N O R TH W ES T ERN U N IV ER SI TY

,INC

AY 2023-2024-1

Armi Caballero
Bely M. Dela Cruz
Joanne Pauline S. Ferrer
Jeflyn Mae C. Navarro
Kathrina M. Reyes

Instructors

NCM 107: CARE OF THE MOTHER, CHILD AND ADOLESCENT (WELL CLIENTS)
Page 1 of 46
N O R TH W ES T ERN U N IV ER SI TY
,INC

Module 4: THE INTRAPARTAL PERIOD

Good day!

I’m very grateful that we have a good

discussion last time and before we begin
a new topic let’s review some
terms/languages related to Maternal and
Child Health.

ACTIVITY 2. Scrambled Words: Re-arrange the jumbled letters to get the correct answer
and write on the space provided.

1. LTNTOICAA -
2. OTPRIRNIUAT -
3. CTTONNRAOCI -
4. TANIOIDL -
5. NTECAFEEFM -
6. AITTONS -
7. IOTCANMI IFDUL -
8. NSUDUF -
9. EXRVET -
10. INOPCIT -
11. ERAOEDILTNEC -
12. TMIISOOEPY -
13. YMMOANOTI -
14. MAONIITC FILDU -
15. LOHAIC -
16. LGIITEHGNN -
17. SDPLLOEO MUVERANE -
18. GEGMENAENT -

NCM 107: CARE OF THE MOTHER, CHILD AND ADOLESCENT (WELL CLIENTS)
Page 2 of 46
N O R TH W ES T ERN U N IV ER SI TY
,INC

19. PMRAOCIETHTORN UMTERSSANMEE -

20. EDHA MFNERECCRIUEC -
21. SHECT FMRCEUCCERENI -
22. RABGEM -
23. KNIS OT IKSN NTATOCC -
24. MACE -
25. NIECE -

NCM 107: CARE OF THE MOTHER, CHILD AND ADOLESCENT (WELL CLIENTS)
Page 3 of 46
N O R TH W ES T ERN U N IV ER SI TY
,INC

TERMS RELATED TO LABOR AND DELIVERY

1. ABORTION – termination by any means before the fetus is sufficiently develop to
survive Categories of spontaneous abortion
1.1 threatened abortion – any vaginal bleeding during the 1st half of pregnancy may or
may not be accompanied by mild cramping
1.2 inevitable abortion – there is gross rupture of the membranes with cervical
dilatation
1.3 incomplete abortion – fetus expelled before 10th week but placenta in whole or in
parts is retained
1.4 habitual abortion – two or more consecutive spontaneous abortion
2. ABRUPTIO PLACENTA – premature separation of a normally implanted/ sited placenta
3. ACME – highest intensity of a uterine contraction
4. AMNIOCENTESIS – removal of liquor by tapping the sac through a needle inserted
through the anterior abdominal and uterine walls
5. AMNION- smooth, tough inner membrane containing the amniotic fluid
6. ATTITUDE (Habitus)- relation of the fetal limbs and head to its trunk usually on flexion
7. BALLOTMENT- rebound of the fetus to its original position with the tap felts by
the examining hand
8. BANDL’S RING – marked ridge between the upper and lower uterine segment noted
in obstructed labor
9. BARTOLOMEW’S RULE – estimation of the duration of pregnancy by noting the
fundic height in relation to the three anatomical landmarks.
10. BATTLE DORE PLACENTA – umbilical cord (funis) inserted to the placental edge.
11. BLASTOCYST – the fertilized ovum ready for implantation about 10 days
after fertilization
12. BRANDT ANDREW – method of placental delivery where the hand is over the lower
abdomen and made to push the uterus upwards to displace the placenta from the lower
segment to the vagina with simultaneously traction of the cord.
13. BRAXTON HICKS – palpable but ordinary painless contractions at irregular
intervals from early stages of gestation.
14. CALKIN’S SIGN – change in the shape and consistency of the uterus from a
flattened discoid body to a firm globular mass. This is the earliest sign of placental
separation
15. CARDINAL MOVEMENT OF LABOR –process of adaptation and accommodation of
the head on the pelvis. This positional change in the presenting part constitutes the

NCM 107: CARE OF THE MOTHER, CHILD AND ADOLESCENT (WELL CLIENTS)
Page 4 of 46
N O R TH W ES T ERN U N IV ER SI TY
,INC

mechanism of labor. The seven cardinal movement in sequence and in orderly fashion
are:
a. engagement e. extension
b. descent f. external rotation
c. flexion g. expulsion
d. internal rotation
16. CESAERIAN SECTION – delivery of the fetus though the incision in the abdominal wall
17. CHADWICKS SIGN – characteristic violet color of the vaginal mucosa due to
increased vascularity
18. CONCEPTION OF FERTILIZATION – fusion of the ovum and spermatozoa
19. COUVELAIRE UTERUS – widespread infiltration of blood into the myometrium and
periimetrium resulting in a bluish/purplish uterus. This is one in danger sign of abruption
placenta
20. CROWNING – encirclement of the largest diameter of the fetal head by the vulvar ring.
21. DENOMINATOR – part of the presentation that determines the position of the fetus. The
denominator in vertex (cephalic) presentation is the occiput, in breech the sacrum, in
face the mentum, in shoulder or transverse the acromion or the scapula.
22. DUNCAN MECHANISM – method of placental extrusion in which separation of
placental occurs first at the periphery and the blood may escape into the vagina even
before the placenta is out
23. ECLAMPSIA – acute disorder or pregnancy characterized by convulsions caused by
hypertension induced or aggravated by pregnancy
24. ECTOPIC PREGNANCY – extra-uterine pregnancy where the blastocyst implants
anywhere else 95% of ectopic pregnancies involve the oviducts. Causes include
salphingitis, peritubal adhesions and tumors that distort the tube
25. EFFACEMENT- shortening (obliteration or taking up) of the cervical canal from
structure about 2 cm in length to one in which the canal is replaced by a mere circular
orifice. The degree of effacement is expressed in terms of the length of the cervical canal
compared to uneffaced cervix.
= cervical canal ¾ of origin length – 25%
= cervical canal ½ of origin length – 50%
= cervical canal ¼ of original length – 75%
= fully dilated - 100%
26. EMBRYO – the product of conception from the 3 to the 7th week
rd

27. ENGAGEMENT – when the greatest transverse diameter of the fetal head
biparietal passes through the pelvic inlet
28. EPISIOTOMY – incision of the perineum to substitute a straight neat surgical incision of
a ragged laceration. It is the most common operation in obstetrics.
29. FORAMEN OVALE – the opening between the two atria of the fetal heart that shunt the
blood from the right to the left auricle
30. FRANK BREECH- type of presentation where the thighs are flexed upon the abdomen
and the legs are extended over the chest with the feet near the chin. The fetal shape is like
a safety pin catch end.
31. GRAVIDA – a woman who is or has been pregnant irrespective of the pregnancy
outcome.

NCM 107: CARE OF THE MOTHER, CHILD AND ADOLESCENT (WELL CLIENTS)
Page 5 of 46
N O R TH W ES T ERN U N IV ER SI TY
,INC

32. GOODEL’S SIGN – softening of the cervix similar to the lips of the mouth in
primigravida by 6-8 weeks of Gestation
33. GYNECOLOGY – deals with the physiology and the pathology of the of the female
reproductive organs in non-pregnant state
34. HAASE RULE – rough estimate of the fetal length in centimeters from crown to heel.
35. HEGAR SIGN – softening of the isthmus of the uterus at 6-8 weeks from the LMP
36. HYDATIFORM MOLE (H-MOLE) – chronic villi are converted into a mass of clear
vesicles sign are:
1. persistent uterine bleeding from spotting to profuse hemorrhage
2. uterine size / growing uterus often enlarges more rapidly than usual
3. Pregnancy induced hypertension
4. embolization – variable amounts of throphoblast escape from the uterus into the
venous outflow
5. spontaneous expulsion most likely the occur around the fourth week
37. HYDRAMNIOS- excessive quantity of amniotic fluid of more than 2,000 ml
38. HYPEREMESIS GRAVIDARUM – excessive nausea and vomiting
39. IMPLANTATION – embedding of the fertilized ovum in the endometrium
40. INVOLUTION – process by which the reproductive organs return to their normal non-
pregnant state
41. LAMAZE- natural or physiology childbirth through;
1. elimination of fear 3. Exercise to promote relaxation
2. muscle control 4. Antepartum education
42. LEOPOLD’S MANEUVER – a systemic abdominal palpation and recognition
of presentation and position
43. LIE – relationship of the long axis of the uterus to the long axis of the fetus and it is
wither longitudinal or transverse.
44. LIGHTENING – descent of the fetal head to or through the pelvis with subsequent
decrease in fundal height. This occurs 2 weeks before the onset of labor
45. LOCHIA – variable amount of uterine discharge early in the puerperium.
Rubra - first 3 days, red lochia; Serosa- 4th –7th day,-pinkish to brownish; Alba – 8th
until 2 to 6 weeks postpartum, cream to yellowish in color.
- Foul smelling lochia suggest infection
46. MACROSOMIA – excessively large infants weighing 4,500 gms.
47. NAEGELE’S RULE – time honored method to estimate EDC by adding 7 days to the
date of the first day of the first day of the LMP and counting 3 months backwards or 9
months forward.
48. NUCHAL CORD – cord loops around the fetal neck
49. NULLIGRAVIDA – a woman who is not now and never been pregnant
50. NULLIPARA – a woman who has never completed beyond an abortion
52. OLIGOHYDRAMNIOS – deficient quantity of amniotic fluid below 500 ml

NCM 107: CARE OF THE MOTHER, CHILD AND ADOLESCENT (WELL CLIENTS)
Page 6 of 46
N O R TH W ES T ERN U N IV ER SI TY
,INC

A. PHYSIOLOGY OF LABOR

LABOR- a series of physiologic and mechanical processes by which the products of

conception (baby, placenta, and fetal membranes) are expelled from the birth canal.

Synonyms : Parturition, travail, accouchement, confinement

CAUSES OF PAIN
1. Traction on the perineum
2. Uterine contraction
3. Emotional tension
4. Hypoxia
5. Pressure

1. PREMONITORY SIGNS / PRODROMAL SIGNS OF LABOR

1. Lightening - descent of the presenting part into the true pelvis

SIGNS OF LIGHTENING
1. relief of dyspnea
2. relief of abdominal tightness
3. increased frequency of urination, varicosities, pedal edema because
of pressure on the bladder and pelvic griddle.
4. shooting pains down the legs because of pressure on the sciatic nerves.
5. increased amount of vaginal discharge

2. Braxton Hicks Contraction aka False labor contractions

 Painless, erratic uterine contractions that occur toward the end of pregnancy. They
ready the cervix for labor, but cervical dilation does not occur with them.
a. Do not dilate the cervix
b. Contractions are felt in the abdomen
c. Relieved by walking, edema

NCM 107: CARE OF THE MOTHER, CHILD AND ADOLESCENT (WELL CLIENTS)
Page 7 of 46
N O R TH W ES T ERN U N IV ER SI TY
,INC

d. generally painless but may be quite annoying

3. Slight Loss Weight
– as progesterone level falls, more fluid is excreted, slightly lowering BW
 Increase in urine production can lead to a wt. loss bet.1 and 3 lb on to two days
before labor.
4. Increased Energy – burst of adrenaline to provide energy for labor
 a woman may awaken on the morning of labor full of energy in contrast to the
feeling of chronic fatigue that she has been feeling for the previous month.
 boost in epinephrine release which initiated by a decreased in progesterone
production by the placenta

5. Backache – beginning but unrecognized uterine contractions

 labor contractions begin in the back, an intermittent backache stronger than
usual may be the first symptom a woman notice
6. Ripening of the Cervix – prostaglandins soften the cervix to allow for shortening
and dilatation.
 Goodle’s sign – the cervix feels soften than usual to palpation – similar to the
consistency of an earlobe
 “Butter soft” – at term the cervix becomes still soften and its tips forward.

NCM 107: CARE OF THE MOTHER, CHILD AND ADOLESCENT (WELL CLIENTS)
Page 8 of 46
N O R TH W ES T ERN U N IV ER SI TY
,INC

2. SIGNS OF TRUE LABOR

- involve both uterine and cervical changes
a. Uterine Contractions – true labor contractions usually begin in the back and
sweep forward across the abdomen.
 Gradually increase in frequency and intensity over a period of hours
 Typical time 5 mins. apart
b. Show / Bloody show
 As the cervix softens and ripens, the mucus plug that filled the cervical canal
during pregnancy is expelled
 The exposed cervical capillaries seep blood as a result of pressure exerted by
the fetus.
 A blood mixed w/ mucus, taken on a pink tinge
c. Rupture of membrane
 Labor may begin with rupture of the membrane experienced either as a sudden
gush or as scanty, slow seeping of clear fluid from the vagina.
 AF continues to produced until delivery of the membranes after the birth of the
child, so no labor is ever “dry”
 EROM – can actually be advantageous as it can cause the fetal head to settle
into pelvis, aiding cervical dilatation and shortening labor.
 Two risk associated with ruptured membranes;
a. intrauterine infection
b. prolapsed of the umbilical cord

NCM 107: CARE OF THE MOTHER, CHILD AND ADOLESCENT (WELL CLIENTS)
Page 9 of 46
N O R TH W ES T ERN U N IV ER SI TY
,INC

ESSENTIAL FACTORS OF LABOR (Passenger, Passage, Power, and Psyche)

The 4Ps of Labor
1. Passenger – fetus (position, presentation, attitude)
 fetal head is the largest presenting part, ¼ of its length
 Bones – 8 bones (sphenoid, 2 temporal, ethmoid, frontal, occipital & 2 parietal bones)
 Sutures / intermembranous spaces
-allows molding and further brain development
 Molding – the overlapping of the sutures of the skull to permit passage of the
head to the pelvis
o Sagittal suture – located between parietal bones
o Coronal suture – located between parietal & frontal bones
o Lambdoidal suture – located between parietal & occipital bones
o Frontal suture – located between frontal bones

 Fontanels
o 6 fontanels only 2 palpable
 anterior fontanel/Bregma
 diamond in shape
 3cm x 4cm size
 close 12-18 mos post delivery
 ↑ 5cm – hydrocephalus

NCM 107: CARE OF THE MOTHER, CHILD AND ADOLESCENT (WELL CLIENTS)
Page 10 of 46
N O R TH W ES T ERN U N IV ER SI TY
,INC

 posterior fontanel/lambda
 triangular in shape
 1 x 1cm size
 close 2-3mos post delivery
 Fetal Lie
 Lie – relationship between the long (cephalocaudal) axis, of the fetal
body and the long axis of mother.
Two Types:
1. Longitudinal Lie (Parallel)/ Vertical
- fetus is lying lengthwise in the mothers abdomen
2. Transverse Lie (Perpendicular)/Horizontal lie
- fetus is lying crosswise in the mother’s abdomen

 Fetal Presentation and Presenting Part

 Presenting part – fetal part that enters to the true pelvis first

NCM 107: CARE OF THE MOTHER, CHILD AND ADOLESCENT (WELL CLIENTS)
Page 11 of 46
N O R TH W ES T ERN U N IV ER SI TY
,INC

Cephalic presentation – head comes first out most frequent type of presentation
1. Vertex presentation
- head is completely flexed so the chin touches the chest
- the most ideal type of presentation
- SOB (9.5 cm); occiput as the presenting part
2. Face presentation – head is sharply extended causing the
occiput to come in contact with the back of the fetus.
- face as the presenting part
3. Brow presentation
- head is extended or bent backward causing OM diameter
(13.5 cm)
- brow or sinciput as the presenting part
4. Chin / mentum presentation – the most very poor presentation
- the head is hyperextended
- chin as presenting part

NCM 107: CARE OF THE MOTHER, CHILD AND ADOLESCENT (WELL CLIENTS)
Page 12 of 46
N O R TH W ES T ERN U N IV ER SI TY
,INC

Breech presentation – the feet or buttocks comes out first during delivery
1. Complete breech – the feet and legs are flexed on the thighs and the
thighs are flexed on the abdomen.
2. Incomplete breech
 Frank breech – thigh resting on abdomen while legs extend
to the head
- buttocks are the presenting part; common type of breech
presentation
 Footling breech- one or both feet are the presenting part

NCM 107: CARE OF THE MOTHER, CHILD AND ADOLESCENT (WELL CLIENTS)
Page 13 of 46
N O R TH W ES T ERN U N IV ER SI TY
,INC

Shoulder Presentation – the fetus is lying perpendicular to the long axis of the mother ;
scapular / acromion is the presenting part.
- vaginal delivery is not possible

Compound Presentation – occurs when there is prolapsed of the fetal hand alongside
the vertex, breech or shoulder.

NCM 107: CARE OF THE MOTHER, CHILD AND ADOLESCENT (WELL CLIENTS)
Page 14 of 46
N O R TH W ES T ERN U N IV ER SI TY
,INC

Position – relationship of the fetal presenting part to specific quadrant of the mother’s pelvis.

OCCIPUT2.ANTERIOR
Passages of –Labor – vagina
head down, & pelvis
facing OCCIPUT POSTERIOR – head down, facing
Pelvis
your back, the easiest - the bones
position for thethat form
fetal a bowl-shaped
head your structure
tummy. Thein the area below
occiput the waist
posterior at the
position cantop of
the legs, and to which the
to traverse the maternal pelvis which allows the leg bones and spine are joined.
make labor and delivery more challenging.
4 main
fetus to move more easily pelvic
through thetypes
pelvis. The baby's head may not align as well with the
1. Gynecoid
Less painful and less discomfort – round, wide, deeper, most ideal pelvis,
mother's for childbirth
which can lead to a slower
- transverse diameter (10 cm) is larger
descent than AP
through diameter
the birth canal and a more
2. Android – heart shape “male pelvis” extended labor. More painful and uncomfortable.
- AP diameter is wider than its transverse diameter
3. Anthropoid – oval “ape-like pelvis“ AP diameter wider than transverse
narrow
4. Platypelloid – flat pelvis; rarest type; transverse diameter is wider than its
AP diameter – c/s for delivery
o Problem :

NCM 107: CARE OF THE MOTHER, CHILD AND ADOLESCENT (WELL CLIENTS)
Page 15 of 46
N O R TH W ES T ERN U N IV ER SI TY
,INC

- mother who encountered accident

- ↓ 4’9”
- ↓ 18y/o – R: pelvis not achieve its full pelvic growth

NCM 107: CARE OF THE MOTHER, CHILD AND ADOLESCENT (WELL CLIENTS)
Page 16 of 46
N O R TH W ES T ERN U N IV ER SI TY
,INC

 Divisions of Pelvis
a. False pelvis – the upper flaring portion of ilium
- provide support to the uterus during pregnancy and to direct the fetus
to the true pelvis during labor.
b. True pelvis - forms the passageway of the fetus during labor
consist the following parts:
1. Inlet or pelvic brim- the entrance of true pelvis. The pelvic inlet, also known as the
pelvic brim, is the uppermost part of the pelvic canal.
2. Outlet – lowest part of the pelvic canal.
3. Canal – situated between inlet and outlet.

NCM 107: CARE OF THE MOTHER, CHILD AND ADOLESCENT (WELL CLIENTS)
Page 17 of 46
N O R TH W ES T ERN U N IV ER SI TY
,INC

o Power: Uterine contractions

 Characteristic of uterine contractions:
- the forces acting to expel the fetus & placenta
 involuntary contractions
 voluntary bearing down efforts
 characteristics: wave like
 timing: frequency, duration, intensity
 myometrium – power of labor
 Monitoring the contractions & fetal heart tone
 Increment/Cresendro - beginning of contraction until it increases
 Apex/Acne – height of contraction
 Decrement/Decresendro – from height of contraction until it
decreases
 Duration – beginning of contraction to the end of the same
contraction
 Interval – from end of contraction to the beginning of the next
contraction
 Frequency – from the beginning of 1 contraction to the beginning of
next contraction
 Intensity – strength of uterine contraction
 Mild contraction
- slightly tense fundus that is easy to indent with fingertips
 Moderste contractions
- firm fundus that is difficult to indent with fingertips
 Strong contractions
- rigid board like fundus that is almost possible to indent with
fingertips
if contract – blood vessel constricts; the fetus will get the oxygen
on the placenta reserve which is capable of giving oxygen to the
fetus up to 1min.

NCM 107: CARE OF THE MOTHER, CHILD AND ADOLESCENT (WELL CLIENTS)
Page 18 of 46
N O R TH W ES T ERN U N IV ER SI TY
,INC

NCM 107: CARE OF THE MOTHER, CHILD AND ADOLESCENT (WELL CLIENTS)
Page 19 of 46
N O R TH W ES T ERN U N IV ER SI TY
,INC

o Psyche/person
 Maternal attitude during labor
 psychological stress exists when the mother is fighting the labor experience.
 Women who manage best in labor are those who have a strong sense of self-
esteem and a meaningful support system with them

DANGER SIGNS OF LABOR

- All throughout the duration of labor, monitor the patient for abnormal signs.
1. Signs of fetal distress: tachycardia, bradycardia
2. Red stained amniotic fluid: abruption placenta, vasa previa
3. Cord prolapsed
4. maternal tachycardia, hypertension and hypotension
5. pallor, cold clammy skin
6. fever, foul smelling vaginal discharge: chorioamnionitis
7. vaginal bleeding: placenta previa

STATUS OF AMNIOTIC FLUID

 Nitrazine Paper Test – test to assess status of BOW, if the mother cannot determine if
her membrane are ruptured.
a. Negative: nitrazine paper is yellow if BOW is intact
b. Positive: it will turn blue if BOW is ruptured
 Immediately after membranes have ruptured:
a.Assess FHR for one minute is the first intervention.
If bradycardia is present, perform IE to assess for cord prolapsed and change
position of the woman
to relieve pressure on the cord.
b.Assess odor of amniotic fluid: cloudy and foul smelling amniotic fluid indicates
infection.
c.Assess the amount and color of amniotic fluid.
 Clear or straw colored with specks of vernix caseosa: normal color
 Yellow colored: hemolytic disease, hyperbilirubenemia
 Gray colored or cloudy: infection
 Pinkish or red stained: bleeding
 Brownish / tea colored / coffee colored: fetal distress
d. record time of rupture, characteristic of fluid and FHR

NCM 107: CARE OF THE MOTHER, CHILD AND ADOLESCENT (WELL CLIENTS)
Page 20 of 46
N O R TH W ES T ERN U N IV ER SI TY
,INC

Difference between True and False Contraction

True False
 No in intensity  There is an in intensity
 Pain confined in the abdomen  Pain begins @ the lower back to abdomen
 Pain is relieved by walking  Pain is intensified by walking Cervical effacement
 No cervical changes (thinning of the cervix, measured thru %) &
dilatation (widening of the cervix,
measurement thru cm) *best/major sign of true
labor

Checkpoint:
Study and review what we have discussed.
A graded quiz will be given online via
canvas. Schedule will be posted.
Good luck!

NCM 107: CARE OF THE MOTHER, CHILD AND ADOLESCENT (WELL CLIENTS)
Page 21 of 46
N O R TH W ES T ERN U N IV ER SI TY
,INC

STAGES OF LABOR
1. First Stage – 12 hours to complete
- onset of true labor contractions to full dilatation & effacement of the cervix

Stage of effacement & dilatation

a. Latent Phase:
 Assessment:
o Dilatations 0-3 cm
o Uterine contraction: Frequency 5-10 mins; Duration 20-40seconds
o Intensity mild
b. Active Phase:
 Assessment:
o Dilatations 4-7 cm
o Uterine contraction: Frequency q 3-5 mins; Duration 40-60 secs
o Intensity moderate

NCM 107: CARE OF THE MOTHER, CHILD AND ADOLESCENT (WELL CLIENTS)
Page 22 of 46
N O R TH W ES T ERN U N IV ER SI TY
,INC

c. Transitional Phase:
 Assessment:
o Dilatations 8-10cm
o Uterine contraction: Frequency q 2-3 mins; Duration 60-70 sec
o Intensity strong
o Time frame: Primi (1 hr); Multi (30 min.)
o Mood of mother suddenly change accompanied by hyperesthesia
(hypersensitivity of mother to touch) of the skin
 Management
o sacral pressure, cold compress
 Nursing care:
o T – tires- the most difficult period of labor,
o I – inform of progress (to relieve emotional support)
o R – restless support her breathing technique
o E – encourage & praise
o D – discomfort

o Pelvic Exams

 Effacement –
- shortening ( obliteration or taking up) of the cervical canal from
structure about 2 cm in length to one in which the canal is replaced
by a mere circular orifice. The degree of effacement
- expressed in terms of the length of the cervical canal compared to
uneffaced cervix.
= cervical canal ¾ of origin length – 25%
= cervical canal ½ of origin length – 50%
= cervical canal ¼ of original length – 75%
= fully dilated - 100%
 Dilatation – degree of opening of the cervix canal; fully dilated – 100%

NCM 107: CARE OF THE MOTHER, CHILD AND ADOLESCENT (WELL CLIENTS)
Page 23 of 46
N O R TH W ES T ERN U N IV ER SI TY
,INC

 Station – relationship of the presenting part to the ischial spine

o - 4 to -1 = the presenting part is above the ischial spine
o Station 0 = the presenting part is in line with the ischial spine; head is engaged
o + 1 to + 4 = the presenting part is above the ischial spine
o + 4 = heat is at outlet.
o (-) fetus is floating
o (+) below the ischial spine

NCM 107: CARE OF THE MOTHER, CHILD AND ADOLESCENT (WELL CLIENTS)
Page 24 of 46
N O R TH W ES T ERN U N IV ER SI TY
,INC

NURSING CONSIDERATION DURING THE FIRST STAGE OF LABOR

 Bath is necessary
 Monitor VS especially BP
o Same BP = rest
o Elevated = notify the physician
 Light meal
 Encourage mother to void
 Perineal preparation (rule of 7)
 Rest on left side lying position
o Prevent supine vena cava syndrome or supine hypotension
 If membrane doesn’t rupture - à amniotomy
 FETAL TRASHING - hyperactivity of fetus due to lack of Oxygen
 For Pain
o Systemic analgesic
 DEMEROL (MeperidineHCl)
 Narcotic and antispasmonic
 Don’t give during latent phase
 Given @ 6-8 cm dilated
 WOF : Respiratory depression
 Epidural Anesthesia
 WOF : Hypotension
 Prehydrate the client to prevent hypotension
 In case of Hypotension
o Elevate leg
o Fast Drip IV

2. Second Stage of Labor (FETAL STAGE)

 Complete dilatation and effacement to birth
 Crowning occurs
 Position in lithotomy, put both legs at the same time on stirrups
 BULGING OF PERENIUM à surest sign of delivery initiation
 PANT & BLOW Breathing, fetal pushing should be done

 Imminent signs of Second Stage of Labor

 Increased bloody show
 Desire to bear down or have bowel
 Bulging of the perineum
 Dilatation of the anal orifice

NCM 107: CARE OF THE MOTHER, CHILD AND ADOLESCENT (WELL CLIENTS)
Page 25 of 46
N O R TH W ES T ERN U N IV ER SI TY
,INC

Mechanism of Labor (ED FIEEE)

 Engagement
 Descent
 Flexion
 Internal Rotation
 Extension
 External Rotation
 Expulsion

1. Engagement
- mechanism by which the greatest transverse diameter of the fetal head, the
biparietal diameter (measures 9.5 cm. in immature fetus), passes through the
pelvic inlet.
2. Descent- the first requisite for the birth of the baby.
-may occur earlier in a nulliparous woman, before labor, usually begins with
engagement in multiparous woman.

Descent is brought about by one or more of four Forces:

1. pressure of the amniotic fluid
2. direct fundal pressure upon the breech/buttocks
3. contraction of the abdominal muscles
4. fetal body extension and straightening and lengthening of the fetal body
or extremities.
3. Flexion- the chin is brought about in contact with the chest.
-results to the smallest anteroposterior diameter of the fetal head, suboccipito

NCM 107: CARE OF THE MOTHER, CHILD AND ADOLESCENT (WELL CLIENTS)
Page 26 of 46
N O R TH W ES T ERN U N IV ER SI TY
,INC

Bregmatic diameter (measures 9.5 cm).

4. Internal Rotation- turning of the head so that the occiput moves anteriorly toward
the symphisis pubis.
-Associated with descent
-after internal rotation, the occiput is just under the symphisis pubis
Descent also continue after engagement.
 In primigravida, descent of the fetus into the true pelvis usually occurs about
10-14 days before labor, or 2 weeks, before the actual birth of the baby. This
descent is referred to as lightening and results in engagement.
5. Extension- delivery of the head in vertex presentation
- emergence of the occiput under the symphysis pubis.
- head leaves the outlet

***A clean surgical incision extending the soft tissue vaginal opening is done
primarily to prevent lacerations.
***The median episiotomy is not commonly done as it easily extends to the anal
region.
6. External Rotation- restitution
-shoulders do internal rotation in restitution
-turning of the back of the baby’s head to line up with his back
7. Expulsion- final birth of the baby
-gentle but firm downward pressure traction of the head is done to deliver the
anterior shoulder, then the head is gently raised to deliver the posterior
shoulder and the entire body follows without much difficulty.

STEPS ON DELIVERY
A. PRIOR TO PATIENT’S TRANSFER TO THE DELIVERY ROOM
1. Ensures that mother is in her position of choice while in labor.
2. Asks mother if she wishes to eat/drink.
3. Communicate with the mother-informed her of labor, gave reassurance and
encouragement.
B. PATIENT ALREADY IN THE DELIVERY ROOM
PREPARING FOR DELIVERY
1. Check temperature in DR area to be 25-28 degrees Celsius; checked for air draft.
2. Ask mother if she is comfortable in semi-upright position.
3. Put mask and cap.
4. Removes all jewelry.
5. Washes hands thoroughly observing the WHO 1-2-3-4-5 procedure.
6. Arrange materials/supplies in a linear sequence:
(2 pairs of surgical gloves, 2 dry linen, bonnet, oxytocin injection, cord clamp,
instrument clamp, scissors, 2 kidney basins).
7. In separate sequence, for after the 1st breastfeed:

NCM 107: CARE OF THE MOTHER, CHILD AND ADOLESCENT (WELL CLIENTS)
Page 27 of 46
N O R TH W ES T ERN U N IV ER SI TY
,INC

(Eye ointment, stethoscope to use for PE, vitamin K, hepatitis B and BCG vaccines,
cotton balls).

NCM 107: CARE OF THE MOTHER, CHILD AND ADOLESCENT (WELL CLIENTS)
Page 28 of 46
N O R TH W ES T ERN U N IV ER SI TY
,INC

8. Cleanse the perineum with antiseptic solution.

9. Scrubs hands surgically for 10 minutes.
10. Puts on sterile gown and 2 pairs of sterile gloves aseptically.
AT THE TIME OF DELIVERY
11. Encourage women to push when there are contractions.
12. Apply perineal support with operating towel/sterile gauze.
13. Control delivery of the head, wipes mucus secretions from mouth to nose.
14. Watches for coil of cord around the neck of the baby. (if there is, inserts fingers to
shift the coil down on baby’s shoulders).
15. Delivers slowly between pains, anterior shoulders first then posterior shoulder, then
rest of the body.
16. Call out time of birth and sex of baby.
17. Inform the mother of outcome.
FIRST 30 SECONDS
18. Place the baby on a clean, dry cloth/towel on the mother’s abdomen.
19. Thoroughly dried baby for at least 30 seconds, starting from the face and head, going
down to the trunk and extremities.
FOR 1-3 MINUTES
20. Remove the wet cloth.
21. Place baby in skin-to-skin contact on the mother’s abdomen.
22. Covers the baby with a clean, dry cloth/towel.
23. Covers baby’s head with a bonnet
24. Exclude a 2nd baby by palpating the abdomen. Use wet cloth to wipe the soiled gloves.
Give IM oxytocin within one minute of baby’s birth. Dispose a wet cloth properly.
25. Remove the 1st set of gloves.
26. Decontaminate used gloves properly by soaking in 0.5 % chlorine solution for at least
10 minutes.
27. Palpates umbilical cord to check for pulsations.
28. After pulsations stopped (1-3 mins), clamp cord using the cord clamp or cord tie at 2
cm from base.
29. Place the instrument clamp 5 cm from the base.
30. Cut near plastic clamp.
31. Perform the remaining steps of the AMTSL:
31.1 Wait for strong uterine contractions then applied controlled cord traction and
counter traction on the uterus, continue until placenta is deliver.
31.2 Massage the uterus until it is firm.
32. Inspect the lower vagina and perineum for lacerations/tears and repair
lacerations/tears, as necessary.
33. Examines the placenta for completeness and abnormalities.
34. Cleanse the mother: flush the perineum and applied perineal pad/napkin/cloth.
35. Check baby’s color and breathing; check if the mother is comfortable, uterus is

contracted.
36. Dispose the placenta in a leak-proof container or plastic bag.

NCM 107: CARE OF THE MOTHER, CHILD AND ADOLESCENT (WELL CLIENTS)
Page 29 of 46
N O R TH W ES T ERN U N IV ER SI TY
,INC

37. Decontaminate (soak in 0.5 % chlorine solution) instruments before cleaning;

decontaminate 2nd pair of gloves before disposal (decontamination lasts for at least 10
minutes).
38. Advise mother to maintain skin-to-skin contact. Baby should be prone on mother’s
chest in between the breast with head turned to one side.
15-90 MINUTES
39. Advise mother to observe for feeding cues and cite examples of feeding cues.
40. Support mother; instruct her on positioning and attachment.
41. Wait for FULL BREASTFEED to be completed.
42. After a complete breastfeed, administer eye ointment (first), do thorough physical
examination, administer vitamin K, hepatitis B and BCG injections ( simultaneously
explain purpose of each intervention).
43. Advise delay bathing of baby.
44. Advise breastfeeding per demand and about Danger Signs for early referral.
45. In the 1st hour: check baby’s breathing and color; and check mother’s vital signs and
massage uterus every 15 minutes.
46. In the second hour: check mother-baby 30 minutes to 1 hour.
47. Complete all records.

EPISIOTOMY- is the surgical incision of the perineum made in order to enlarge the
vaginal introitus when a laceration is imminent. The straight and clean edges of an
episiotomy heal better than the ragged tear of laceration.
 It is performed when the head is
crowning.
Types of episiotomy
1. Median episiotomy
a. Advantages:
1. easier to make and repair
2. rare faulty healing
3. rare dyspareunia and less discomfort during healing
5. involves less blood loss
b. Disadvanntages:
1. possible extension to anal sphincter and rectum

NCM 107: CARE OF THE MOTHER, CHILD AND ADOLESCENT (WELL CLIENTS)
Page 30 of 46
N O R TH W ES T ERN U N IV ER SI TY
,INC

2. Mediolateral episiotomy - incision start from the midline of vaginal orifice and
continue away from the anus.
a. Advantages
- tearing in anus and rectum is rare
b. Disadvantages:
1. difficult to repair
2. common faulty healing
3. involve more discomfort during healing
4. occasional dyspareunia

Nursing Care
 MODIFIED RITGEN’S MANEUVER
o Done by supporting the perineum with a towel during delivery
o Facilitates complete flexion
o Avoids laceration
 First intervention: Support the head and suction secretion as needed
 Do not milk the cord, wait for pulsation to stop before cutting
 When there is still birth, let the mother see the baby to accept the finality
of Death

3. Third Stage of Labor (PLACENTAL STAGE)

 5– 20 minutes after child birth

 Signs of Placental Separation

o Fundus becomes globular and rises à CALKIN’S SIGN
o Lengthening of the cord
o Sudden gush of blood
 Crede maneuver – gentle pressure on the contracted uterine fundus by the
primary health care provider
 BRANT – ANDREW’S MANEUVER
o slowly pulling the cord and wind at the clamp
o rapidly à may cause uterine inversion

NCM 107: CARE OF THE MOTHER, CHILD AND ADOLESCENT (WELL CLIENTS)
Page 31 of 46
N O R TH W ES T ERN U N IV ER SI TY
,INC

 Methods of Placental Delivery

 SHULTZ mechanism (Shiny)
o From center to the edges
o Inverted umbrella shape -presentation
o Presenting fetal side
 DUNCAN (Dirty)
o Form edges to center
o Umbrella shape - presentation
o Presenting the maternal side

Nursing Considerations during placental delivery

 Check placental completeness
o Should be 500 g
o 15-20 cotylydones
o 1 lobe
 Check Fundus – Massage if Boggy (atony)
 BP Check before giving uterotonic drugs
 Methergine, methylergonovine mallate (IM)
 Oxytocin (IV/ IM)
 Check perenium for lacerations
 Assist in episiorraphy
 Vaginoplasty/ Vaginal Landscape – Virgin again

4. Fourth Stge of Labor (Recovery Stage)

 Hemorrhage is the main danger on this stage; First 1 – 2 hours after delivery
of placenta

NCM 107: CARE OF THE MOTHER, CHILD AND ADOLESCENT (WELL CLIENTS)
Page 32 of 46
N O R TH W ES T ERN U N IV ER SI TY
,INC

 Maternal observation – body system stabilize

o v/s monitoring on 1st hour – q15 min 2nd hour - q 30 min
 Placement of fundus
o immediately after delivery - located midway between umbilicus
and pubis symphysis
o After several hours it gradually raises to the level of the umbilicus
afterwards; then descends to pelvic cavity by one cm or
fingerbreadth a day.
o Located at midline and firm
o Check bladder, assist in voiding, May lead to uterine atony ànd
hemorrhage
 Lochia: fleshy odor
o Rubra – from delivery up to 3rd day; bright red in color; may contain
small clots
 Check the perineal pad and estimate amount of blood loss based on how much
saturated it is:
MOUNT OF LOCHIAL FLOW:
o 1 inch stain after one hour: scant amount
o 2-4 inch stain after one hour: light amount
o 4-6 inch stain after one hour: moderate amount
o Fully saturated after one hour: heavy amount
o Fully saturated – 30 – 40 cc
o Weighing – 1 cc = 1 gram Common Board Question
 Perineum
o Just after delivery – swollen, discolored and painful, often with
lacerations & episiotomy

Nursing Consideration during Recovery

 NSD- allowed to ambulate 4 to 8 hours; CS allowed to get out on bed 8 hours when
they fully awake and reflexes are returned.
 Instruct woman to sit on the edge of the bed for a few minutes before standing and
walking about
- to prevent dizziness
 If with Chills à give blanket due to dehydration
 Give nourishment (progression of meal)
o Clear liquids – gatorade, ginger juice, gelatins
o Full liquid – milk, ice cream
o Soft diet – noodles, porridge
o Regular diet - DAT
 Check VS/ Pain and Pychic State
 Bonding – interaction between mother and newborn
o Strict – 24 hours with mother

NCM 107: CARE OF THE MOTHER, CHILD AND ADOLESCENT (WELL CLIENTS)
Page 33 of 46
N O R TH W ES T ERN U N IV ER SI TY
,INC

POSTPARTUM PERIOD
Puerpera: term for a woman who just delivered her baby.
Puerperium- refers to the first six weeks after delivery.
- At this time, the woman undergoes psychologic and physiologic as she
returns to non-pregnant state.

Specific changes on the mother: Physiologic Adaptations after Delivery

1. REPRODUCTIVE SYSTEM
A. UTERUS:
a. Uterine involution
 refers to the return of the uterus to its pre-pregnant size, shape,and function.
 Most of the reduction in size and weight occurs in the first 2 weeks.
 W/in 6 weeks
- Sealing off of placental site by contraction of uterus and clotting
factor (thrombosis)
b. Diminution of uterine size
 due to a decrease in size of myometrial cells not in their number.
 sudden withdrawal of estrogen and progesterone after delivery
- result in atrophy of myometrial cells and a decrease in uterine weight.
c. basal layer regenerates and gives rise to the new endometrium.
d. By 16th day - the endometrium is restored throughout the uterus, except at the
placental site.
e. By three weeks - the entire endometrium heals.
f. slightly increase in size after each pregnancy.
g. breastfeeding promote involution
e. weight of the uterus:
 Right after delivery: 1000 grams
 One week after delivery: 500 grams
 Two weeks after delivery: 300gms
 Six weeks after delivery: 50-60 gram
 Measures to promote involution of the uterus
1. proper positioning
2. oxytocin drugs
3. breastfeeding
4. early ambulation
5. bladder emptying
6. proper diet
7. Monitor and evaluate

NCM 107: CARE OF THE MOTHER, CHILD AND ADOLESCENT (WELL CLIENTS)
Page 34 of 46
N O R TH W ES T ERN U N IV ER SI TY
,INC

8. monitor and evaluate

a.1. Fundus:
- fundic height: measure using umbilicus as landmark
 immediately after delivery
- located midway between umbilicus and symphisis pubis or slightly higher.
 After several hours it rises to the level of the umbilicus.
 then descent into the pelvic cavity by one cm or one fingerbreadth a day (1-
10th day postpartum); at 11th day no longer palpable.
a.2. lochia – is the uterine discharge after delivery consisting of blood,
mucus, epithelial cells, leukocytes and bacteria.

CHARACTERISTICS OF LOCHIA
TYPE COLOR POSTPARTUM DAY COMPOSITION
Lochia rubra Bright Red, fleshy odor From delivery to up to Small Blood clots
3rd day (1-3) days ,fragments of decidua
Lochia Pinkish to brownish 4th -7th day Blood mucus
serosa increased WBC
Lochia alba Cream to yellowish in from 8th day until 2 to 6 Largely mucus,
color; white postpartum weeks postpartum increase WBC

Smell: lochia should smell like menstrual discharge (fleshy odor). A foul smelling lochia is a
sign of infection

SIGNS OF ABNORMAL LOCHIA

Signs Possible Cause

Foul smell Infection

Large clots Retained fragments
Excessive amount with contracted Lacerations of birth canal
uterus
Return of rubra after serosa or Retained fragments
alba Infection
A reddish color in lochia that persist for more than 2
weeks is indicative of retained fragments
Bleeding after 6 weeks Subinvolution of the uterus, infection

NCM 107: CARE OF THE MOTHER, CHILD AND ADOLESCENT (WELL CLIENTS)
Page 35 of 46
N O R TH W ES T ERN U N IV ER SI TY
,INC

FACTORS DELAYING INVOLUTION (UTERINE ATONY)

1. Multiple fetuses
2. Hydramnios
3. Exhaustion from prolonged / difficult delivery
4. Grand multiparity
5. Physiologic effects of excessive anesthesia
6. Infection
7. Bladder distention
8. Retained placental membrane
a.3. Cervix – is soft, edematous and relaxed after birth
 After the first week – it regains its prepregnant firmness but the external os does
not return to its original prepregnant condition as it is lacerated during delivery,
after childbirth, the internal os assumes a slit like or stellate appearance
 By the end of the first week- the external os is closed and will not admit a finger
B. VAGINA
 Right after birth - the vagina is a smooth and swollen passage.
 after 2 weeks -lacerations and episiotomy are usually healed
 After 3-4 weeks- rugae reappear, but not as numerous as before pregnancy
 After 6 to 8 weeks -it returns to its prepregnant condition but does not regain
its original vaginal state.
 The hymen is converted to myrtiformes caruncles
 Women who are BF - Resolution of the vagina to its prepregnat condition is
delayed in due to persistent low estrogen levels. Prolactin inhibits estrogen
production.
C. PERINEUM
 It is open swollen, discolored and painful after delivery often with laceration
and episiotomy
o Watch signs of trauma and infection: Redness, Edema, Purulent
discharge, Gaping at suture line
 By 6 weeks - most of the perineal muscle tone is regained
 The discomfort of episiotomy does not last for more than one week
 Perineal care is necessary to prevent infection, to ease the woman and
eliminate odor.
D. OVARIES
 Period of BF: first cycle is usually anovulatory.
 Ovulation and resumption of menstruation depends on lactation
 by 7 to 9 weeks - nonlactating women usually menstruate and ovulate by 8-10
weeks after delivery.

NCM 107: CARE OF THE MOTHER, CHILD AND ADOLESCENT (WELL CLIENTS)
Page 36 of 46
N O R TH W ES T ERN U N IV ER SI TY
,INC

HORMONAL SYSTEM
 Pregnancy hormones decrease after the delivery of the placenta
 HUMAN CHORIONIC GONADOTROPIN (HCG) and human placental
lactogen (HPL)
- are almost negligible by 24 hours
 1 week postpartum - Progestin, estrone, and estradiol are at the prepregnancy
levels
 1 week after delivery - Estrol remains elevated
 12 days after delivery - Follicle stimulating hormone (FSH) remains low

2. CIRCULATORY SYSTEM
 Blood loss: NSD -500 ml; CS – bet. 500 to 1000 ml
 Blood loss and dieresis in the postpartum period contribute to reduction in
blood volume.
 w/in 5 to 10 minutes after placental delivery
 the 40% in blood volume during pregnancy enters the maternal circulation -
making this period very critical to gravidocardios.
 one to two weeks after delivery
 blood vol. resulting to nonpregnant levels resulting in a decline in cardiac
output by 30%.
 Hctt rises in the first 3 to 7 days - due to hemoconcentration caused by
excretion of large amounts of fluid in the urine.
 Fourth to fifth postpartum week – hct level returns to normal
 during the first 12 days
- Leucocytosis of 20,000 to 30,000 (normal 5,000 to 10,000):
- increases on neutrophils and eosinophils
- decrease lymphocytes.
 Until the third postpartum week
- Fibrinogen and thromboplastin remains elevated
 Varicosities and vascular blemishes lessen or fade slightly

3. GASTROINTESTINAL SYSTEM
 Digestion and absorption begins immediately after birth
 Good appetite is expected
 Added CHON and calories:
ocaloric requirements : 2500 but increases by 500 to make it 3000 if mother is
lactating

NCM 107: CARE OF THE MOTHER, CHILD AND ADOLESCENT (WELL CLIENTS)
Page 37 of 46
N O R TH W ES T ERN U N IV ER SI TY
,INC

 May still experience constipation despite active bowel sounds.

4. URINARY SYSTEM
 12 hours after delivery and extends up to the fifth day
- Diuresis begins as the body gets rid of ECF accumulated during pregnancy.
- loses up to 9 lbs wt. from the excretion of these fluids and electrolytes
 at the 2nd to 5th day postpartum - urine output of 15000-3000 ml/day
 until 4 weeks after delivery - Hydronephrosis during pregnancy remains.

5. INTEGUMENTARY SYSTEM
 Striae gravidarum do not disappear and assumes a silvery white appearance
 6 weeks after giving birth - Chloasma, palmar erythema, linea negra become
barely detectable.
 Hypopigmentation of the areola may not disappear completely and some
women are left with a wider and darker areola after pregnancy

VITAL SIGNS
1. Pulse rate:
 immediately after delivery - slightly elevated due to the effect of epinephrine from
stress of labor.
 Rates > than 100 b/min - indicate bleeding and hypovolemia, dehydration, fever
infection or pain.
 Usual slight bradycardia during early postpartum - with average PR at 60 b/min.
2. Respiratory rate: within the range 16-20 b/min.
3. Blood Pressure: changes minimally and is usually stabilized with in the first 6
hours.
o HPN may be due to the effects of epidural analgesia or anesthesia or bleeding
o hemorrhage may be difficult to identify in postpartum woman if BP is used as a
parameter.
 -BP may still be within normal limits even if she is bleeding due to increase
circulating volume during pregnancy.
 Hypotension from hemorrhage, therefore maybe a late sign of hemorrhage in
puerpera.
o orthostatic hypotension is common and may cause dizziness and faintness.
o oxytocin (syntocinon), pitocin - can cause decrease BP
o methergin, ergot, methylgometrine - can cause increase BP
4. Temperature: slight elevation after delivery.
o normal postpartum oral temperature -36.2°C to 38°C.
o in the first 24 hours after delivery, > than 38°C

NCM 107: CARE OF THE MOTHER, CHILD AND ADOLESCENT (WELL CLIENTS)
Page 38 of 46
N O R TH W ES T ERN U N IV ER SI TY
,INC

- may indicate dehydration from loss of fluids during delivery but may also be
due to the excitement and stress of labor.
o after 24 hours, temperature reading > than 38°C six hours apart for 2
consecutive days
- indicate a postpartum infection.
Weight: after birth, loss about 5 to 6 kg of wt and continue to lose wt until the end of the
postpartum period primarily due to diuresis and diaphoresis.
 About 3 lbs higher than her weight before pregnancy
- is a baseline weight that the woman usually attains after the postpartum period
 2nd to 5th day postpartum: wt. loss of 5 lbs (2-4 kg) the 2-3 lb (kg) is due to
lochial flow.
 Weight is influenced by nutrition and BF

BREAST (LACTATION)
o 1ST – 2ND day postpartum: breasts are soft and continue to secrete colostrums.
o 3rd day – breast become full and tender
o 3rd -4th day – primarily engorgement

POSTPARTUM EXERCISES
- the purpose is to prevent complications, promote psychological well being, for
rapid return of woman’s figure and strengthen muscles of the back, pelvic floor
and abdomen
a. abdominal breathing: tighten abdominal muscles
b. kegel exercise: tighten perineal muscle
c. chin to chest: strengthen abdominal muscles
d. arm raising: return of breast and abdominal muscles tone
e. leg raising; tighten abdominal muscles
f. sit ups: tighten abdominal muscles

PSYCHOLOGICAL ADAPTATIONS AFTER DELIVERY

REVA RUBIN’S POSTPARTUM PHASE (Phases of Puerperium)

1. Taking-In Phase
- occurs the first 2 to 3 days postpartum.
- the woman’s attention is focused on her own needs for sleep, rest ( self-centered )
and she is dependent on others (passive)
2. Taking-hold Phase

NCM 107: CARE OF THE MOTHER, CHILD AND ADOLESCENT (WELL CLIENTS)
Page 39 of 46
N O R TH W ES T ERN U N IV ER SI TY
,INC

- a period extends from 3rd day to 2nd weeks postpartum .

- prefers to do things by herself (expresses strong interest in taking care of
her child).
- as she is not yet completely recovered, she feels impatient that she’s not strong
enough to do everything she wishes to accomplish.
3. Letting-go Phase
- mother realizes that the infant is a separate individual and not a part of
herself; then experiences a feeling of loss.
- as the mother realizes the individuality of the baby, she gives up fantasies about
the child.
- mother also undergoes role transition: she gives up her role as a childless
woman and adjust herself and lifestyle to meet the needs of her child.

PSYCHOLOGICAL PROBLEMS DURING PUERPERIUM (POSTPARTUM

PSYCHIATRIC DISORDERS)
- the exact cause of these is unknown.
- current beliefs on the causes on its cause include the ff views:
1. due to stress of the peripartum period and the responsibilities of child rearing
2. sudden hormonal changes that occur during the postpartum period characterized by
sudden decrease in the endorphins, estrogen and progesterone levels that occur
after delivery.
3. low free serum tryptophan levels have been observed, which consistent with
findings in major depression in other settings
4. postpartum thyroid dysfunction has also been correlated with postpartum
psychiatric disorders
RISKS FACTORS
1. Unwanted pregnancy
2. Feeling unloved by mate
3. Below 20 years old
4. Single mother
5. Medical indigence
6. Low self-esteem
7. Dissatisfaction with extent of education
8. Economical problem with housing and income
9. Poor relationship with husband or boyfriend

NCM 107: CARE OF THE MOTHER, CHILD AND ADOLESCENT (WELL CLIENTS)
Page 40 of 46
N O R TH W ES T ERN U N IV ER SI TY
,INC

10. Being part of a family of 6 or more siblings

11. Limited parental support (either as a child or as a adult)
12. Past or present evidence of emotional problems.

DIFFERENTIATION OF POSTPARTUM BLUES, POSTPARTUM DEPRESSION,

AND POSTPARTUM PSYCHOSIS
Characteristics Postpartum blues Postpartum Depression Postpartum Psychosis
Incidence  70% to 80% of 7% to 20% of new 15 to 25 of mothers per
new mothers mothers 1,000 live births
 26% in
adolescent
mothers
Onset 3 to 5 days after Usually within 6 Usually within 2 to 4
childbirth months after childbirth weeks following
childbirth.
Symptoms Periodic crying, Anorexia, weight loss,  Early symptoms may
spells, sadness, insomnia, fear of resemble depression
confusion, insomnia harming the baby, and then suddenly
and anxiety neglect of personal escalate to delirium,
care, self-destructive, hallucinations, anger
feeling of towards self
worthlessness, guilt, and baby,
fatigue, hypochondria bizarre
and low self esteem behavior,
manifestations manifestations of
mania and thought of
hurting self or baby.

NCM 107: CARE OF THE MOTHER, CHILD AND ADOLESCENT (WELL CLIENTS)
Page 41 of 46
N O R TH W ES T ERN U N IV ER SI TY
,INC

PREVENTION AND MANAGEMENT OF COMMON DISCOMFORTS OF

PURPERIUM
1. Breast engorgement
2. after pains
3. urinary retention
4. hemorrhoids
5. painful episiotomy wound

Management for Episiotomy

1. apply ice pack to perineum (applied 20-30 min and removed for at least 20 minutes)
2. inspect every 15 mins. during the first hour after birth for redness, swelling,
tenderness and hematomas.

POSTPARTAL NURSING MANAGEMENT

1. Provide rest and sleep
2. provide high in calories
3. monitor v/s, fundus, lochia, urinary output, maternal behavior
4. promote bowel and bladder function
5. provide physical and psychological comfort
6. administer oxytocin ad ordered
7. meets the mother’s needs so she can meet the child’s needs as necessary
8. encourage KAEGEL’S exercise
9. strict asepsis in perineal care
10. emphasize the importance of hand washing in caring for the baby and self
11. provide breast care, inspect for problems and complications
12. assist with self care and baby care as indicated.
13. emphasize the need for and importance of postpartum follow-up

PROMOTION OF SUCCESSFUL BREASTFEEDING

1. Hormonal influences of lactation
 Increase in estrogen level (placenta) stimulates growth of breast and milk glands
 A low level of estrogen and progesterone after delivery of placenta enhances the
release of prolactin – necessary in milk production

NCM 107: CARE OF THE MOTHER, CHILD AND ADOLESCENT (WELL CLIENTS)
Page 42 of 46
N O R TH W ES T ERN U N IV ER SI TY
,INC

 On the 3rd day postpartum, mother experiences breast engorgement (full tense and
tender breast, milk secretions starts).
 The stimulation of PPG results to secretion of pitocin, triggering now the letdown
reflex
 Sign of (+) letdown reflex is mother’s gown wet at nipple line
2. Factors on successful BF
 Start early
 Feed early and frequently or per demand
 Empty the breast totally with each feeding time
 Allow NB to nurse in short frequent periods 2-3 mins. during the first day,
increasing gradually to 10 mins. on each breast in later days.
 Be present during the initial feeding and remain with the mother to each feeding
time until she becomes confident.
 Proved a relaxed, warm and supportive environment as the letdown reflex is
affected by maternal emotions, provide reinforcement for positive behavior or
successful actions.
 Motivate mother by informing her of the benefits derived from breastfeeding.
 Diet should be balanced
 Promote breast comfort and hygiene
 Express excess amount of milk
 Wear a well-fitting bra
 Cold or warm compress
 Breast massage
 Analgesics as ordered
 Breast hygiene
a. daily wash at bath time
b. no soap, alcohol or antiseptic agents
c. do not use plastic lined bra
TEACHING THE MOTHER ON BREASTFEEDING PROCEDURE
1. instruct mother to wash her hands before BF to protect the infant and mother
from infection
2. let mother lie on left side with pillow under head. Position left arm above the head or at
the other side. Or use a chair with a back support and place a pillow on lap to hold
infant. The mother should be relaxed and comfortable.
3. wash nipple with lukewarm water and dry with soft and clean cloth
4. with the right hand, press darkened area around nipple into infant’s mouth. This
maneuver is necessary for adequate suction.
5. if breast are full, use 1 finger to press breast away from infant’s nose. This prevents
airway obstruction

NCM 107: CARE OF THE MOTHER, CHILD AND ADOLESCENT (WELL CLIENTS)
Page 43 of 46
N O R TH W ES T ERN U N IV ER SI TY
,INC

6. use both breasts at each feeding, alternate that is used first. The infant will empty the
first breast, nursing at the 2nd will increase milk production.
7. break the suction by putting a finger into the corner of infants mouth. Pulling the nipple
abruptly away from the nipple will result in sore nipples.
8. burp infant midway through the feeding. Pat gently on the back or hold in an
upright position, helps infant release air bubbles in the stomach.

2. POSSIBLE COMPLICATIONS DURING POSTPARTUM:

A. POSTPARTUM HEMORRHAGE
- refers to excessive blood loss during or after the third stage of labor.
 NSD blood loss >500 ml and >1000 ml at CS.
 the leading cause of maternal mortality.
 the first two hours postpartum - most dangerous time at which hemorrhage is likely
occur.
TYPES OF POSTPARTUM HEMORRHAGE
1. Early Postpartum Hemorrhage: occurs during the first 24 hours after delivery.
- The common causes are:
a. uterine atony
b. laceration of birth canal
c. inversion of uterus
2. Late Postpartum Hemorrhage: occurs from 24 hours after birth to 4
weeks postpartum
- The common causes are:
a. retained placental fragments
b. subinvolution of the uterus
c. infection of the uterus (endometritis)

CAUSES OF POSTPARTUM HEMORRHAGE (4 T’s)

1. Tone – failure of the uterine myometrial muscle fibers to contract and react
2. Tissue – presence of retained placental tissues prevents full uterine contractions
3. Trauma – 20% of postpartum hemorrhage is due to trauma anywhere in the
genital tract
4. Thrombosis- disorders of coagulation system and platelets pre-existed or acquired,
can result in bleeding or aggravate bleeding.
a. pre existent coagulation disorder: thrombocytopenia purpura
b. acquired disorders: HELLP and DIC
c. dilutional coagulapathy – clotting factor significantly reduce with aggressive
transfusion of crystalloid and PRBC’s

NCM 107: CARE OF THE MOTHER, CHILD AND ADOLESCENT (WELL CLIENTS)
Page 44 of 46
N O R TH W ES T ERN U N IV ER SI TY
,INC

 SHEEHAN’ SYNDROME
- may occur with severe hemorrhage during labor and delivery.
- severe blood loss results in poor supply to the pituitary gland causing tissue
death that eventually cause hypopituitarism.
- also known as postpartum hypopituitarism, pituitary insufficiency and
hypopituitarism syndrome.

B. PUERPERAL INFECTION
 PUERPERIAL FEVER OR INFECTION (also known as CHILDBED FEVER)
 Is a general term used to describe infection of the genital tract after delivery.

Infecting Organisms
1. Anaerobic streptococci – causative agents are those that normally inhibit the
colon, vagina and cervix.
2. Escherichia coli – are those that are part of the normal flora of the woman’s body.
3. The causative agent may be introduced during labor and delivery - by hospital
personnel through droplet infection.

PREDISPOSING FACTORS
- PROM
- prolong labor
- postpartum hemorrhage
- anemia
- malnutrition
- retained placental fragments
- instrumental deliveries: CS
- intrauterine manipulation such as manual exploration of the uterus
- excessive vaginal manipulation (IE) during labor
- presence of infection elsewhere in the body or in the genital tract during
labor, delivery and puerperium
- sexual intercourse near labor or after membranes
ruptured 12, low socio-economic status
SIGNS AND SYMPTOMS
1. fever:
- elevation of temperature (100.4°F and above) for 2 consecutive days or more
after 24 hours postpartum - the most important characteristic of postpartum

NCM 107: CARE OF THE MOTHER, CHILD AND ADOLESCENT (WELL CLIENTS)
Page 45 of 46
N O R TH W ES T ERN U N IV ER SI TY
,INC

infection
2. foul smelling lochia or vaginal discharge.
3. Rapid pulse
4. abdominal pain or tenderness
5. body malaise
6. lack of appetite
7. perineal discomfort
8. nausea and vomiting

Endometritis – is the infection of the lining of the uterus. The most common uterine
puerperial infection.
UTI – baaterial inflammation of the bladder or urethra. It is common during puerperium
because of trauma to the bladder after delivery, urinary retention and over distention
of the bladder due to anesthesia. May also introduced during catheterization.
MASTITIS – infection of breast tissue occurs most commonly in breastfeeding mothers.
 Usually appears during the 2nd and 3rd week postpartum when milk supply is
already established

Evaluation:

It’s time to evaluate, this can be in the form of a

quiz/examinations or any summative assessment
related to the topics that have been discussed. On
this part it will be conducted online via canvas.
Announcement of schedule will be made ahead of
time in the canvas.

Good Luck!

NCM 107: CARE OF THE MOTHER, CHILD AND ADOLESCENT (WELL CLIENTS)
Page 46 of 46