductive life, postpartum family
planning (PPFP) focuses on the prevention of unintended and
closely spaced pregnancies through the first 12 months following
childbirth. Table 1 identifies the continuum of points of
contact within the health care system that can provide
opportunities to integrate PPFP with maternal, newborn and child
health (MNCH) interventions during the 12-month period after
childbirth. While this document’s parameters cover the first
year postpartum only, programmes should also undertake
strategies for continuing contraception, or effective switching,
during the second and subsequent years after birth, depending on
a woman’s desire to space or limit future pregnancies (WHO
2012a)

CONTINUUM OF POINTS OF CONTACT FOR PPFP

RATIONALE OF PPFP

Globally, FP is recognized as a key life-saving

intervention for mothers and their children (WHO 2012b). PPFP
has an important role to play in strategies to reduce the unmet
need for FP. Postpartum women are among those with the greatest
unmet need for FP. Yet they often do not receive the services
they need to support longer birth intervals or reduce unintended
pregnancy and its consequences. PPFP addresses the needs of
those who wish to have children in the future (referred to as
‘spacers’), as well as those who have reached their desired
family size and wish to avoid future pregnancies (referred to as
‘limiters’). Further rationale for PPFP includes the following:

• According to an analysis of Demographic and Health Surveys

data from 27 countries, 95% of women who are 0–12 months
postpartum want to avoid a pregnancy in the next 24 months; but
70% of them are not using contraception (Ross & Winfrey 2001).
• FP can avert more than 30% of maternal deaths and 10% of child
mortality if couples space their pregnancies more than 2 years
apart (Cleland et al. 2006).

• Closely spaced pregnancies within the first year postpartum

are the riskiest for mother and baby, resulting in increased
risks for adverse outcomes, such as preterm, low birth weight
and small for gestational age (Da Vanzo et al. 2007).

• Risk of child mortality is highest for very short birth-to-

pregnancy intervals

VITAMIN K PROPYLAXIS

Early VKDB :This presents in the first 24 hours of life,

usually with severe haemorrhage, including GI bleeding , and
intracranial hemorrhage. It is caused by severe vitamin K
deficiency in utero, usually result of maternal medication that
interferes with vitamin K ( ex. Anticonvulsants)Classical VKDB
:This presents at 2-7 days old in babies who have not received
prophylactic vitamin k at birth. The risk is increased in
breastfeed babies in those with poor oral intake.

Late VKDB : This occurs in the first week of life ,most

often between 2 and 8 weeks after birth. The characteristic
presentation is of sudden intracranial hemorrhage in an
otherwise well, breastfed term infant or in babies with liver
disease or malabsorptive states.

Prevention of vitamin K deficiency bleeding (VKDB) with

intramuscular vitamin K is of primary importance in the medical
care of neonates. A single dose of intramuscular vitamin K after
birth effectively prevents classic vitamin K deficiency
bleeding. Conversely, oral vitamin K prophylaxis improves
coagulation test results at 1-7 days, but vitamin K administered
by this route has not been tested in randomized trials for its
efficacy in preventing either classic or late vitamin K
deficiency bleeding.

Action : Vitamin K is required for synthesis of prothrombin and

three other clotting factors : VII, IX, and X. All of these
vitamin k –dependent factors are needed for coagulation of
blood.Forms and Sources of Vitamin K : Vitamin K occurs in
nature in two forms: (1) vitamin K1, or phytonadione (
phyloquinone) and (2) vitamin k2. Vitamin k2 is present in wide
variety of foods. Vitamin K2 is synthesized by the normal flora
of the gut. Two other forms – vitamin k4 ( menadiol) and vitamin
k3 (menadione)- are produced synthetically. At this time,
phytonadione is the only form of vitamin k available for
therapeutic use.

Interaction : Wash hands. Inject a single dose of Vitamin K 1 mg

IM.

Therapeutic Use and Dosage Vitamin K Deficiency

Vitamin K deficiency produces bleeding tendencies. If the

deficiency is severe, spontaneous hemorrhage may occur. In
newborns , intracranial hemorrhage is of particular concern. The
normal infant is born vitamin k deficient . Consequently , in
order to rapidly elevate prothrombin levels, and thereby reduce
the risk of neonatal hemorrhage, it is recommended that all
infants receive a single injection of phytonadione ( vitamin K1
), 0.5mg to 1mg, immediately after (Lehne, 2013, p ).

Hepatitis B Vaccine

Hepatitis B (Hep B) is a viral infection in the blood that

cause liver problems including liver cancer. 25% of babies who
develop chronic infection will die of liver failure or liver
cancer later in life.90% of baby infected with Hep b around the
time of birth will carry the infection for life (chronic). If a
mother is infected with Hep B, the virus can be transmitted to
the baby during birth.

Prevention of perinatal HBV transmission In order to

prevent HBV transmission from mother to infant, the first dose
of HB vaccine needs to be given as soon as possible after birth
(preferably within 24 hours).

The NIP policy recommends Hep B birth vaccine is given

within 24 hrs after birth, as this is when it is most effective.
It can be given up to 7 days where this can not be achieved.

Hepatitis B vaccines are available in liquid single- dose

glass vials. The standard paediatric dose is 0.5 ml. Injection
equipment 0.5 ml auto-disable (AD) syringes are recommended.
Route If AD syringes are not available, standard disposable
syringes (1 ml or 2 ml with 22/23 gauge needle is recommended)
must be used ONCE ONLY. Dosage. Intramuscular (IM) injection
into the right thigh.

All the baby should have Hep B vaccine

◦ Low birth weight baby

◦ Premature baby

◦ Jaundice (yellow)

◦ HIV mother should still given Hep B vaccine.

Severe reaction: anaphylaxis (1.1/1000000)

Minimal side effect:

◦ Local pain (3-29/100)

◦ Myalgia

◦ Transient fever (mostly within 24hrs) (1- 6/100)

◦ Swelling (3/100)

◦ Erythema (3/100)

◦ Headache (3/100)

BCG

BCG (Bacille Calmette Guerin) called Mycobacterium bovis

which is closely related to Mycobacterium tuberculosis, the
agent responsible for tuberculosis. It is prevent children
getting more severe forms of TB, particularly TB meningitis. It
is freeze-dried and need to be mixed with the correct diluent
from the same manufacturer before administration

BCG can give up to baby 1 year old. BCG vaccine vials must be
discarded 6hrs after mixing.

Route: ID into the upper arm.

Dose: a vial with 20doses, dose for new born is 0.05ml.

Mild side effect

  Papule may be red, tender and indurated (2-4wks).
 The papule commences two or more weeks after vaccination
and then may progress to become ulcerated healing after 2-5
months leaving a superficial scar.

Severe adverse effect (rarely)

◦ Local abscess ◦ Keloid

◦ Lymphadenitis ◦ Suppuration (onset 2-6 months)- 1per 1000-

100000 ◦ Systemic (1-12 months onset time)

◦ Cutaneous skin lesions

◦ Osteitis (1/3333-100000000)

◦ Disseminated BCG

◦ Immune Reconstitution Syndrome: collection of inflammatory

disorders

Crede’s Propylaxis

 done to prevent Opthalmia Neonatorum or Gonorrheal

Conjunctivitis
 legal requirement for all NB
 infection can be acquired during delivery from a mother
with untreated Gonorrhea

Medications – Ag NO31% -1-2gtts

Site: lower conjunctival sac; inner to outer cantus.

Anthropometric Measurements

A baby's birthweight is an important indicator of health. The

average weight for full-term babies (born between 37 and 41
weeks gestation) is about 7 lbs (3.2 kg). In general, small
babies and very large babies are more likely to have problems.
Newborn babies may lose as much as 10% of their birthweight.
This means that a baby weighing 7 pounds 3 ounces at birth might
lose as much as 10 ounces in the first few days.

Pediatric Anthropometric Measurement

 Pediatric anthropometric measurements are commonly used as
indicators of growth and development for infants. These
measurements are plotted against the standard World Health
Organization’s growth charts to assess the growth of your baby
compared with national or international standards.
In our studies, we are interested in monitoring changes in
growth because poor growth in early life or excessive weight
change, as well as periods of rapid weight gain, have been
related with increased risks of metabolic disease such as
obesity and diabetes.
The pediatric assessments that we do in our Unit include a wide
range of measurements:
Weight
The baby will be placed on a digital scale like the one in the
picture below. Please note that we will be asking you to remove
the baby’s nappy before the measurement.

Recumbent length
The length will be measured with the baby lying down on the
measuring equipment (see below). We measure from the top of the
head to the heel.

Head circumference
The head circumference is taken with a measuring tape like the
one in the picture below. We will wrap the tape around the
baby’s head above the eyebrows and ears.

Waist circumference
This measure is to estimate fat distribution and the amount of
fat around the tummy area. A small measuring tape will be placed
above the belly button.
Anogenital distance
This measure allow us to estimate hormone levels in your baby.
In particular, this measure is used as an indicator of whether
boys are developing properly in response to male hormones called
androgens (e.g. testosterone). We will be using a small caliper
(like the one in the picture) to measure the distance from the
anus to the genitalia.

Penile length and undescended testes assessment

This assessment is to establish the presence of undescended
testes. It appears that undescended testes are related to
patterns of weight gain and excessive fat during infancy. The
length will be measured with the caliper pictured above.
Undescended testicles are determined by examining the scrotum.
Skinfold thickness measurements
This assessment allow us to estimate body fat in your baby. A
caliper is used to measure the thickness of a fold of the baby’s
skin with its underlying layer of fat (the subcutaneous fat).
The measurements are taken from the following body sites:
triceps (upper arm), subscapular (shoulder blade area),
quadriceps (thigh area), flank (at the back between rib and
hip).
Triceps
The measurement of the triceps skinfold is taken halfway between
the top of the shoulder and the elbow (halfway along the upper
arm).

Subscapular
The measurement of the subscapular skinfold is taken at the
bottom right corner of the left shoulder blade.

Quadriceps
The Measurement of the quadriceps (thigh) skinfold is taken
halfway along the top of the upper leg.
NEWBORN ASSESSMENT
NEWBORN REFLEXES

Fetal Circulation
The cardiovascular system is one of the first systems to become
functional in intrauterine life. Simple blood cells joined to
the walls of the yolk sac progress to become a network of blood
vessels and a single heart tube, which forms as early as the
16th day of life and beats as early as the 24th day. The septum
that divides the heart into chambers develops during the sixth
or seventh week. Heart valves begin to develop in the seventh
week. The heartbeat may be heard with a Doppler instrument as
early as the 10th to 12th week of pregnancy. An
electrocardiogram (ECG) may be recorded on a fetus as early as
the 11th week, although the accuracy of such ECGs is in doubt
until about the 20th week of pregnancy, when conduction is more
regulated.

The heart rate of a fetus is affected by oxygen level, activity,

and circulating blood volume, just as in adult life. After the
28th week of pregnancy, when the sympathetic nervous system has
matured, the heart rate begins to show a baseline variability of
about 5 beats per minute on a fetal heart rate rhythm strip

As early as the third week of intrauterine life, fetal blood be-

gins to exchange nutrients with the maternal circulation across
the chorionic villi. Fetal circulation differs from extrauterine
circulation because the fetus derives oxygen and excretes carbon
dioxide not from gas exchange in the lung but from gas exchange
in the placenta.

Blood arriving at the fetus from the placenta is highly

oxygenated. This blood enters the fetus through the umbilical
vein (called a vein even though it carries oxygenated blood,
because the direction of the blood is toward the fetal heart).
Specialized structures present in the fetus then shunt blood
flow to first supply the most important organs of the body: the
brain, liver, heart, and kidneys. Blood flows from the umbilical
vein to the ductus venosus, an accessory vessel that directs
oxygenated blood directly to the fetal liver. Blood then empties
into the fetal inferior vena cava so oxygenated blood is
directed to the right side of the heart. Because there is no
need for the bulk of blood to pass through the lungs, it is
shunted, as it enters the right atrium, into the left atrium
through an opening in the atrial septum, called the foramen
ovale. From the left atrium, it follows the course of adult
circulation into the left ventricle and into the aorta.

A small amount of blood that returns to the heart via the vena
cava does leave the right atrium via the adult circulatory
route—that is, through the tricuspid valve into the right
ventricle, and then into the pulmonary artery and lungs to
service the lung tissue. However, the larger portion of even
this blood is shunted away from the lungs through an additional
structure, the ductus arteriosus, directly into the descending
aorta.

Most of the blood flow from the descending aorta is transported

by the umbilical arteries (called arteries, even though they are
now transporting deoxygenated blood, because they are carrying
blood away from the fetal heart) back through the umbilical cord
to the placental villi, where new oxygen exchange takes place.

The blood oxygen saturation level of the fetus is about 80% of a

newborn’s saturation level. The rapid fetal heart rate during
pregnancy (120–160 beats per minute) is necessary to supply
oxygen to cells, because the red blood cells are never fully
saturated. Despite this low blood oxygen saturation level,
carbon dioxide does not accumulate in the fetal system because
it rapidly diffuses into maternal blood across a favorable
placental pressure gradient.

Cord Care

The aim of cord care is to prevent infection in the Newborn

baby. It is essential that it is carried out with the baby’s
care, in a manner that minimises cross infection.

EQUIPMENT

 Cotton wool  Cx powder

PROCEDURE

 Demonstrate and explain procedure to parents

  Umbilicus to be checked daily for

1) Security of clamp to reduce the risk of

exsanguination

2) General condition to detect for signs of infection –

redness or discharge or imbilical flare

 Wash hands to prevent cross infection

 Cord should be cleaned thoroughly with tap water, cotton

wool and dried to remove any debris

 Put Cx onto cotton wool ball and lightly dust cord with Cx
powder to reduce risk of umbilical staphylococcus infections
and neonate inhaling Cx.

 Advise parents to observe umbilicus at each nappy change.

Wash and re-apply Cx powder as appropriate (minimum twice in
24 hours), to encourage parental involvement and ensure
continuation of umbilical care. Allow umbilicus to dry.

 If abnormally sticky or offensive inform the Doctor/CNNP in

order for them to assess cord and instigate any necessary
treatment.

 Cord clamp may be left on until cord separation, weight of

clamp aids separation. If clamp to be removed single use only
clamp removers must be used and discarded.

Documentation

 Record care given in nursing records

APGAR SCORING

Apgar is a quick test performed on a baby at 1 and 5 minutes

after birth. The 1-minute score determines how well the baby
tolerated the birthing process. The 5-minute score tells the
health care provider how well the baby is doing outside the
mother's womb.

The baby’s APGAR score is what doctors will use to check their
heart rate, to check their muscle tone, and to look for other
signs that may indicate that the baby requires additional
medical care or emergency care.

The APGAR test is a standard procedure and it is administered

for every infant, however, the baby’s score will determine how
medical staff care for the baby during their first few days at
the hospital. The test is always given twice, but if there are
concerns, it may be given more than twice. In rare cases, the
test will be done 10 minutes after birth.

The APGAR score is used to check some key signs of the newborn
baby, but keep in mind that most babies rarely gets a perfect
score and it should not cause alarm if your baby does get a low
score. A low score just indicates to doctors that they need to
look for potential issues so that your infant can be cared for
the best.

Generally, the APGAR score is a baby's first assessment. Its

purpose is to check their basic health, like heart rate, but
it's not an indicator (in any way) of your baby's future
behavior or intellect. The test is only a basic assessment to
help doctors provide your baby with the highest level of care.

The test itself was developed all the way back in 1952 by
Virginia APGAR, an obstetric anesthesiologist. It is a standard
tool by which all newborn babies are assessed.

A stands for Appearance (skin color)

P stands for Pulse (heart rate)

G stands for Grimace response (reflexes)

A stands for Activity (muscle tone)

R stands for Respiration (breathing rate and effort)

Each category is scored with 0, 1, or 2, depending on the

observed condition.

Breathing effort:

 If the infant is not breathing, the respiratory score is 0.

  If the respirations are slow or irregular, the infant
scores 1 for respiratory effort.

 If the infant cries well, the respiratory score is 2.

Heart rate is evaluated by stethoscope. This is the most

important assessment:

 If there is no heartbeat, the infant scores 0 for heart

rate.

 If heart rate is less than 100 beats per minute, the infant
scores 1 for heart rate.

 If heart rate is greater than 100 beats per minute, the

infant scores 2 for heart rate.

Muscle tone:

 If muscles are loose and floppy, the infant scores 0 for

muscle tone.

 If there is some muscle tone, the infant scores 1.

 If there is active motion, the infant scores 2 for muscle

tone.

Grimace response or reflex irritability is a term describing

response to stimulation, such as a mild pinch:

 If there is no reaction, the infant scores 0 for reflex

irritability.

 If there is grimacing, the infant scores 1 for reflex

irritability.

 If there is grimacing and a cough, sneeze, or vigorous cry,

the infant scores 2 for reflex irritability.

Skin color:
  If the skin color is pale blue, the infant scores 0 for
color.

 If the body is pink and the extremities are blue, the

infant scores 1 for color.

 If the entire body is pink, the infant scores 2 for color.

Ballard Scoring System

A system for estimating newborn gestational age by rating

physical and neuromuscular characteristics of maturity. For
infants born between 20 and 28 weeks' gestation, Ballard tools
are more accurate than other systems of estimating gestational
age. Six neuromuscular markers are assessed: posture, square
window (degree of wrist flexion), arm recoil, popliteal angle
(degree of knee flexion); scarf sign (ability to extend infant's
arm across the chest past the midline); and heel-to-ear
extension. Seven physical characteristics are also evaluated:
skin; lanugo; plantar creases; breast; eye and ear; and
genitals. Each factor is scored independently, and then an
overall sum is used to determine the gestational age. The tool
is most accurate if performed within the first 12 to 20 hr of
life or as soon as the baby's condition stabilizes.
Vital Signs of Mother and Newborn

Pediatric Vital Sign Normal Ranges

Phototherapy

Phototherapy is
treatment with
a special type
of light (not
sunlight).
It's sometimes
used to treat
newborn
jaundice by
lowering the
bilirubin
levels in your
baby's blood
through a
process called
photo-
oxidation.
Photo-oxidation
adds oxygen to
the bilirubin so it dissolves easily in water. This makes it
easier for your baby's liver to break down and remove the
bilirubin from their blood.

There are 2 main types of phototherapy.

 Conventional phototherapy – where your baby is laid under a

halogen or fluorescent lamp with their eyes covered
 Fibreoptic phototherapy – where your baby lies on a blanket
that incorporates fibreoptic cables; light travels through
the fibreoptic cables and shines on to your baby's back
In both methods of phototherapy, the aim is to expose your
baby's skin to as much light as possible. In most cases,
conventional phototherapy is usually tried first, although
fibreoptic phototherapy may be used if your baby was born
prematurely.

These types of phototherapy will usually be stopped for 30

minutes every 3 to 4 hours so you can feed your baby, change
their nappy and give them a cuddle. If your baby's jaundice
doesn't improve after conventional or fibreoptic phototherapy,
continuous multiple phototherapy may be offered. This involves
using more than one light and often a fibreoptic blanket at the
same time. Treatment won't be stopped during continuous multiple
phototherapy. Instead, milk expressed from your breasts in
advance may be given through a tube into your baby's stomach, or
fluids may be given into one of their veins (intravenously).

During phototherapy, you baby's temperature will be monitored to

ensure they're not getting too hot, and they'll be checked for
signs of dehydration.Intravenous fluids may be needed if your
baby is becoming dehydrated and they aren't able to drink a
sufficient amount.

The bilirubin levels will be tested every 4 to 6 hours after

phototherapy has started to check if the treatment is working.
Once your baby's bilirubin levels have stabilised or started to
fall, they'll be checked every 6 to 12 hours. Phototherapy will
be stopped when the bilirubin level falls to a safe level,
which usually takes a day or two. Phototherapy is generally very
effective for newborn jaundice and has few side effects,
although your baby may develop a temporary rash and diarrhoea.

Perineal Care

Postpartal women are particularly prone to perineal infection

because lochia, if allowed to dry and harden on the vulva and
perineum, furnishes a rich bed for bacterial growth, which then
can spread to the uterus. Because the vagina lies in close
proximity to the rectum, there is also always the danger that
bacteria will spread from the rectum to the vagina. Interruption
in skin integrity from an episiotomy also increases the client’s
risk for infection.

Teach a woman to include perineal care as part of her daily bath

or shower and after every voiding or bowel movement. If the
woman is on bed rest during the first hour after birth, you will
need to provide perineal care for her.

Before beginning perineal care, wash your hands and pull on

clean gloves to prevent the risk of infection transmission.
Place a plastic-covered pad under the woman’s buttocks to
protect the bed during the procedure. With the woman lying in a
supine position, remove the perineal pad from the front to back;
the direction is important to prevent the portion of the pad
that was over her rectal area from sliding forward to
contaminate the vaginal opening.

Perineal care is a clean but not a sterile procedure. Agencies

differ as to the type of cleansing that is done and the articles
and solutions used. If actual washing is to be done, use a clean
gauze square or a clean portion of a washcloth with soap and
water for each stroke, always washing from front to back, from
the pubis toward the rectum. Rinse the area in the same manner,
and dry it.

A second common method is to spray the perineum with clear tap

water from a spray bottle. Direct the spray toward the front of
the perineum, and allow t to flow from front to back. Be certain
that none of the solution enters the vagina, as it could be a
source of contamination. The labia have a tendency to close and
cover the vaginal opening, which normally pre- vents solution
from entering the vagina. Do not separate the labia; instead,
allow them to perform this protective function. Spray gently to
avoid splashing any blood-tinged solution on yourself (to guard
against contacting body secretions).

It may be advantageous to have a woman turn on her side in a

Sims’ position, to permit better visualization of an episiotomy
area. In some women, better cleaning of this area can also be
done in this position.

Perineal Self-Care

As soon as a woman is allowed to get up to go to the bathroom

(if her infant was born without an anesthetic, this is within
the first hour after birth), teach her how to carry out her own
perineal care.

The bathroom should have an area close to the toilet where a

woman can place the equipment she needs for care: a spray
bottle, sponges to dry, clean pads, and so forth. Instruct her
how to remove the soiled perineal pad and where to dispose of
it. Remind her of the importance of using any cream or
medication that has been prescribed. Caution her not to flush
the toilet until she is standing upright. Otherwise, the
flushing water might spray her perineum and cause infection.

If women are given a clear explanation as to why perineal care

is important, they perform it well. However, self-care does not
eliminate a nurse’s responsibility for checking a woman’s
perineum to assess its condition and the amount and type of
lochia flow present. By continuing with these assessments, a
nurse remains a woman’s first line of defense against postpartal
complications such as infection and hemorrhage.

Psychosexual Stages of Development by Sigmund Freud

Freud proposed that psychological development in childhood takes

place during five psychosexual stages: oral, anal, phallic,
latency, and genital. These are called psychosexual stages
because each stage represents the fixation of libido (roughly
translated as sexual drives or instincts) on a different area of
the body. As a person grows physically certain areas of their
body become important as sources of potential frustration
(erogenous zones), pleasure or both.
Freud (1905) believed that life was built round tension and
pleasure. Freud also believed that all tension was due to the
build-up of libido (sexual energy) and that all pleasure came
from its discharge.
In describing human personality development as psychosexual
Freud meant to convey that what develops is the way in which
sexual energy of the id accumulates and is discharged as we
mature biologically. (NB Freud used the term 'sexual' in a very
general way to mean all pleasurable actions and thoughts).
Freud stressed that the first five years of life are crucial to
the formation of adult personality. The id must be controlled in
order to satisfy social demands; this sets up a conflict between
frustrated wishes and social norms.
The ego and superego develop in order to exercise this control
and direct the need for gratification into socially acceptable
channels. Gratification centers in different areas of the body
at different stages of growth, making the conflict at each stage
psychosexual.

Oral Stage (Birth to 1 year)

In the first stage of personality development, the libido is
centered in a baby's mouth. It gets much satisfaction from
putting all sorts of things in its mouth to satisfy the libido,
and thus its id demands. Which at this stage in life are oral,
or mouth orientated, such as sucking, biting, and
breastfeeding.
Freud said oral stimulation could lead to an oral fixation in
later life. We see oral personalities all around us such as
smokers, nail-biters, finger-chewers, and thumb suckers. Oral
personalities engage in such oral behaviors, particularly when
under stress.

Anal Stage (1 to 3 years)

The libido now becomes focused on the anus, and the child
derives great pleasure from defecating. The child is now fully
aware that they are a person in their own right and that their
wishes can bring them into conflict with the demands of the
outside world (i.e., their ego has developed).
Freud believed that this type of conflict tends to come to a
head in potty training, in which adults impose restrictions on
when and where the child can defecate. The nature of this first
conflict with authority can determine the child's future
relationship with all forms of authority.
Early or harsh potty training can lead to the child becoming an
anal-retentive personality who hates mess, is obsessively tidy,
punctual and respectful of authority. They can be stubborn and
tight-fisted with their cash and possessions.
This is all related to pleasure got from holding on to their
faeces when toddlers, and their mum's then insisting that they
get rid of it by placing them on the potty until they perform!
Not as daft as it sounds. The anal expulsive, on the other
hand, underwent a liberal toilet-training regime during the anal
stage.
In adulthood, the anal expulsive is the person who wants to
share things with you. They like giving things away. In
essence, they are 'sharing their s**t'!' An anal-expulsive
personality is also messy, disorganized and rebellious.

Phallic Stage (3 to 6 years)

Sensitivity now becomes concentrated in the genitals and
masturbation (in both sexes) becomes a new source of pleasure.
The child becomes aware of anatomical sex differences, which
sets in motion the conflict between erotic attraction,
resentment, rivalry, jealousy and fear which Freud called
the Oedipus complex (in boys) and the Electra complex (in
girls).
This is resolved through the process of identification, which
involves the child adopting the characteristics of the same sex
parent.

Latency Stage (6 years to puberty)

No further psychosexual development takes place during this
stage (latent means hidden). The libido is dormant.
Freud thought that most sexual impulses are repressed during the
latent stage, and sexual energy can be sublimated (re: defense
mechanisms) towards school work, hobbies, and friendships.
Much of the child's energy is channeled into developing new
skills and acquiring new knowledge, and play becomes largely
confined to other children of the same gender.

Genital Stage (puberty to adult)

This is the last stage of Freud's psychosexual theory of
personality development and begins in puberty. It is a time of
adolescent sexual experimentation, the successful resolution of
which is settling down in a loving one-to-one relationship with
another person in our 20's.
Sexual instinct is directed to heterosexual pleasure, rather
than self-pleasure like during the phallic stage.
For Freud, the proper outlet of the sexual instinct in adults
was through heterosexual intercourse. Fixation and conflict may
prevent this with the consequence that sexual perversions may
develop.
For example, fixation at the oral stage may result in a person
gaining sexual pleasure primarily from kissing and oral sex,
rather than sexual intercourse.

Erik Erikson’s Stages of Psychosocial Development

Erikson maintained that personality develops in a predetermined
order through eight stages of psychosocial development, from
infancy to adulthood. During each stage, the person experiences
a psychosocial crisis which could have a positive or negative
outcome for personality development.
According to the theory, successful completion of each stage
results in a healthy personality and the acquisition of basic
virtues. Basic virtues are characteristic strengths which the
ego can use to resolve subsequent crises.
Failure to successfully complete a stage can result in a reduced
ability to complete further stages and therefore a more
unhealthy personality and sense of self. These stages, however,
can be resolved successfully at a later time.

Trust vs. Mistrust

Trust vs. mistrust is the first stage in Erik Erikson's theory
of psychosocial development. This stage begins at birth
continues to approximately 18 months of age. During this stage,
the infant is uncertain about the world in which they live, and
looks towards their primary caregiver for stability and
consistency of care.
If the care the infant receives is consistent, predictable and
reliable, they will develop a sense of trust which will carry
with them to other relationships, and they will be able to feel
secure even when threatened.
If these needs are not consistently met, mistrust, suspicion,
and anxiety may develop.
If the care has been inconsistent, unpredictable and unreliable,
then the infant may develop a sense of mistrust, suspicion, and
anxiety. In this situation the infant will not have confidence
in the world around them or in their abilities to influence
events.
uccess in this stage will lead to the virtue of hope. By
developing a sense of trust, the infant can have hope that as
new crises arise, there is a real possibility that other people
will be there as a source of support. Failing to acquire the
virtue of hope will lead to the development of fear.
This infant will carry the basic sense of mistrust with them to
other relationships. It may result in anxiety, heightened
insecurities, and an over feeling of mistrust in the world
around them.
Consistent with Erikson's views on the importance of trust,
research by Bowlby and Ainsworth has outlined how the quality of
the early experience of attachment can affect relationships with
others in later life.

2. Autonomy vs. Shame and Doubt

Autonomy versus shame and doubt is the second stage of Erik
Erikson's stages of psychosocial development. This stage occurs
between the ages of 18 months to approximately 3 years.
According to Erikson, children at this stage are focused on
developing a sense of personal control over physical skills and
a sense of independence.
Success in this stage will lead to the virtue of will. If
children in this stage are encouraged and supported in their
increased independence, they become more confident and secure in
their own ability to survive in the world.
If children are criticized, overly controlled, or not given the
opportunity to assert themselves, they begin to feel inadequate
in their ability to survive, and may then become overly
dependent upon others, lack self-esteem, and feel a sense of
shame or doubt in their abilities.

What Happens During This Stage?

The child is developing physically and becoming more mobile, and
discovering that he or she has many skills and abilities, such
as putting on clothes and shoes, playing with toys, etc. Such
skills illustrate the child's growing sense of independence and
autonomy.
For example, during this stage children begin to assert their
independence, by walking away from their mother, picking which
toy to play with, and making choices about what they like to
wear, to eat, etc.

3. Initiative vs. Guilt

Initiative versus guilt is the third stage of Erik Erikson's
theory of psychosocial development. During the initiative versus
guilt stage, children assert themselves more frequently.
These are particularly lively, rapid-developing years in a
child’s life. According to Bee (1992), it is a “time of vigor of
action and of behaviors that the parents may see as aggressive."
During this period the primary feature involves the child
regularly interacting with other children at school. Central to
this stage is play, as it provides children with the opportunity
to explore their interpersonal skills through initiating
activities.

Children begin to plan activities, make up games, and initiate

activities with others. If given this opportunity, children
develop a sense of initiative and feel secure in their ability
to lead others and make decisions.

Conversely, if this tendency is squelched, either through

criticism or control, children develop a sense of guilt. The
child will often overstep the mark in his forcefulness, and the
danger is that the parents will tend to punish the child and
restrict his initiatives too much.
It is at this stage that the child will begin to ask many
questions as his thirst for knowledge grows. If the parents
treat the child’s questions as trivial, a nuisance or
embarrassing or other aspects of their behavior as threatening
then the child may have feelings of guilt for “being a
nuisance”.
Too much guilt can make the child slow to interact with others
and may inhibit their creativity. Some guilt is, of course,
necessary; otherwise the child would not know how to exercise
self-control or have a conscience.
A healthy balance between initiative and guilt is important.
Success in this stage will lead to the virtue of purpose, while
failure results in a sense of guilt.

4. Industry vs. Inferiority

Erikson's fourth psychosocial crisis, involving industry

(competence) vs. inferiority occurs during childhood between the
ages of five and twelve.
Children are at the stage where they will be learning to read
and write, to do sums, to do things on their own. Teachers begin
to take an important role in the child’s life as they teach the
child specific skills.
It is at this stage that the child’s peer group will gain
greater significance and will become a major source of the
child’s self-esteem. The child now feels the need to win
approval by demonstrating specific competencies that are valued
by society and begin to develop a sense of pride in their
accomplishments.
If children are encouraged and reinforced for their initiative,
they begin to feel industrious (competent) and feel confident in
their ability to achieve goals. If this initiative is not
encouraged, if it is restricted by parents or teacher, then the
child begins to feel inferior, doubting his own abilities and
therefore may not reach his or her potential.
If the child cannot develop the specific skill they feel society
is demanding (e.g., being athletic) then they may develop a
sense of inferiority.
Some failure may be necessary so that the child can develop some
modesty. Again, a balance between competence and modesty is
necessary. Success in this stage will lead to the virtue
of competence.

5. Identity vs. Role Confusion

The fifth stage of Erik Erikson's theory of psychosocial

development is identity vs. role confusion, and it occurs during
adolescence, from about 12-18 years. During this stage,
adolescents search for a sense of self and personal identity,
through an intense exploration of personal values, beliefs, and
goals.
During adolescence, the transition from childhood to adulthood
is most important. Children are becoming more independent, and
begin to look at the future in terms of career, relationships,
families, housing, etc. The individual wants to belong to a
society and fit in.
The adolescent mind is essentially a mind or moratorium, a
psychosocial stage between childhood and adulthood, and between
the morality learned by the child, and the ethics to be
developed by the adult (Erikson, 1963, p. 245)
This is a major stage of development where the child has to
learn the roles he will occupy as an adult. It is during this
stage that the adolescent will re-examine his identity and try
to find out exactly who he or she is. Erikson suggests that two
identities are involved: the sexual and the occupational.
According to Bee (1992), what should happen at the end of this
stage is “a reintegrated sense of self, of what one wants to do
or be, and of one’s appropriate sex role”. During this stage the
body image of the adolescent changes.
Erikson claims that the adolescent may feel uncomfortable about
their body for a while until they can adapt and “grow into” the
changes. Success in this stage will lead to the virtue
of fidelity.
Fidelity involves being able to commit one's self to others on
the basis of accepting others, even when there may be
ideological differences.
During this period, they explore possibilities and begin to form
their own identity based upon the outcome of their explorations.
Failure to establish a sense of identity within society ("I
don’t know what I want to be when I grow up") can lead to role
confusion. Role confusion involves the individual not being sure
about themselves or their place in society.
In response to role confusion or identity crisis, an adolescent
may begin to experiment with different lifestyles (e.g., work,
education or political activities).
Also pressuring someone into an identity can result in rebellion
in the form of establishing a negative identity, and in addition
to this feeling of unhappiness.
In response to role confusion or identity crisis, an adolescent
may begin to experiment with different lifestyles (e.g., work,
education or political activities).
Also pressuring someone into an identity can result in rebellion
in the form of establishing a negative identity, and in addition
to this feeling of unhappiness.

6. Intimacy vs. Isolation

Intimacy versus isolation is the sixth stage of Erik Erikson's

theory of psychosocial development. This stage takes place
during young adulthood between the ages of approximately 18 to
40 yrs.
During this period, the major conflict centers on forming
intimate, loving relationships with other people.
During this period, we begin to share ourselves more intimately
with others. We explore relationships leading toward longer-term
commitments with someone other than a family member.
Successful completion of this stage can result in happy
relationships and a sense of commitment, safety, and care within
a relationship.
Avoiding intimacy, fearing commitment and relationships can lead
to isolation, loneliness, and sometimes depression. Success in
this stage will lead to the virtue of love.

7. Generativity vs. Stagnation

Generativity versus stagnation is the seventh of eight stages of

Erik Erikson's theory of psychosocial development. This stage
takes place during during middle adulthood (ages 40 to 65 yrs).
Generativity refers to "making your mark" on the world through
creating or nurturing things that will outlast an individual.
People experience a need to create or nurture things that will
outlast them, often having mentees or creating positive changes
that will benefit other people.
We give back to society through raising our children, being
productive at work, and becoming involved in community
activities and organizations. Through generativity we develop a
sense of being a part of the bigger picture.
Success leads to feelings of usefulness and accomplishment,
while failure results in shallow involvement in the world.
By failing to find a way to contribute, we become stagnant and
feel unproductive. These individuals may feel disconnected or
uninvolved with their community and with society as a whole.
Success in this stage will lead to the virtue of care.

8. Ego Integrity vs. Despair

Ego integrity versus despair is the eighth and final stage of
Erik Erikson’s stage theory of psychosocial development. This
stage begins at approximately age 65 and ends at death.
It is during this time that we contemplate our accomplishments
and can develop integrity if we see ourselves as leading a
successful life.
Erikson described ego integrity as “the acceptance of one’s one
and only life cycle as something that had to be” (1950, p. 268)
and later as “a sense of coherence and wholeness” (1982, p. 65).
As we grow older (65+ yrs) and become senior citizens, we tend
to slow down our productivity and explore life as a retired
person.
Erik Erikson believed if we see our lives as unproductive, feel
guilt about our past, or feel that we did not accomplish our
life goals, we become dissatisfied with life and develop
despair, often leading to depression and hopelessness.
Success in this stage will lead to the virtue of wisdom. Wisdom
enables a person to look back on their life with a sense of
closure and completeness, and also accept death without fear.
Wise people are not characterized by a continuous state of ego
integrity, but they experience both ego integrity and despair.
Thus, late life is characterized by both integrity and despair
as alternating states that need to be balanced.

STAGE THEORY OF COGNITIVE DEVELOPMENT (PIAGET)

Piaget’s Stage Theory of Cognitive Development is a description
of cognitive development as four distinct stages in children:
sensorimotor, preoperational, concrete, and formal.

Swiss biologist and psychologist Jean Piaget (1896-1980)

observed his children (and their process of making sense of the
world around them) and eventually developed a four-stage model
of how the mind processes new information encountered. He
posited that children progress through 4 stages and that they
all do so in the same order. These four stages are:
SENSORIMOTOR STAGE (BIRTH TO 2 YEARS OLD)
The infant builds an understanding of himself or herself and
reality (and how things work) through interactions with the
environment. It is able to differentiate between itself and
other objects. Learning takes place via assimilation (the
organization of information and absorbing it into existing
schema) and accommodation (when an object cannot be assimilated
and the schemata have to be modified to include the object.

PREOPERATIONAL STAGE (AGES 2 TO 4)

The child is not yet able to conceptualize abstractly and needs
concrete physical situations. Objects are classified in simple
ways, especially by important features.

CONCRETE OPERATIONS (AGES 7 TO 11)

As physical experience accumulates, accomodation is increased.
The child begins to think abstractly and conceptualize, creating
logical structures that explain his or her physical experiences.

FORMAL OPERATIONS (BEGINNING AT AGES 11 TO 15)

Cognition reaches its final form. By this stage, the person no
longer requires concrete objects to make rational judgements. He
or she is capable of deductive and hypothetical reasoning. His
or her ability for abstract thinking is very similar to an
adult.

References:

Pillitteri, A. Maternal and Child Health Nursing: Care of the

Childbearing and Childrearing Family 7th Edition. (2014).
Lipincott Williams & Wilkins, Philadelphia.

Obstetrics Data Definitions Issues and Rationale for Change-

Gestational Age and Term. (November, 2012). American Congress of
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https://meandmydangerousideas.weebly.com/notes/mchn-obstetric-
history-and-changes-during-pregnancy
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the Philippines. Retrievedfrom:
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https://www.birthinjurysafety.org/birth-injuries/apgar-scoring-
system.html

https://www.nhs.uk/conditions/jaundice-newborn/treatment/

https://medical-dictionary.thefreedictionary.com/Ballard+score

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