Maternal and Child Nursing Lecture

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FAMILY
FAMILY is the basic social institution and the primary group in society.
 According to Murdok, family is a social group characterized by common
residence, economic cooperation and reproduction.
 According to Burges and Locke, family is a group of persons united by ties of
marriage, blood or adoption, constituting a single household, interacting and
communicating with each other in their respective social roles of husband and
wife, mother and father, son and daughter, brother and sister, and creating and
maintaining a common culture.
 According to Murray and Zentner (1997) is a social system and primary reference
group made up of two or more persons living together who are related by blood,
marriage or adoption or who are living together by arrangement over a period of
time.
CHARACTERISTICS OF A FAMILY
 The family as a social group is universal and is significant element in man’s
social life
 It is the first social group to which the individual is exposed. Family contact and
relationships are repetitive and continuous
 The family is very close and intimate group. It is setting of the most intense
emotional experiences during the life time of the individual.The family affects the
individual social values, disposition and outlook in life
 The family has the unique position of serving as a link between the individual and
the larger society
 The family is also unique in providing continuity of social life.
Functions of Family
 Regulates sexual behavior and reproduction
 Biological maintenance function

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 Socialization function
 Provide legitimate children with a status
 Social control function
 Economic function
 Educational, recreational, religious and political functions
Classification of Family Structure
Based on Descent
 Patrilineal- affiliates a person with a group of relatives through his or her father.
 Matrilineal- affiliates a person with a group of relatives through his or her mother.
 Bilateral- affiliates a person with a group of relatives related through both his or
her parents.
Based on Authority
 Patriarchial- authority is vested on the oldest male in the family, often the father.
 Matriarchial- authority is vested in the mother or mother’s kin
 Matricentric- prolonged absence of the father gives the mother a dominant
position in the family, although the father may also share with the mother in
decision making.
Based on Internal Organization and Membership
 Nuclear Family. Also known as primary or elementary family.
 Extended Family. Extensions maybe through the parent-child relationship or
husband-wife relationship, as in polygamous marriage.
Based on Place of Residence
 Patrilocal- requires the newly wed to reside near the groom’s parents.
 Matrilocal- near the bride’s parents.
 Bilocal- provides the couple the choice to reside on either parents.
 Neolocal- permits the couple to reside independently of their parents

 Avunculocal- prescribes the newly wed couple to reside with or near the maternal
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uncle of the groom.
Families consist of special functional subsystems:
 marital subsystem (parents)
 sibling subsytem (children)
 individual parent –child system subsystem
View of the person: The person is a member of the family where each new member
adds to the complexity of the interaction within the family.
Stages of Family
1. Beginning *Establishing a mutually satisfying Family marriage *Planning to have
or not to have children.
2. Child- *Having and adjusting to infant bearing family *Supporting the needs of all
three members *Renegotiating marital relationships.
3. Family with *adjusting to cost of family life a pre-school *adapting to the needs of
pre-school children *Coping with parental loss of energy and privacy
4. Family with *Adjusting to the activity of the growing school age children
*Promoting joint decisions between children and parents *Encouraging and
supporting children’s educational achievements
5. Family with *Maintaining open communication among teenagers and members
young adult *Supporting ethical and moral values within the family *Balancing
freedom with responsibility of teenagers *Releasing young adults with
appropriate rituals and assistance
6. Post- *Strengthening marital relationships parental *Maintaining supportive home
base family *Preparing for retirement
7. Aging *Maintaining ties with younger and Family older generations *Adjusting for
retirement *Adjusting to loss of spouse *Closing family house

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FETAL AND MATERNAL HEALTH PRENATAL CARE
 Ensures the overall health of newborns and their mothers.
OB
Follow-up visits
 Every 4 weeks through the 28th week
 Every 2 weeks through the 36th weeks
 Every week until delivery
The health care given to a woman and her family during pregnancy.
The earliest stage at which fetuses could survive if they were born at that time.
Any pregnancy terminated before the age of viability.
An infant born at the end of 37 weeks to the end of 42 weeks.
An infant born before 37 weeks.
An infant born beyond 42 weeks.
A woman in labor.
A woman who has just given birth.
A pregnant woman or refers to the present pregnancy.
The number of pregnancy that reached viability.
A woman who is pregnant the first time.
A woman with a second or later pregnancy.
A woman who has never been pregnant and is nor currently pregnant.
A woman who has completed one pregnancy of viability.
A woman who has carried two or more pregnancies of viability.
A woman who had 6 or more viable pregnancies.
History of past pregnancies
Gravida (G)
 A number of times the woman has been pregnant.
Para (P)
 A number of children above viability the woman has previously borne.
 Multigestation is considered as one para
GTPAL
G- number of times the woman has been pregnant.

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P- is broken down into:
T- term BIRTH
P- preterm BIRTH
A- Abortion
L- living children
GTPALM
G- number of times the woman has been pregnant
P- is broken down into:
T- term INFANT
P- preterm INFANT
A- abortion
L- living children
M- multiple pregnancies
History of present pregnancy
Estimate date of birth/ date of delivery
Naegele’s rule
 standard method used to predict the length of a pregnancy
 approximates that pregnancy last 40 weeks from LMP
 To get EDB/ EDD
 1st day of LMP
Estimate fetal growth
McDonald’s Rule
 Common method of determining fetal growth in utero.
 Symphisis-fundal height measurement
 The distance from the symphisis pubis to the uterine fundus in cm es equal to the
week of gestation between the 20th and 31st weeks of preganancy
 To estimate AOG
 Fundic height in cm x 2/7= AOG in moths

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 Fundic height in cm x 8/7= AOG in weeks
Leopold’s Maneuver
 A systematic method of observation and palpation of the abdomen to determine
fetal presentation and position.
Preparation
 Explain the procedure
 Ask to void
 Supine with knees slightly flexed
 Wash hands with warm water
Purpose Procedure Findings
First Maneuver:
Fundal Grip
To determine fetal
part lying in the
fundus.
To determine
presentation.
Using both hands,
feel for the fetal
part lying in the
fundus.
Head is more firm,
hard and round
that moves
independently of
the body.
Breech is less well
defined that moves
only in conjunction
with the body.
Second
Maneuver:
Umbilical Grip
To identify
location of fetal
back.
To determine
position.
One hand is used
to steady the
uterus on one
side of the
abdomen while
the other hand
moves slightly on
a circular motion
from top to the
lower segment of
the uterus to feel
for the fetal back
and small fetal
parts.
Use gentle but
deep pressure.
Fetal back is
smooth, hard, and
resistant surface
Knees and
elbows of fetus
feel with
a number of
angular nodulation
Third Maneuver:
Pawlik’s Grip
To determine
engagement of
presenting part.
Using thumb and
finger, grasp the
lower portion of
the abdomen
above symphisis
pubis, press in
slightly and make
The presenting
part is notengaged
if it is not movable.
It is not yet
engaged if it is still
movable.

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gentle movements
from side to side.
Fourth
Maneuver:
Pelvic Grip
To determine the
degree of flexion
of fetal head.
To determine
attitude or habitus.
Facing foot part of
the woman,
palpate fetal head
pressing
downward about 2
inches above the
inguinal ligament.
Use both hands
Good attitude – if
brow correspond to
the side (2nd
maneuver) that
contained the
elbows and knees.
Poor atitude – if
examining fingers
will meet an
obstruction on the
same side as fetal
back
(hyperextended
head)
Also palpates
infant’s
anteroposterior
position. If brow is
very easily
palpated, fetus is
at posterior
position (occiput
pointing towards
woman’s back)
PRENATAL VISIT
8-12 weeks: Initial prenatal visit. The plan for your prenatal care at the practice you
have chosen will be explained. A health history is taken, and a physical exam, including
a pelvic exam is done. Lab work is completed, including your blood type and
hemoglobin, sexually transmitted infection screening, a urine test, and a PAP test if you
are due for one. You may be able to hear the baby's heart beat at this visit. If you

cannot say with accuracy when you had your last period, an ultrasound might be
scheduled to help determine how far along you are.
Optional genetic counseling visit: Early in your pregnancy, you may be offered
genetic screening. This is commonly offered to women over the age of 35, or women
who have a family history of genetic problems, but it is increasingly being offered to
every woman. If you choose this screening, your care provider and/or genetic counselor
may suggest additional genetic screening or diagnostic tests, including blood tests,
chorionic villus sampling, ultrasound, and/or amniocentesis. These tests are done at
specific times during pregnancy.
First two trimesters: Prenatal visits continue every 4-6 weeks through the first two
trimesters, or until you are 28 weeks along. At each appointment, your care provider will
weigh you and take your blood pressure, listen to the baby's heartbeat, and measure
the growth of your uterus and baby. Some providers check your urine for protein and
sugar at each visit.
15 to 20 weeks: At one of your appointments within this period, you will be offered the
Quad Screen test, which screens for genetic and spinal cord abnormalities. You may
also be offered an ultrasound between 18 and 20 weeks to view the baby's organs, and
measure the growth of the baby and the placenta.
27 or 28 weeks: At an appointment within this period, you will be encouraged to take a
glucose challenge test to screen for gestational diabetes. Your hemoglobin may be
rechecked. Some providers do a pelvic exam. Expect to review warning signs of late
pregnancy that would alert you to preterm labor or high blood pressure. You may be
encouraged to sign up for prenatal classes, find a doctor or nurse-practitioner who will
provide well-child care for your baby, and information may be provided about making
plans for labor.
28 to 36 weeks: After 28 weeks, prenatal visits continue every 2-3 weeks until 36
weeks. Your doctor or midwife will continue to record the growth of the baby, listen to
the baby's heartbeat, and will check the position of the baby.
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36 weeks: At this visit, your midwife or doctor will do a pelvic exam, and encourage you
to have a Group B Strep test. Screening tests for sexually transmitted infections may be
repeated at this visit. The position and size of the baby are estimated. If your baby is not
head down, your provider may suggest exercises to encourage the baby to turn, or
suggest a physical manipulation called external version. The risks and benefits of this
procedure should be carefully explained.
36 to 40 weeks: The usual monitoring of your weight and blood pressure, and the
baby's size, position, and heart rate are done. Your care provider may offer to check
your cervix for dilation.
40+ weeks: After your due date, your care provider may offer what is called "post-dates"
testing, including nonstress tests, ultrasound, and biophysical profiles. Some
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providers start at 40 weeks, others not until 10 days past your due date.
Safe Medications to Take During Pregnancy
Allergy
 Benadryl (diphenhydramine)
 Claritin
Check with your doctor before taking these in the first trimester.
Cold and Flu
 Tylenol (acetaminophen)
 Saline nasal drops or spray
 Warm salt/water gargle
Check with your doctor before taking any other medications, especially in the first
trimester.
Constipation
 Colace
 Metamucil
First Aid Ointment

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 Bacitracin
 J&J First-Aid Cream
 Neosporin
 Polysporin
Rashes
 Benadryl cream
 Caladryl lotion or cream
 Hydrocortisone cream or ointment
 Oatmeal bath (Aveeno)
*Note: No drug can be considered 100% safe to use during pregnancy.
What Alternative Therapies Are Considered Safe During Pregnancy?
Some alternative therapies have been shown to be safe and effective for pregnant
women to relieve some of the uncomfortable side effects of pregnancy. Talk it over with
your doctor first before using any of them. And remember, “Natural” doesn’t always
equal “safe” when you’re pregnant.
Nausea in early pregnancy: Acupuncture, acupressure, ginger root (250 milligram
capsules 4 times a day), and vitamin B6 (pyridoxine, 25 milligrams two or three times a
day) work well. Sipping the thick syrup from inside a can of peaches, pears, mixed
fruits, pineapples, or orange slices may also help.
Backache: Chiropractic manipulation holds the best track record. Another option is
massage but it is important to make sure your massage therapist is adequately trained
in pre-natal massage.
Turning a breech baby: Exercise and hypnosis may help.
Pain relief in labor: Epidurals are most effective, but immersion in a warm bath can
also relieve tension. Relaxation and breathing techniques, emotional support, and self-hypnosis
are widely used in labor. Acupuncture can also work for some women.

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Common Discomforts During Pregnancy
Symptoms of discomfort due to pregnancy vary from woman-to-woman. The following
are some common discomforts. However, each mother-to-be may experience
symptoms differently or not at all:
 Nausea and vomiting
About half of all pregnant women experience nausea and sometimes vomiting in the
first trimester--also called morning sickness because symptoms are most severe in the
morning. Some women may have nausea and vomiting throughout the
pregnancy. Morning sickness may be due to the changes in hormone levels during
pregnancy.
Morning sickness seems to be aggravated by stress, traveling, and certain foods, such
as spicy or fatty foods. Eating small meals several times a day may help lessen the
symptoms. A diet high in protein and complex carbohydrates (such as whole wheat
bread, pasta, bananas, and green, leafy vegetables) may also help reduce the severity
of the nausea.
If vomiting is severe, causing a woman to lose fluids and weight, it may indicate a
condition called hyperemesis gravidarum. Hyperemesis can lead to dehydration and
may require hospitalization for intravenous fluids and nutrition. Call your physician or
midwife if you are having constant or severe nausea and vomiting.
 Fatigue
As the body works overtime to provide a nourishing environment for the fetus, it is no
wonder a pregnant woman often feels tired. In the first trimester, her blood volume and
other fluids increase as her body adjusts to the pregnancy. Sometimes anemia is the
underlying cause of the fatigue. Anemia is a reduction in the oxygen-carrying capability
of red blood cells, and is usually due to low iron levels. A simple blood test performed at
a prenatal visit will check for anemia.
 Hemorrhoids
Because of increased pressure on the rectum and perineum, the increased blood
volume, and the increased likelihood of becoming constipated as the pregnancy

progresses, hemorrhoids are common in late pregnancy. Avoiding constipation and
straining may help to prevent hemorrhoids. Always check with your physician or midwife
before using any medication to treat this condition.
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 Varicose veins
Varicose veins--swollen, purple veins--are common in the legs and around the vaginal
opening during late pregnancy. In most cases, varicose veins are caused by the
increased pressure on the legs and the pelvic veins, and by the increased blood
volume.
 Heartburn and indigestion
Heartburn and indigestion, caused by pressure on the intestines and stomach (which, in
turn, pushes stomach contents back up into the esophagus), can be prevented or
reduced by eating smaller meals throughout the day and by avoiding lying down shortly
after eating.
 Bleeding gums
Gums may become more spongy as blood flow increases during pregnancy, causing
them to bleed easily. A pregnant woman should continue to take care of her teeth and
gums and go to the dentist for regular checkups. This symptom usually disappears after
pregnancy.
 Pica
Pica is a rare craving to eat substances other than food, such as dirt, clay, or coal. The
craving may indicate a nutritional deficiency.
 Swelling/fluid retention
Mild swelling is common during pregnancy but severe swelling that persists may
indicate preeclampsia (abnormal condition marked by high blood pressure). Lying on
the left side, elevating the legs, and wearing support hose and comfortable shoes may
help to relieve the swelling. Be sure to notify your physician or midwife about sudden
swelling, especially in the hands or face, or rapid weight gain.
 Skin changes
Due to fluctuations in hormone levels, including hormones that stimulate pigmentation of

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the skin, brown, blotchy patches may occur on the face, forehead, and/or cheeks. This
is often called the mask of pregnancy, orchloasma, and often disappears soon after
delivery. Using sunscreen when outside can reduce the amount of darkening that
occurs.
Pigmentation may also increase in the skin surrounding the nipples, called the areola. In
addition, a dark line frequently appears down the middle of the abdomen. Freckles may
darken, and moles may grow.
 Stretch marks
Pinkish stretch marks may appear on the abdomen, breasts, thighs, or buttocks. Stretch
marks are generally caused by a rapid increase in weight, and the marks usually fade
after pregnancy.
 Yeast infections
Due to hormone changes and increased vaginal discharge, also called leukorrhea, a
pregnant woman is more susceptible to yeast infections. Yeast infections are
characterized by a thick, whitish discharge from the vagina and itching. Yeast infections
are highly treatable. Always consult your physician or midwife before taking any
medication for this condition.
 Congested or bloody nose
During pregnancy, the lining of the respiratory tract receives more blood, often making it
more congested. This congestion can also cause stuffiness in the nose or nosebleeds.
In addition, small blood vessels in the nose are easily damaged due to the increased
blood volume, causing nosebleeds.
 Constipation
Increased pressure from the pregnancy on the rectum and intestines can interfere with
digestion and subsequent bowel movements. In addition, hormone changes may slow
down the food being processed by the body. Increasing fluids, regular exercise, and
increasing the fiber in your diet are some of the ways to prevent constipation. Always
check with your physician or midwife before taking any medication for this condition.

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 Backache
As a woman's weight increases, her balance changes, and her center of gravity is
pulled forward, straining her back. Pelvic joints that begin to loosen in preparation for
childbirth also contribute to this back strain. Proper posture and proper lifting techniques
throughout the pregnancy can help reduce the strain on the back.
 Dizziness
Dizziness during pregnancy is a common symptom, which may be caused by:
o Low blood pressure due to the uterus compressing major arteries
o Low blood sugar
o Low iron
o Quickly moving from a sitting position to a standing position
o Dehydration
To prevent injury from falling during episodes of dizziness, a pregnant woman should
stand up slowly and hold on to the walls and other stable structures for support and
balance.
 Headaches
Hormonal changes may be the cause of headaches during pregnancy, especially during
the first trimester. Rest, proper nutrition, and adequate fluid intake may help alleviate
headache symptoms. Always consult your physician or midwife before taking any
medication for this condition. If you have a severe headache or a headache that does
not resolve, call your health care provider. It may be a sign of preeclampsia.
Danger signs of Pregnancy
1. Decreased fetal movement
If you notice that your baby isn't moving around as much as she normally does, stop
exercising and take a minute to pay attention to what she's doing. Remember that
sometimes it's hard to tell if your baby is moving around when you're moving around,

too. Also, be sure to eat and drink water before your workout because that may affect
your baby's movements.
Call your healthcare provider: if your baby isn't moving around as much as normal or
you notice a sudden decrease in your baby's movement.
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2. Dizziness
Is It Safe During Pregnancy?
Persistent dizziness together with fatigue and headaches can be symptoms of severe
anemia or another serious condition.
Call your healthcare provider: if you're still dizzy after you've cooled down, rested,
and had some water.
3. Overheating
If you feel faint or dizzy, or if you develop a headache, nausea, cramps, or a racing
heart, your body's telling you that it's having a hard time regulating your internal
temperature, which can be harmful to your baby. The baby can get overheated just as
you do. When your body overheats, blood flowing to the uterus is diverted to the skin to
help the body cool itself off, putting the baby in jeopardy.
It's unusual to overheat from exercise alone, but if it's hot outside or in the gym where
you exercise, you could run into trouble. If you're exercising indoors, it's best to do so in
a well-ventilated room with fans. If you're exercising outdoors, avoid the sun when it's
strongest in the middle of the day. Consider staying inside if it's especially hot out.
Call your healthcare provider: if you feel very hot and you have symptoms of
overheating, like profuse sweating, dizziness or lightheadedness, a headache, nausea,
cramps, or an irregular heartbeat.
4. Heart palpitations
If your heart is pounding and you can't carry on a conversation without being out of
breath, or if you sweat buckets while you exercise, you're probably working too hard.
Heart palpitations may be a sign of dehydration, severe anemia, thyroid disease, or a
heart problem.
Call your healthcare provider: if your heart continues to race after you've cooled
down, rested, and had some water.
5. Swelling in your calf

Your feet and hands may puff up a little after you exercise, but if you notice calf pain or
swelling, it could be a sign of deep vein thrombosis (DVT), a potentially life-threatening
condition caused by a type of blood clot. DVT usually affects veins deep in the lower leg
and thigh and occurs on one side of the body. You may experience redness and skin
that feels warm to the touch.
Also, sudden swelling in your legs (and face and hands), along with high blood
pressure, may be a sign of preeclampsia.
Call your healthcare provider: immediately if you think you have DVT. If you have
DVT and you experience chest pain, difficulty breathing, fainting, or any other serious
condition, go to the emergency room right away.
6. Vaginal bleeding
Some women do experience light spotting throughout their pregnancy, but vaginal
bleeding during pregnancy is always a cause for concern. Early in your pregnancy, it
could signal a miscarriage. In the second and third trimesters, bleeding is associated
with premature labor and complications with the placenta, such as placenta
previa or placenta abruption. All require immediate medical attention.
Call your healthcare provider: immediately if you have vaginal bleeding. If you
can't reach anyone, go to the emergency room.
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7. Blurred vision
It's common for blood pressure to drop during the first 6 months of pregnancy. But
combine low blood pressure with exercise and dehydration, and you may be headed for
trouble.
If your eyesight gets hazy in the middle of your workout, you may be dehydrated. That
alone is enough to send your blood pressure plummeting and your heart into overdrive.
As a result, not enough blood may be getting to your developing baby's vital organs.
Blurred vision may also be a sign of preeclampsia. This condition can be dangerous for
your baby because preeclampsia can severely restrict the flow of blood to the placenta.
Call your healthcare provider: immediately. If you can't reach anyone, go to the
emergency room.
8. Fainting
Fainting during pregnancy shouldn't be taken lightly. It could signal something as simple
as dehydration or something serious like major circulatory or heart problems. You may

not be getting enough oxygen to your brain, which means your baby may not be getting
enough either.
emergency room.
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9. Recurring pain in abdomen or chest
It may just be your ligaments stretching, but you could also be having contractions –
especially if the pain recurs at somewhat regular intervals.
Women experience labor pain differently: For some the pain is similar to a severe
menstrual cramp. For others, the pain is sharp and comes in waves or feels like a
recurring pain in the back. Abdominal pain accompanied by bleeding might be a sign
of placental abruption. You may need to be hooked up to a fetal monitor so your
healthcare provider can determine whether you're in labor.
Life-threatening chest pain most likely signals a serious problem with your heart or
lungs. If you're pregnant and have chest pain while exercising, the American College of
Obstetricians and Gynecologists recommends that you stop what you're doing right
away.
emergency room.
10. Fluid leaking from your vagina
If your underpants are constantly wet or if you feel watery fluid leaking (or gushing) from
your vagina, it could mean premature rupture of the membranes. That can be a signal
that your body is about to go into labor.
Theories of Labor Onset
Labor is a coordinated sequence of involuntary, intermittent uterine contractions. It is
the series of events that expels the fetus and placenta out of the mother’s body. This is
made possible by the presence of uterine contractions and abdominal pressure that
push the fetus out during the expulsion period of delivery. Regular contractions result to
gradual cervical effacement and dilatation. Adequate pressure from abdominal
muscles allows the baby to be pushed outside the mother’s womb.

Labor and delivery require a woman to utilize her coping methods psychologically and
physiologically. Normally, labor begins when the fetus reaches a mature age (38-42
weeks age of gestation). This is to ensure survival of the fetus with the extrauterine life.
The mechanism that converts Braxton Hicks Contractions (painless contractions) to
strong and coordinated uterine contractions is unknown. In some cases, labor occurs
before the fetus reaches the mature age (preterm birth) while in others it is delayed
(postterm birth).
Although the exact mechanism that initiates labor is unknown. Theories have been
proposed to explain how and why labor occurs.
Uterine Stretch theory
The idea is based on the concept that any hollow body organ when stretched to its
capacity will inevitably contract to expel its contents. The uterus, which is a hollow
muscular organ, becomes stretched due to the growing fetal structures. In return, the
pressure increases causing physiologic changes (uterine contractions) that initiate
labor.
Oxytocin theory
Pressure on the cervix stimulates the hypophysis to release oxytocin from the maternal
posterior pituitary gland. As pregnancy advances, the uterus becomes more sensitive to
oxytocin. Presence of this hormone causes the initiation of contraction of the smooth
muscles of the body (uterus is composed of smooth muscles).
Progesterone deprivation theory
Progesterone is the hormone designed to promote pregnancy. It is believed that
presence of this hormone inhibits uterine motility. As pregnancy advances, changes in
the relative effects estrogen and progesterone encourage the onset of labor. A marked
increase in estrogen level is noted in relation to progesterone, making the latter
hormone less effective in controlling rhythmic uterine contractions. Also, in later
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pregnancy, rising fetal cortisol levels inhibit progesterone production from the placenta.
Reduce progesterone formation initiates labor.
Prostaglandin theory
In the latter part of pregnancy, fetal membranes and uterine decidua increase
prostaglandin levels. This hormone is secreted from the lower area of the fetal
membrane (forebag). A decrease in progesterone amount also elevates the
prostaglandin level. Synthesis of prostaglandin, in return, causes uterine contraction
thus, labor is initiated.
Theory of Aging Placenta
Advance placental age decreases blood supply to the uterus. This event triggers uterine
contractions, thereby, starting the labor.
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Signs of Labor
A common concern of women as they near the end of pregnancy is how they will know
if they are beginning labor
Preliminary Signs of Labor
Before labor , a woman often experiences subtle signs that signal labor is imminent. It is
important to review these with women during the last trimester of pregnancy so they can
more easily recognize beginning signs .
Lightening
In primiparas, lightening or descent of the fetal presenting part into the pelvis, occurs
approximately 10 to 14 days before labor begins. This fetal descent changes a woman’s
abdominal contour , because it positions the uterus lower and more anterior in the
abdomen. Lightening gives a woman relief from the diaphragmatic pressure and
shortness of breath that she has been experiencing and in this way “lightens” her load.
Lightening probably occurs early in primiparas because of tight abdominal muscles. In
multiparas, it is not as dramatic and usually occurs on the day of labor or even after

labor has begun. As the fetus sinks lower into the pelvis, a woman may experience
shooting leg pains from the increased pressure on her sciatic nerve, increased amounts
of vaginal discharge, and urinary frequency from pressure on her bladder.
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Increase in level of Activity
A woman may awaken on the morning of labor full of energy, in contrast to the feeling of
chronic fatigue she felt during the previous month. This increase in activity is related to
increase in epinephrine release initiated by decrease in progesterone produced by
placenta . This additional epinephrine prepares a woman’s body for the work of labor
ahead.
Slight loss of weight
As progesterone level falls body fluid is more easily excreted from the body. This
increase in urine production can lead to a weightloss between 1 and 3 pounds.
Braxton Hicks Contraction
Braxton Hicks contractions are sporadic uterine contractions that start about 6 weeks
into your pregnancy, although you won't be able to feel them that early. You probably
won't start to notice them until sometime after mid-pregnancy, if you notice them at all.
(Some women don't.) They get their name from John Braxton Hicks, an English doctor
who first described them in 1872.
As your pregnancy progresses, Braxton Hicks contractions tend to come somewhat
more often, but until you get to your last few weeks, they'll probably remain infrequent,
irregular, and essentially painless. Sometimes, though, Braxton Hicks contractions are
hard to distinguish from early signs of preterm labor.
Play it safe and don't try to make the diagnosis yourself. If you haven't hit 37 weeks yet
and you're having more than four contractions in an hour — or you have any other signs
of preterm labor

By the time you're within a couple of weeks of your due date, your cervix has likely
begun to "ripen" or gradually soften up in preparation for labor. Your contractions may
get more intense and more frequent, and they may cause some discomfort. Unlike the
earlier painless and sporadic Braxton Hicks contractions, which caused no obvious
cervical changes, these contractions may help your cervix thin out (efface) and maybe
even open up (dilate) a bit. This period is sometimes referred to as pre-labor.
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True labor vs. false labor
True Labor or False Labor
“How will I know when it is real labor?” This is a question you may have as you near the
end of your pregnancy.
Many women have periods of “false” labor late in their pregnancy. During false labor,
you have contractions that seem to come and go. False labor pains are called “Braxton
Hicks” contractions. These contractions help soften and thin your cervix. They tend to
happen more often as you get closer to your due date (2 to 4 weeks before birth).
Sometimes it is hard to tell the difference between false labor and true labor. Don’t be
upset or embarrassed if you think labor is beginning when it is actually a false alarm.
Differences between false labor and true labor
There are several ways to tell the difference between true and false labor.
Timing of contractions
 False labor: Contractions are often irregular. They don’t get closer together over time.
 True labor: Contractions come regularly and get closer together. Each contraction lasts
about 30 to 60 seconds.

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Strength of contractions
 False labor: Contractions are often weak and do not get stronger.
 True labor: Contractions get stronger as time goes on.
Change with movement
 False labor: Contractions may stop or slow down when you walk, lie down, or change
positions.
 True labor: Contractions continue no matter what you do.
Pain with contractions
 False labor: Discomfort is usually felt in the front, like menstrual cramps.
 True labor: Discomfort or pressure starts in the back and moves to the front.
If your water breaks
Sometimes labor begins when the bag of waters, or membranes, breaks. This may
happen with your early contractions. Or your water may not break until later into your
labor.
If your water breaks, you may notice a near constant trickle of fluid from the vagina or a
sudden gush of fluid.
If you think your bag of waters is leaking or broken, call your doctor right away.
Other physical changes
You also may have physical changes that occur as your body gets ready for labor. It is
normal to have a slight increase of thin, white discharge at the end of pregnancy.
Activities like coughing, sneezing, or laughing may cause leaking of urine.
You also may notice a change in appetite, nausea, diarrhea, or constipation. The loss of
your mucus plug often precedes labor by a few days. Mucus may be present 2 to 14
days before true labor begins.

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Everyone experiences labor in a different way. Call your doctor if you think you are in
labor.
True Labor vs. False Labor
One of the biggest confusions many expectant mothers face is telling the difference
between true labor and false labor. The chart below describes the specific
characteristics of both true and false labor contractions.
Characteristic True Labor False Labor
Frequency Regular, usually happens 4-6
minutes apart as they become
closer together. Lasts 30-70
seconds
Irregular, don’t show signs of
consistency or becoming
closer together
Strength Consistently increase in
strength as time goes on,
vaginal pressure likely to
increase
Weak, usually do not gain
strength as time goes on, can
begin strong then weaken as
time passes
Amount of Pain Starts in the back and moves
forward
Usually only felt in the front of
the abdomen

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Changing Positions Changing positions has no
effect on pain, strength or
frequency
Inconsistent, may stop or slow
down when you walk, lie
down, increase fluids or
change positions in any other
way
False contractions
 Begin and remain irregular
 Felt first abdominally and remain confined to abdomen and groin
 Often disappear with ambulation or sleep
 Do not increase in duration, frequency, or intensity
 Do not achieve cervical dilation
True Contraction
 Begin irregularly but become regular and predictable
 Felt first in lower back and sweep around to the abdomen in a wave
 Continue no matter what the woman’s level of activity
 Increase in duration, frequency, and intensity
 Achieve cervical dilation.
5 P’s Components of labor
 Passenger (fetus)
 Powers (uterine contractions)
 Passage (the pelvis & maternal soft parts)
 Position (maternal)
 Psyche (maternal psychological status)

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PASSENGER (FETUS):
 Biological influences
A pregnancy that terminates during the 38-42 week gestation is likely to indicate a
healthy fetus.
 Mechanical influences
 Fetal head
 Fetopelvic relationships
 Cardinal movements
 Fetal Head: ( a mechanical influence)
 Bones: The head is the largest portion of the fetal body, & because it is a firm,
noncompliant bony structure, it is the fetal component that is of most significance
(from an obstetrical perspective).
 Sutures & Fontanelles: Between the bones of the fetal head are membranous
spaces called sutures. The fontanelles are areas of the head where suture lines
intersect.
 Landmarks: Head is divided into designated areas (1) the sinciput or brow
portion; (2) the vertex, or top of the head between the 2 fontanelles; (3) the
occiput or back of the head over the occipital bone.
 Diameters: During birth it is desirable that the smallest diameter of the fetal head
move through the maternal bony pelvis. The diameter tht presents through the
pelvis depends on the amount of flexion or extension of the head (attitude).
 Fetopelvic Relationships:
 Fetal Lie: refers to the relationship of the long axis of the fetus, as related to the
spinal column, to the long axis of the mother. (vertical lie = most common).
 Fetal Attitude: refers to the relationship of the fetal parts to one another. Fetus is
described as being in a state of flexion or extension.
 Fetal Presentation: The part of the fetal body that enters (or presents to) the
maternal pelvis. Most common = cephalic presentation (head first).

 Fetal Position: refers to the relationship of an assigned area of the presenting
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part (often called the fetal denominator) to the maternal pelvis.
 Determine the fetal denominator.
 Mentally divide the maternal pelvis into 4 quadrants (R&L anterior, R&L
posterior).
 Assign a standard abbreviation indicating the fetal position based on
findings of vaginal exam.
 Synclitism & Asynclitism: Asynclitic refers to a fetal head that is not parallel to
the anteroposterior plane of the pelvis. The head is synclitic when the sagittal
suture lies midway between the symphysis pubis and the sacral promontory.
 Cardinal Movements:
 Also called the “mechanisms of labor”.
 A series of adaptations the fetus makes as it moves through the maternal bony
pelvis during the process of lavor & birth.
 Influenced by the size and position of the fetus, the powers of labor, the size and
shape of the maternal pelvis, and the mother’s position.
 8 Cardinal Movements: (in an anterior occiput position)
 Engagement
 Descent
 Flexion
 Internal rotation
 Extension
 Restitution
 External rotation of the shoulders
 Expulsion
 Engagement: the mechanism by which the fetus nestles into the pelvis.
 Also referred to as “dropping” or “lightening”.

 A fetus is engaged when the biparietal diameter of the fetal head
reached the level of the maternal ischial spines; known as zero station.
 Leopold’s maneuvers: the head is more difficult to move and less of
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the head is able to be palpated abdominally after engagement.
 Descent: describes the process that the fetal head undergoes as it
begins its journey through the pelvis.
 Pressure from uterine ctx, hydrostatic forces, abdominal muscles, and
gravity promote descent of the fetus through the pelvic inlet and
midplane.
 Descent is continuous from the time of engagement until birth.
 Assessed by measurements called stations.
 Ranges from –3 to +3 station.
 Flexion: the process of the fetal head’s nodding forward toward the fetal chest
and occurs as a result of descent, the thickening of the uterine fundus, &
increased resistance of the soft tissues.
o Engagement, descent and flexion tend to occur simultaneously.
 Internal Rotation: most commonly the fetus rotates internally from the occiput
transverse position assumed at engagement into the pelvis to an occiput anterior
position while continuously descending.
 Extension: enables the head to be born when the fetus is in a cephalic position.
Results from the downward forces of the uterine contractions and the resistance
of the pelvic floor muscles.
o Begins after the head has crowned and is complete when the head
passes under the symphysis pubis and the occiput, anterior fontanelle,
brow, face, and chin pass over the sacrum & coccyx and are born over the
perineum.
 Restitution: results in a realignment of the fetal head with the body, after the
head is born.
 It is common that as the head internally rotates to an anterior position
before its birth, the shoulders may enter the pelvis in the oblique diameter.

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 This allows the head to turn, but as a result, the neck twists.
 Restitution occurs when the head is free of pelvic resistance, allowing the
head to turn back until it is again at right angles to the shoulders.
 External Rotation: After the head is born & restitution occurs, the shoulders
externally rotate so that they are in the anteroposterior diameter of the pelvis.
 This is the largest diameter of the outlet, it easily allows the birth of the
broad shoulders.
 Shoulders are born by first delivering the anterior shoulder from under the
symphysis pubis and then the posterior shoulder from over the perineum.
 Expulsion: the last cardinal movement; consists of the birth of the entire body.
 The body usually follows easily after the birth of the head and shoulders.
 The time of birth is often documented at the moment of expulsion.
PASSAGE: “P” # 2
 Major pelvic bones include the innominate bones (formed by the fusion of the
ilium, ischium, and pubis around the acetabulum), the sacrum, and the coccyx.
DIVISIONS:
 Pelvis is arbitrarily divided into halves – the false pelvis and the true pelvis.
 False pelvis: wide broad area btw. the iliac crests & has no major clinical
significance for L&D.
 True Pelvis: the actual bony passage that the fetus must traverse during labor
and birth. Shape is a curved axis, not a straight passage , d/t the diameters &
planes of the pelvis.

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PLANES:
 3 common planes of the pelvis are the inlet (the pelvic brim), midpelvis, and
outlet.
 A pelvis with an adequate inlet & midplane rarely if ever has reduced diameters
for the outlet.
 The coccyx also has slight mobility, which increases the available space in the
outlet.
PRENATAL ASSESSMENT OF PELVIS:
 Clinical pelvimetry reassures both the health care provider & the woman about
the normalcy of the pelvis.
 When any variation exists in the pelvic structures, it can be discussed &
anticipatory guidance given (ex- how to cope with back aches, back labor, etc.)
 Rarely an abnormal pelvis such as true android, guidance may include the
planning for a C/S.
SOFT PASSAGE THROUGH MATERNAL SOFT TISSUE STRUCTURES:
 Soft tissues of the cervix, vagina, and perineum must stretch to allow passage of
the fetus through the axis of the birth canal.
 Progesterone & relaxin help facilitate the softening & increase the elasticity of
muscles & ligaments.
POWERS: “P” # 3
 Uterine labor ctx. of the myometrium.
 Ctx.phase consists of a descending gradient:
o The wave begins in the fundus (greatest # myometrial cells).
o Then moves downward through the corpus of the uterus.
o Intensity of ctx.diminishes from fundus to cervix.

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 Retraction phase.
EFFACEMENT & DILATATION:
 The purpose of uterine ctx.
o Accomplish the effacement and dilation of the cervix.
o Facilitate the descent & rotation of the fetus through the passages.
o Facilitate the separation & expulsion of the placenta.
o Control bleeding after delivery by compressing blood vessels.
 Effacement= the thinning or shortening of the cervix.
 Dilatation = the gradual opening of th cervix and is a continued extension of the
contraction-retraction process already described.
 Dilatation and effacement take place concurrently throughout labor.
 Dilatation is assessed by vaginal examination, and is recorded in centimeters
from 0-10 cm.
 Hydrostatic Force = another power that facilitates the process of labor and birth.
 Includes the pressure of the fetus within the amniotic sac.
 As ctx. occur, the membranes and amniotic fluid facilitates dilation and
effacement.
 Since the lower uterine segment and cervix are regions of lesser resistance, the
additional pressure of the amniotic sac is of great importance in promoting the
birth process.
 Abdominal Force = the final power for labor & birth. Intra-abdominal force.
 This power is reserved for the 2nd stage of labor, after effacement & dilation are
complete.
 Maternal pushing, or bearing down effort.
 In the expulsion stage, the ctx.change in character, & many women begin to
experience an involuntary urge to push.

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POSITION: “P” # 4
 In the last half of the 20th century, the position used most frequently for labor in
the US has supine in a hospital bed.
 The most common position for birth has been a lithotomy position.
 Limited ambulation of laboring women resulted from use of continuous fetal
monitoring, routine use of IV hydration, epidural anesthesia and use of analgesia
PSYCHOLOGY OF BIRTH: “P” # 5
 The progress of labor and birth can be adversely affected maternal fear and
tension.
 Norepinephrine and epinephrine may stimulate both alpha and beta receptors of
the myometrium and interfere with the rhythmic nature of labor.
 Anxiety can also increase pain perception and lead to an increased need for
analgesia & anesthesia.
STAGES OF LABOR
Childbirth usually occurs in three stages:
First stage: The time of the onset of true labor unti l the cervix is completely
di lated to 10 cm.
Second stage: The period after the cervix is di lated to 10 cm unti l the baby is
delivered.
Third stage: Delivery of the placenta.
First Stage
The first stage of labor is the longest and involves three phases:
 Early Labor Phase -The time of the onset of labor until the cervix is dilated to 3
cm.

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 Active Labor Phase - Continues from 3 cm. until the cervix is dilated to 7 cm.
 Transition Phase - Continues from 7 cm. until the cervix is fully dilated to 10 cm.
Each phase is characterized by di fferent emotions and physical
challenges. Think of i t as a big adventure wi th some important guidelines.
Early Labor Phase
What to do:
During this phase you should just try to relax. It is not necessary to rush to the
hospi tal or bi rth center. Try to enjoy the comfort of the fami liar surroundings at
home. If early labor occurs during the day, do some simple routines around the
house. Keep yourself occupied whi le conserving your energy. Drink ple nty of
water and eat small snacks. Keep track of the time of your contractions. If early
labor begins during the night i t is a good idea to try to get some sleep. If you are
unable to fall asleep, focus on doing some light activities like cleaning out your
closet, packing your bag, or making sack lunches for the next day.
What to expect:
 Early labor will last approximately 8-12 hours
 Your cervix will efface and dilate to 3 cm
 Contractions will last about 30-45 seconds, giving you 5-30 minutes of rest
between contractions
 Contractions are typically mild, somewhat irregular, but become progressively
stronger and more frequent
 Contractions can feel like aching in your lower back, menstrual cramps, and
pressure or tightening in the pelvic area
 Your water might break. This is known as amniotic sac rupture and can happen
any time within the first stage of labor.
 When experiencing contractions, ask if they are:

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 Growing more intense
 Following a regular pattern
 Lasting longer
 Becoming closer together
 When your water breaks (amniotic sac rupture) note the following:
 Color of fluid
 Odor of fluid
 Time rupture occurred
 Tips for the support person:
 Practice timing contractions
 Be a calming influence
 Offer comfort, reassurance, and support
 Suggest simple activities to draw her focus from the labor
 Keep up your own strength. You will need it!
 Active Labor Phase:
 What to do:
 Now is time for you to head to the hospi tal or bi rth center.Your
contractions wi ll be stronger, longer and closer together. It is very
important that you have plenty of support. It is also a good time to start
your breathing techniques and try a few relaxation exercises for use
between contractions. You should swi tch posi tions often during this time.
You might want to try walking or taking a warm bath. Continue to drink
plenty of water and urinate periodically.
 What to expect:
 Active labor will last about 3-5 hours
 Your cervix will dilate from 4cm to 7cm

 Contractions during this phase will last about 45-60 seconds with3-5
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minutes rest in between
 Contractions will feel stronger and longer
 This is usually the time to head to the hospital or birth center
 Give the mother your undivided attention
 Offer her verbal reassurance and encouragement
 Massage her abdomen and lower back
 Keep track of the contractions (if she is being monitored, find out how the
machine works)
 Go through the breathing techniques with her
 Help make her comfortable (prop pillows, get her water, apply touch)
 Remind her to change positions frequently (take her for a walk or offer her a
bath)
 Continue with distractions from labor such as music, reading a book, or playing a
simple card game
 Don’t think that there is something wrong if she is not responding to you
 Transition Phase
 What to do:
 During this phase the mother wi ll rely heavily on her support person. This
is the most challenging phase but i t is also the shortest. Try to thi nk “one
contracti on at a time” (Thi s may be hard to do i f the contractions are very
close together). Remember how far you have already come, and when
you feel an urge to push, tell your health care provider.
 What to expect:
 Transition will last about 30 min-2 hrs
 Your cervix will dilate from 8cm to 10cm

 Contractions during this phase will last about 60-90 seconds with a 30 second-
35
2 minute rest in between
 Contractions are long, strong, intense, and can overlap
 This is the hardest phase but also the shortest
 You might experience hot flashes, chills, nausea, vomiting, or gas
 Offer lots of encouragement and praise
 Avoid small talk
 Continue breathing with her
 Help guide her through her contractions with encouragement
 Encourage her to relax between contractions
 Don’t think that there is something wrong if she seems to be angry. It is a normal
part of transition.
Non stress test
This simple, painless procedure is done during pregnancy to evaluate your baby's
condition. During the test, your healthcare practitioner or a technician monitors your
baby's heartbeat, first while the baby is resting and then while he's moving. Just as your
heart beats faster when you're active, your baby's heart rate should go up while he's
moving or kicking.
The test is typically done if you've gone past your due date, or in the month or two
leading up to your due date if you're having a high-risk pregnancy. Here are some
reasons you might have a nonstress test:
 You have diabetes that's treated with medication, high blood pressure, or some
other medical condition that could affect your pregnancy.
 You have gestational hypertension.
 Your baby appears to be small or not growing properly.
 Your baby is less active than normal.

36
 You have too much or too little amniotic fluid.
 You've had a procedure such as an external cephalic version (to turn a breech
baby) or third trimester amniocentesis (to determine whether your baby's lungs are
mature enough for birth or to rule out a uterine infection). Afterward, your practitioner
will order a nonstress test to make sure that your baby's doing well.
 You're past your due date and your practitioner wants to see how your baby is
holding up during his extended stay in the womb.
 You've previously lost a baby in the second half of pregnancy, for an unknown
reason or because of a problem that might happen again in this pregnancy. In this
case, nonstress testing may start as early as 28 weeks.
 You have a medical problem that may jeopardize your baby's health.
 Your baby has been diagnosed with an abnormality or birth defect and needs
to be monitored.
How Is A NST Performed?
The test i nvolves attachi ng one belt to the mother’ s abdomen to measure fetal
heart rate and another belt to measure contractions. Movement, heart rate and
“reacti vi ty” of heart rate to movement i s measured for 20-30 minutes. If the baby
does not move, i t does not necessari ly indicate that there is a problem; the baby
could just be asleep. A nurse may use a small “buzzer” to wake the baby for the
remainder of the test.
Why Would A NST Be Performed?
A NST may be performed if:
 You sense that the baby is not moving as frequently as usual
 You are overdue
 There is any reason to suspect that the placenta is not functioning adequately
 You are high risk for any other reason

The test can indicate i f the baby is not receiving enough oxygen because of
placental or umbi lical cord problems; i t can also indicate other types of fetal
distress.
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When Is A NST Performed?
NSTs are generally performed after 28 weeks of gestation. Before 28 weeks, the
fetus is not developed enough to respond to the test proto col.
What Does The NST Look For?
The primary goal of the test is to measure the heart rate of the fetus in response
to i ts own movements. Healthy babies wi ll respond wi th an increased heart rate
during times of movement, and the heart rate wi ll decrease at rest. The concept
behind a non-stress test is that adequate oxygen is requi red for fetal activity and
heart rate to be wi thin normal ranges. When oxygen levels are low, the fetus
may not respond normally. Low oxygen levels can often be caused by problems
wi th the placenta or umbi lical cord.
What Do The NST Results Mean And What Are The Reasons For Further Testing?
A reactive non-stress result indicates that blood flow (and oxygen) to the fetus is
adequate. A nonreactive non-stress result requi res addi tional testing to
determine whether the result is truly due to poor oxygenation, or whether there
are other reasons for fetal non reactivity.
Contraction Stress Test
What is a contraction stress test?
A contraction stress test uses fetal monitoring to check the health of an unborn baby. An
external fetal monitor is attached with belts to the mother's abdomen (belly) to record
the baby's heart rate during contractions. If you are not having contractions, you may be

given the medicine oxytocin to cause contractions. During the test, the baby's heart rate
and the mother's contractions are recorded.
Most contractions decrease the flow of blood and oxygen to the baby for a short time.
By seeing how the baby's heart rate reacts to contractions, your healthcare provider can
tell if the baby will be able to handle the stress of the contractions that occur during
labor. Normally, a healthy baby's heart rate does not change during contractions.
38
This test is also called an oxytocin challenge test.
When is it used?
A contraction stress test is usually done the 32nd week of pregnancy or later. If a
pregnancy is high risk, the first test may be done at 26 to 28 weeks.
This test may be done if:
 During a nonstress test the baby's heart rate did not rise enough during
movements to be considered a reactive result. (A nonstress test uses an external
fetal monitor to look at how the baby's heart rate changes when the baby moves.)
 The biophysical profile score is low. (For a biophysical profile, an ultrasound scan
is done with a nonstress test.)
 Your healthcare provider knows or thinks that your baby or you have a high-risk
condition.
Often a biophysical profile may be done instead of a contraction stress test.
How do I prepare for this test?
 Pregnant women should not smoke, but if do you smoke, do not smoke for at
least 4 hours before the test. Smoking can decrease your baby's movements.
 Ask your provider if you need to avoid eating for 4 to 8 hours before the test.
What happens during the test?
You will lie on your left side with a strap and pressure gauge around your abdomen. The
gauge measures contractions of the uterus. An ultrasound transducer will be placed on

your abdomen over the baby's heart to measure the baby's heart rate. Your blood
pressure, the baby's heart rate, and contractions of the uterus will be recorded for
several minutes.
For the test to be valid, you must have contractions that are strong and frequent enough
to be similar to the first phase of labor. Your healthcare provider may give you a very
small amount of oxytocin through a vein (IV) to start contractions if you are not having
contractions that are strong and frequent enough. The oxytocin may be given until you
have 3 contractions, each lasting 40 seconds, in 10 minutes.
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How is the test interpreted?
Your provider will look at when and how often the baby's heart rate slows.
 If the baby's heart rate does not slow during the contractions, the result of the
test is normal. (A normal result is called negative.) This is a reassuring result that
suggests that the baby is healthy.
 If the baby's heart rate slows during a contraction, the result of the test may be
interpreted as abnormal and nonreassuring. (An abnormal result is called
positive.) This may mean that the baby may be having some problems and there
is a chance the baby may have more serious problems during labor. It is
important to remember that not all slowing of the heart rate during a contraction
means the baby may have a problem. The test has to be read by your healthcare
provider based on the situation and circumstances of the test.
What happens after the test?
A result that is not clearly positive or negative may be repeated in 24 hours. Your
healthcare provider may want to repeat the contraction stress test weekly if your
pregnancy is high risk.
If the result of the stress test is positive and nonreassuring, you may be admitted to the
hospital. If your baby is having a problem that cannot be corrected, your healthcare
provider may want to deliver the baby early by inducing labor, or with a cesarean
section (C-section).

What are the benefits of this procedure?
The contraction stress test allows your healthcare provider to check the baby's
response to contractions. If the baby is not doing well, steps may be taken to help the
baby. If the monitoring shows a normal pattern, it is reassuring to the mother and her
provider.
What are the risks of a contraction stress test?
The stress test could cause too many uterine contractions, especially if you are given
oxytocin to stimulate the contractions. It could make you go into labor. For this reason
the oxytocin is given slowly and carefully. It is stopped if it is causing too many
contractions.
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Your healthcare provider may not use this test if:
 You are at risk of going into premature labor.
 You had a previous C-section with a vertical incision of the uterus.
 There is a chance that the placenta will separate from the uterus early (placental
abruption).
 You have more than 1 baby in the uterus.
 The placenta is low in the uterus (placenta previa).
 You have early rupture of your membranes (your bag of waters has broken).
Disclaimer: This content is reviewed periodically and is subject to change as new health
information becomes available. The information provided is intended to be informative
and educational and is not a replacement for professional medical evaluation, advice,
diagnosis or treatment by a healthcare professional.

41
Signs of Impending Labor
1. Lightening: You can breathe again! This is an indication that the baby has
dropped, settling deeper into your pelvis and relieving some of the pressure on
yourdiaphragm helping you to not be so short of breath. You may feel increased
pressure on your bladder, meaning more trips to the bathroom. People may
comment on your changed appearance even though you might not recognize the
changes.
2. Bloody show: Loss of mucus plug. During pregnancy, a thick plug of mucus
protects the cervical opening from bacteria entering the uterus. When your
cervix begins to thin and relax, this plug is expelled. Some women think the
plug wi ll look solid like a cork, but i t is actually stringy mucus or discharge. It
can be clear, pink or blood tinged and can appear minutes, hours or even days
before the onset of labor. Not all women notice this sign.
3. Rupture of membranes: Your water breaks! Only 1 in 10 woman experience
a dramatic gush of amniotic fluid. This event usually happens at home, often
when you are in bed. Sometimes the amniotic sac breaks or leaks prior to labor
and because your uterus is resting di rectly on top o f your bladder, i t can cause
you to leak urine. Sometimes i t can be di fficult to distinguish the urine from
amniotic fluid.
If your membranes have ruptured and you are leaking amniotic fluid, i t wi ll be an
odorless fluid. The discharge can be a sudden gush or a constant trickle. If you
notice fluid leaking, you should try to determine i f i t smells like urine or i f i t is
odorless. If i t does not seem to be urine, you should contact your health care
provider.
Unti l you see your physician or midwi fe do not use tampons, have sexual
intercourse or do anything that would introduce bacteria into your vagina. Let
your health care provider know i f the fluid is anything other than clear and
odorless, especially i f i t is green in color or foul smelling which can indi cate the
presence of infection.

4. Nesting: Spurt of energy. For most of your pregnancy you have probably
been fighting the urge to take a nap, so you should easi ly recognize this
symptom. A day wi ll come when you wi ll wake up feeling full of energy! You wi ll
be motivated to make lists of things to do, things to clean, things to buy, etc.,
and you wi ll feel a sense of urgency about everythi ng you’ ve put off doi ng.
D espi te these urges, remember that “Labor D ay” may be just around the corner,
so try to conserve your energy.
5. Effacement: Thinning of the cervix. In the last month of pregnancy the
cervix wi ll begin to stretch and thin. This is an indication that the lower p ortion of
the uterus is getting prepared for delivery because a thinner cervices di late more
easi ly.
Your health care provider can check for effacement in the final 2 months of
pregnancy. Effacement is measured in percentages. You might hear your health
care provi der say,“You are 25% effaced, 50% effaced, 75%…” TheBraxton
Hicks contracti ons or “practi ce contracti ons” you have been experi enci ng may
play a part in the effacement process. You wi ll not have the abi li ty to evaluate
your degree of effacement. It can only be determined by a health care provi der’ s
exam.
6. Dilation: Opening of the cervix. Di lation is the process of the cervix opening
in preparation for chi ldbi rth. Di lation is measured in centimeters or, less
accurately, i n “fi ngers” duri ng an i nternal (manual) pelvi c exam. “ Fully di lated”
means you’ re at 10 centimeters and are ready to gi ve bi rth. Your health care
provider can tell you how many centimeters your cervix has di lated.
42

43
Fontanelle
The anterior fontanelle (bregmatic fontanelle, frontal fontanelle) is the
largest fontanelle, and is placed at the junction of the sagittal suture, coronal suture,
and frontal suture; it is lozenge-shaped, and measures about 4 cm in its antero-posterior
and 2.5 cm in its transverse diameter. The fontanelle allows the skull to deform
during birth to ease its passage through the birth canal and for expansion of the brain
after birth.
While the posterior and lateral fontanelles are obliterated by about six months after
birth, the anterior is not completely closed until about the middle of the second year. Full
ossification starts in the late twenties and finishes before the age of 50 .
The posterior fontanelle (lambdoid fontanelle, occipital fontanelle) is a gap
between bones in the human skull (known asfontanelle), triangular in form and situated
at the junction of the sagittal suture and lambdoidal suture. It generally closes in 6–8
weeks from birth. A delay in closure is associated with congenital hypothyroidism.

44
Fetal presentation
In obstetrics, the presentation of a fetus about to be born refers to which anatomical
part of the fetus is leading, that is, is closest to the pelvic inlet of the birth canal.
According to the leading part, this is identified as a cephalic, breech,
or shoulder presentation. A malpresentation is any presentation other than a vertex
presentation (with the top of the head first).
Classification
Thus the various presentations are:
 cephalic presentation (head first):
 vertex (crown) — the most common and associated with the fewest
complications
 occiput (forehead)
 brow (eyebrows)
 face
 chin
 breech presentation (buttocks or feet first):
 complete breech
 footling breech

45
 frank breech
 shoulder presentation:
 arm
 shoulder
 trunk
Related obstetrical terms
Attitude
 Definition: Relationship of fetal head to spine:
 flexed, (this is the normal situation)
 neutral (“military”),
 extended.
Position
 Definition: Relationship of presenting part to maternal pelvis: and based on
presentation:
 Cephalic presentation
 Vertex presentation with longitudinal lie:[1]
 Left occipitoanterior (LOA)—the occiput is close to the vagina (hence
known as vertex presentation) faces anteriorly (forward with mother
standing) and towards left. This is the most common position and lie.
 Right occipitoanterior (ROA)—the occiput faces anteriorly and towards
right. Less common than LOA, but not associated with labor
complications.
 Left occipitoposterior (LOP)—the occiput faces posteriorly (behind) and
towards left.
 Right occipitoposterior (ROP)—the occiput faces posteriorly and towards
right.
 Occipitoanterior —the occiput faces anteriorly (absolutely straight without
any turning to any of the sides)

 Occipitoposterior —the occiput faces posteriorly (absolutely straight
46
without any turning to any of the sides)
 Face presentation
 Breech presentation with longitudinal lie:[1]
 Left sacrum anterior (LSA)—the buttocks, as against the occiput of the vertex
presentation, like close to the vagina (hence known as breech presentation),
which like anteriorly and towards the left.
 Right sacrum anterior (RSA)—the buttocks face anteriorly and towards the
right.
 Left sacrum posterior (LSP)—the buttocks face posteriorly and towards the
left.
 Right sacrum posterior (RSP)—the buttocks face posteriorly and towards
right.
 Sacrum anterior(SA)—the buttocks face anteriorly.
 Sacrum posterior (SP)—the buttocks face posteriorly.
 Shoulder presentation with transverse lie are classified into four types, based on
the location of the scapula (shoulderblade); note: this presentation needs to be
delivered bycesarean section.
 Left scapula-anterior (LSA)
 Right scapula-anterior (RSA)
 Left scapula-posterior (LSP)
 Right scapula-posterior (RSP)
Lie
 Definition: Relationship between the longitudinal axis of fetus and mother:
 longitudinal, (resulting in either cephalic or breech presentation)
 oskie, (cephalic presentation, fetus legs straight along frontal axis of mother)
 oblique, (unstable, will eventually become either transverse or longitudinal)

47
 transverse (resulting in shoulder presentation).
THE THREE STAGES OF LABOR
Labor is described in three stages, and together these stages complete the delivery and
the passage of the placenta.
Stage One
The first stage is the process of reaching full cervical dilatation. This begins with
the onset of uterine labor contractions, and it is the longest phase of labor. The first
stage is divided into three phases: latent, active, and deceleration.
 In the latent phase, the contractions become more frequent, stronger, and gain
regularity, and most of the change of the cervix involves thinning, or effacement. The
latent phase is the most variable from woman to woman, and from labor to labor. It
may take a few days, or be as short as a few hours. We typically expect the latent
phase to be 10 to 12 hours for a woman who has had children. For first pregnancies,
it may last closer to 20 hours. For many women, the latent phase of labor can be
confused with Braxton Hicks contractions. Membranes may spontaneously rupture in
the early- to mid-portion of the first stage of labor. If they rupture, the labor process
usually speeds up.
 The next portion of the first stage of labor is the active phase, which is the phase of
the most rapid cervical dilatation. For most women this is from 3 to 4 centimeters of
dilatation until 8 to 9 centimeters of dilatation. The active phase is the most
predictable, lasting an average of five hours in first-time mothers and two hours in
mothers who have birthed before.
 Finally, there is the deceleration phase, during which the cervical dilation continues,
but at a slower pace, until full dilation. In some women the deceleration phase is not
really noticeable, blending into the active phase. This is also a phase of more rapid
descent, when the baby is passing lower into the pelvis and deeper into the birth
canal. The deceleration phase is also called transition, and, in mothers with no
anesthesia, it’s often punctuated by vomiting and uncontrollable shaking. These
symptoms can be frightening to watch, but they’re a part of normal birth, and they
signal that the first state is almost completed.

48
Stage Two
The second stage is the delivery of the infant. During the second stage, mom
actively pushes out the baby. For first time mothers, this can take two to three hours, so
it’s important to save your energy and pace yourself. For second babies and beyond,
the second stage often lasts less than an hour – and sometimes, only a few minutes.
Stage Three
The third stage of labor is the passage of the placenta, which can be
immediate, or take up to thirty minutes. The process may be sped up naturally by
breastfeeding (which releases oxytocin), or medically by administering a drug called
pitocin.
FETAL HEART TONE MONITORING
The picture below is known as an “early decelerations”. The top line is monitoring
the baby’s heart rate and the bottom line is monitoring mom’s contractions. On the
bottom line (mom’s contraction), you can see that the line start to go up and then down.
This means mom is having a contraction. The top line (baby’s heart rate) then responds
to this contraction and notice that it slightly dips down while mom is having her
contraction.
The key to remembering if this
an early deceleration is to see if the
baby’s heart rate mirrors moms
contraction and it does here. Plus look
to see if the baby’s heart rate is staying
within normal limits of 110-160 beats
per minutes. The baby’s heart rate dips

slightly at the same time the contraction starts and recovers to a normal range after
49
mom’s contraction is over.
Early decelerations are nothing to be alarmed about. The reason the
baby’s heart rate starts to slightly decrease is due to head compression (probably from
the baby’s head being in the birth canal) causing the vagus nerve to be compressed
which in turn decreases the heart rate.
This crazy looking strip is called
“variable decelerations“. I
remember it because the dips in the
fetal heart tones look like V’s. The v’s
remind me that this is a “variable
deceleration”. Variable decelerations
are NOT good! Notice that every time
mom has a contraction the baby’s heart
rate majorly decreases. Remember a
normal fetal heart rate is 110-160
bpms.
The cause of the decrease fetal heart rate is due to umbilical cord compression.
So if you are presented with this type of strip on NCLEX or HESI some of the answers
you would need to pick would be change mom’s position (moving her around could help
relieve cord compression), administer Oxygen usually 10 L (because cord is being
compressed which in turn is causing the baby to not receive enough Oxygen), stop

Picotin infusion if running, and contact the doctor. Plus you may be asked on the exam
50
what is causing this strip to look like this and the answer would be cord compression.
The picture beside is known as “late
decelerations“. The name tells you
exactly what should be presented on the
strip. Late decelerations are NOT good
either just like variable decelerations.
Notice that when mom has a contraction
the baby’s heart rate goes down long after
the beginning of mom’s contraction and
recovers way after the contraction is over.
Umbilical Cord Compression
Because the fetus moves and kicks inside the uterus, the umbilical cord can wrap
and unwrap itself around the baby many times throughout pregnancy. While there are
"cord accidents" in which the cord gets twisted around and harms the baby, this is
extremely rare and usually can't be prevented.
Sometimes the umbilical cord gets stretched and compressed during labor,
leading to a brief decrease in blood flow to the fetus. This can cause sudden, short
drops in fetal heart rate, called variable decelerations, which are usually picked up by

monitors during labor. Cord compression happens in about one in 10 deliveries. In most
cases, these heart rate changes are of no major concern, and the birth proceeds
normally. But a C-section may be necessary if the baby's heart rate worsens or the baby
51
shows other signs of distress.
Fetal tachycardia
It is an abnormal increase in fetal heart rate and is variably defined as a heart
rate above 160-180 beats per minute (bpm). The rate typically ranges between 170-220
bpm (higher rates can however occur with tachyarrhythmias).
Epidemiology: The estimated prevalence is at around 0.4-1 of pregnancies.
Pathology: In the majority of cases, the abnormal electrical impulses origniate from the
atria.
Classification: A fetal tachycardia can range from a simple sinus tachycardia to
various fetal tachyarrhythmia’s. In a sinus tachycardia there is a one to one conduction
from the atria through to the ventricles.
Associations: A fetal tachycardia can be associated with many maternal as well as
fetal conditions which include
 maternal
o maternal hyperthyroidism
o maternal medications
 fetal
o in utero infection
o in utero hypoxia
o fetal anaemia
o chromosomal anomalies
 trisomy 13

52
 Turner syndrome
Radiographic assessment
Ultrasound
Fetal echocardiography
An M-mode Doppler study is best for assessment. It is recommended that the sampling
line intercepts both the atrial and ventricular walls thereby allowing simultaneous
assessment of both ventricular and atrial contractility.
Ancilliary features
Ulrasound may also show evidence of development complications such as signs
ofhydrops fetalis.
Treatment and prognosis
The long-term prognosis for most fetuses diagnosed with a sinus tachycardia is
generally good, with the abnormal rhythm resolving spontaneously during the first year
of life in the majority of cases. Treatment options (if at all required) include
transplacental administration of antiarrhythmic drugs.
Fetal Bradycardia
It refers to an abnormally low fetal heart rate. It is regarded as a sustained first
trimester heart rate below 100 beats per minute (bpm). The average fetal rate however
changes during pregnancy and some consider the lower limit of normal at.
 100 bpm up to 6.2 weeks of gestation
 120 bpm at 6.3 - 7.0 weeks

53
Pathophysiology
A fetal bradycardia can arise from a number of causes which include
 underlying conduction abnormality
 following cordocentesis
 vagal cardiovascular reflex (especially if transient during 2nd trimester): this may
occur from
o fetal head compression
o umbilical cord occlusion / compression
o maternal exertion : possibly from indequate maternal gas exchange
o hypoxia caused by myocardial depression
o stimulation of the stretch receptors in aortic arch and / or carotid sinus
walls
Classification
 fetal sinus bradycardia
 fetal bradyarrhythmia(s)
o fetal partial atrioventricular block (PAVB)
o fetal complete atrioventricular block (CAVB) : commonest type of
bradyarrhythmia
o blocked premature atrial contractions
Associations
 increased risk of chromosomal anomalies especially trisomy
 maternal connective tissue disease : particularly with bradyarrhythmias

54
Treatment and prognosis
The lower the rate the worse the prognosis and heart rates of less than 90 bpm in the
first trimester are considered to have dismal prognosis. Transfer to a tertiary centre with
cardiology support is often recommended.
Differential diagnosis
General considerations include
 transient sinus bradycardia from excessive transducer pressure
Laceration Classified by Degrees :
 First-degree tear:
Laceration is limited to the fourchette and superficial perineal skin or vaginal
mucosa.
 Second degree tear:
Laceration extends beyond fourchette, perineal skin and vaginal mucosa to
perineal muscles and fascia, but not the anal sphincter.
 Third-degree tear:
Fourchette, perineal skin, vginal mucosa, muscles, and anal sphincter are torn
Third-degree teas maybe further subdivided into three subcategories.
3a: Partial tear of the external anal sphincter involving less than 50%
thickness
3b: Greater than 50% tear of the external sphincter
3c: Internal sphincter is torn
 Fourth-degree tear:
Fourchette, perineal skin, vaginal mucosa, muscles, anal sphincter, and rectal
mucosa are torn.
POSTPARTUM ASSESSMENT AND PATIENT EDUCATION

55
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.
Many nurses find it useful to use the acronym BUBBLE-LE to remember the necessary components of
the postpartum assessment and teaching topics. These include:
 Breasts
 Uterus
 Bowel function
 Bladder
 Lochia
 Episiotomy/perineum
Breasts
Assess the breasts 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 women who are breastfeeding
Breastfeeding women should wear a comfortable, well-fitted support bra. Instruct them to gently rub
colostrum or breast milk into their nipples and allow the nipples to air dry after each feeding to “condition” the
nipples. Mothers can prevent drying by avoiding soap when washing the nipples.
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 upon mothers’ breastfeeding experiences.
Otherwise, mothers may develop sore, cracked, and sometimes bleeding nipples, which can discourage the
continuation of breastfeeding.
Uterus
Assess the fundus:
 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 10 days postpartum.
 In addition, assess patients for uterine cramping and treat 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. Encourage patients to
void before palpation of the uterine fundus because a full bladder displaces the uterus and
can lead to excessive bleeding.

56
Bowel Function
Assessment of the bowel is important in all postpartum patients. It is especially vital for patients following C-sections.
Assess for the following:
 Bowel sounds
 Return of bowel function
 Flatus
 Color and consistency of stool
Administer prescribed stool softeners or laxatives as needed to treat constipation and ease perineal
discomfort during defecation.
Encourage patients to ambulate soon after delivery. Teach 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
Assess urination and bladder function for the following:
 Return of urination, which should occur within 6 to 8 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)
 The bladder should be nonpalpable above the symphysis pubis.
 Encourage patients 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
Assess lochia during the postpartum period:
 Saturating one pad in less than an hour, a constant trickle of lochia, or the presence of large blood
clots is indicative of more serious complications and should be investigated immediately.
 Foul-smelling lochia typically indicates an infection .
 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
57
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. Instruct patients to avoid sexual
activity until lochial flow has ceased.
Episiotomy / Perineum
The acronym REEDA is often used to assess an episiotomy or laceration of the perineum. REEDA stands for:
 Redness
 Edema
 Ecchymosis
 Discharge
 Approximation
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.
Signs of Hypovolemic Shocks:
 Hypertension
 Cold Clummy skin
 Tachycardia
Types of Forceps Assisted Delivery
1.Outlet = Crowning
2.Low Forceps = + 2 station
3.Mid Forceps = + 1 station
Indication
1.Maternal Exhaustion
2.Fetal Distress
3.Arrested rotaion
4.Cardiac Disease
Requirements in Forceps

58
1.Full effacement
2.Engagement
3.Cphalic Presentation
4.Ruptured membreane
5.Empty bowel and bladder
6.No CPD – Cephalo Pelvic Disproportion
7.Fetal Heart Rate is stable
Vacuum Assissted Delivery
1.Crowning
2.A cap is connected to occiput station
Cesarean Delivery
Indication:
1.Fetal Distressed
2.CPD
3.Placenta Previa
4.Abruptio Placenta
5.Pregnancy induce
6.Multiple Gestation
7.Breech presentation , Transverse presentation
8.Hydrocephalus
9.Genital Herpes
Types of Caesarean incisions
There are 3 types of incisions that can be used to perform a Caesarean birth. These are:
 A low, transverse or horizontal incision, in the lower segment of the uterus. This is referred to a Lower
Segment Caesarean Section (or LSCS).
 A vertical incision made higher up the middle of the uterus into the upper segment of the uterus. This is
referred to as a Classical Caesarean (or CS).
 A low vertical incision, in the lower segment of the uterus, which can be extended into a classical
incision into the upper segment if necessary.

59
Informed Consent
 Risk
 Disadvantage
 Advantage
 Complications
Maylard Incision
 The Maylard incision is an abdominal incision that can afford extensive exposure to the
pelvic organs when this is needed. Although it can be used for most gynecologic procedures,
it is not particularly useful in such upper abdominal surgeries as ovarian cancer that may be
associated with tumor in and around the liver or spleen.
 Its main disadvantage is that it is a more painful incision for the patient during the first
postoperative week. This may be weighed against its reduced rate of incisional hernia and
the fact that it is cosmetically advantageous, since it does not scar the midabdomen.
Induction of Labor
Description:
1. The deliberate initiation of labor before spontaneous contractions begin may be
either mechanical (amniotomy ie, rupture of amniotic membranes]), physiologic
(ambulation and nipple stimulation), or chemical (prostaglandins and oxytocin).
2. Artificial rupture of membranes (AROM) may be adequate stimulation to initiate
contractions, or AROM may be done after oxytocin administration establishes
effective contractions.
3. Induction and AROM are initiated when the cervix is soft, partially effaced, and
slightly dilated, preferably when the fetal presenting part is engaged.

4. Oxytocin-induced labor must be done with careful, ongoing monitoring; oxytocin
is a powerful drug. Hyper stimulation of the uterus may result in tonic
contractions prolonged to more than 90 seconds, which could cause fetal
compromise due to impaired uteroplacental perfusion, abruption placentae, and
laceration of the cervix, uterine rupture, and neonatal trauma.
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Indications :
Commonly accepted medical reasons for induction include:
 Post terrm pregnancy, i.e. if the pregnancy has gone past the 41st week.
 Intrauterine fetal growth retardation (IUGR).
 There are health risks to the woman in continuing the pregnancy (e.g. she
has pre-eclampsia).
 Premature rupture of the membranes (PROM); this is when the membranes have
ruptured, but labor does not start within a specific amount of time.[1]
 Premature termination of the pregnancy (abortion).
 Fetal death in utero.

61
 Twin pregnancy continuing beyond 38 weeks.
Methods of induction:
 Methods of inducing labor include both pharmacological medication and
mechanical or physical approaches.
 Mechanical and physical approaches can include artificial rupture of membranes
or membrane sweeping. The use of intrauterine catheters are also indicated.
These work by compressing the cervix mechanically to generate release on
prostaglandins in local tissues. There is no direct effect on the uterus.
 Pharmacological methods are mainly using either dinoprostone (prostaglandin
E2) or misoprostol (a prostaglandin E1 analogue)
Medication
 Intravaginal, endocervical or extra-amniotic administration of prostaglandin, such
as dinoprostone or misoprostol.[2] Prostaglandin E2 is the most studied compound
and with most evidence behind it. A range of different dosage forms are available
with a variety of routes possible. The use of misoprostol has been extensively
studied but normally in small, poorly defined studies. Only a very few countries have
approved misoprostol for use in induction of labour.
 Intravenous administration of synthetic oxytocin preparations, such as Pitocin.
 Use of mifepristone has been described but is rarely used in practice.[3]
 Relaxin has been investigated,[4] but is not currently commonly used.
Post mature pregnancy
Post maturity is the condition of a baby that has not yet been born after 42 weeks of
gestation, two weeks beyond the normal 40. Post-term, post maturity, prolonged
pregnancy, and post-dates pregnancy all refer to post mature birth. Post-mature births
can carry risks for both the mother and the infant, including fetal malnutrition. After the
42nd week of gestation, the placenta, which supplies the baby with nutrients and

oxygen from the mother, starts aging and will eventually fail. If the fetus passes fecal
matter, which is not typical until after birth, and the child breathes it in, then the baby
could become sick with Meconium aspiration syndrome. Post term pregnancy may be a
reason to induce labor.
62
Causes
The causes of post-term births are unknown, but post-mature births are more likely
when the mother has experienced a previous post-mature birth. Due dates are easily
miscalculated when the mother is unsure of her last menstrual period. When there is a
miscalculation, the baby could be delivered before or after the expected due date.Post-mature
births can also be attributed to irregular menstrual cycles. When the menstrual
period is irregular it is very difficult to judge when the ovaries would be available for
fertilization and subsequently result in pregnancy. Some post-mature pregnancies are
because the mother is not certain of her last period, so in reality the baby is not
technically post-mature However in most first world countries where gestation is
measured by ultrasound scan technology, this is less likely.
Symptoms
Post maturity symptoms vary. The most common are dry skin, overgrown nails, creases
on the baby's palms and soles of their feet, minimal fat, a lot of hair on their head, and
either a brown, green, or yellow discoloration of their skin. Doctors diagnose post-mature
birth based on the baby's physical appearance and the length of the mother's
pregnancy.[4] Some post mature babies will show no or little sign of post maturity.
Complications
Fetal and Neonatal Risks
 Reduced placental perfusion—Once a pregnancy has surpassed the 40 week
gestation period, doctors closely monitor the mother for signs of placental
deterioration. Toward the end of pregnancy, calcium is deposited on the walls of
blood vessels, and proteins are deposited on the surface of the placenta, which

changes the placenta. This limits the blood flow through the placenta and ultimately
leads to placental insufficiency, and the baby is no longer properly nourished.
Induced labor is strongly encouraged if this happens
63
 Oligohydramnios
 Meconium aspiration
Maternal Risks
 Large for gestational age:
 Increased incidence of forceps assisted, vacuum assisted or cesarean birth—Post-term
babies may be larger than an average baby, thus increasing the length of
labor. The labor is increased because the baby's head is too big to pass through the
mother's pelvis. This is called cephalopelvic disproportion. Caesarean sections are
encouraged if this happens. When post-mature babies are larger than average,
forceps or vacuum delivery may be used to resolve the difficulties at the delivery
time. Difficulty in delivering the shoulders, shoulder dystocia, becomes an increased
risk.
 Increased psychological stress
 Probable labour induction
Methods of Monitoring Post-Mature Babies
Once a baby is diagnosed post-mature, the mother should be offered additional
monitoring as this can provide valuable clues that the baby's health is being maintained.
Fetal movement recording
Regular movements of the baby is the best sign indicating that it is still in good health.
The mother should keep a "kick-chart" to record the movements of her baby. Less than
10 movements in 2 hours is not a good sign, and a doctor should be contacted. If there
is a reduction in the number of movements it could indicate placental deterioration.
Electronic fetal monitoring

Electronic fetal monitoring uses a cardiotocograph to check the baby's heartbeat and is
typically monitored over a 30-minute period. If the heartbeat proves to be normal, the
doctor will not usually suggest induced labor.
64
Ultrasound scan
An ultrasound scan evaluates the amount of amniotic fluid around the baby. If the
placenta is deteriorating, then the amount of fluid will be low, and induced labor is highly
recommended. However, ultra sounds are not always accurate since they also monitor
the fetus's development, and if the fetus is smaller than normal, the doctor's guess at
the age can be quite off. The actual placenta won't start to deteriorate until about 48
weeks. Because of the risks, doctors favour induction by 42 weeks.
Biophysical profile
A biophysical profile checks for the baby's heart rate, muscle tone, movement,
breathing, and the amount of amniotic fluid surrounding the baby.
Doppler flow study
Doppler flow study is a type of ultrasound that measures the amount of blood flowing in
and out of the placenta.
Fetal Macrosomia
Large for gestational age :
Large for gestational age (LGA) is an indication of high prenatal growth rate. LGA is
often defined as a weight, length, or head circumference that lies above the 90th
percentile for that gestational age. However, it has been suggested that the definition be
restricted to infants with birth weights greater than the 97th percentile (2 standard
deviations above the mean) as this more accurately describes infants who are at
greatest risk for perinatal morbidity and mortality. Macrosomia, which literally means
"big body," is sometimes confused with LGA. Some experts consider a baby to be big
when it weighs more than 8 pounds 13 ounces (4,000 g) at birth, and others say a baby

is big if it weighs more than 9 pounds 15 ounces (4,500 g). A baby is also called “large
for gestational age” if its weight is greater than the 90th percentile at birth.
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Diagnosis
It's important to note that LGA and macrosomia cannot be diagnosed until after birth, as
it is impossible to accurately estimate the size and weight of a child in the womb.Babies
that are large for gestational age throughout the pregnancy may be suspected because
of an ultrasound, but fetal weight estimations in pregnancy are quite imprecise. For non-diabetic
women, ultrasounds and care providers are equally inaccurate at predicting
whether or not a baby will be big. If an ultrasound or a care provider predicts a big baby,
they will be wrong half the time.
Although big babies are only born to 1 out of 10 women, the 2013 Listening to Mothers
Survey found that 1 out of 3 American women were told that their babies were too big.
In the end, the average birth weight of these suspected “big babies” was only 7 pounds
13 ounces (3,500 g). In the end, care provider concerns about a suspected big baby
were the 4th most common reason for an induction (16% of all inductions), and the 5th
most common reason for a C-section (9% of all C-sections). Unfortunately, this
treatment is not based on current best evidence.
In fact, research has consistently shown that the care provider’s perception that a baby
is big is more harmful than an actual big baby by itself. In a very important 2008 study,
researchers compared what happened to women who were suspected of having a big
baby to what happened to women who were not suspected of having a big baby—but
who ended up having one. In the end, women who were suspected of having a big baby
(and actually ended up having one) had a triple in the induction rate; more than triple
the C-section rate, and a quadrupling of the maternal complication rate, compared to
women who were not suspected of having a big baby but who had one anyway.
Complications were most often due to C-sections and included bleeding (hemorrhage),
wound infection, wound separation, fever, and need for antibiotics. There were no
differences in shoulder dystocia between the two groups. In other words, when a care
provider “suspected” a big baby (as compared to not knowing the baby was going to be

big), this tripled the C-section rates and made mothers more likely to experience
complications, without improving the health of babies.
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Ceasarian Delivery
A Caesarean sectio is a surgical procedure in which one or more incisions are made
through a mother's abdomen (laparotomy) and uterus (hysterotomy) to deliver one or
more babies, or, rarely, to remove a dead fetus. A late-term abortion using Caesarean
section procedures is termed a hysterotomy abortion and is very rarely performed. The
first modern Caesarean section was performed by German gynecologist Ferdinand
Adolf Kehrer in 1881.
A Caesarean section is often performed when a vaginal delivery would put the baby's or
mother's life or health at risk. Some are also performed upon request.
C-sections result in a small overall increase in bad outcomes in low risk pregnancies
(8.6% of vaginal deliveries and 9.2% of C-sections). The bad outcomes that occur with
C-section differ from those that occur with vaginal delivery. Professional societies have
established guidelines for non-medically indicated cesarean before 39 weeks.
A Cesarean section (C-section) is surgery to deliver a baby. The baby is taken out
through the mother's abdomen. In the United States, about one in four women have
their babies this way. Most C-sections are done when unexpected problems happen
during delivery. These include
 Health problems in the mother
 The position of the baby
 Not enough room for the baby to go through the vagina
 Signs of distress in the baby
C-sections are also more common among women carrying more than one baby.
The surgery is relatively safe for mother and baby. Still, it is major surgery and carries
risks. It also takes longer to recover from a C-section than from vaginal birth. After

healing, the incision may leave a weak spot in the wall of the uterus. This could cause
problems with an attempted vaginal birth later. However, more than half of women who
have a C-section can give vaginal birth later.
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Medical indications
Some medical indications are below. Not all of the listed conditions represent a
mandatory indication, and in many cases the obstetrician must use discretion to decide
whether a Caesarean is necessary.
Complications of labor and factors impeding vaginal delivery, such as:
 abnormal presentation (breech or transverse positions)
 prolonged labour or a failure to progress (dystocia)
 fetal distress
 cord prolapse
 uterine rupture or an elevated risk thereof
 increased blood pressure (hypertension) in the mother or baby after amniotic
rupture
 increased heart rate (tachycardia) in the mother or baby after amniotic rupture
 placental problems (placenta praevia, placental abruption or placenta accreta)
 failed labour induction
 failed instrumental delivery (by forceps or ventouse (Sometimes a trial of
forceps/ventouse delivery is attempted, and if unsuccessful, it will be switched to
a Caesarean section.)
 large baby weighing >4000g (macrosomia)
 umbilical cord abnormalities (vasa previa, multilobate including bilobate and
succenturiate-lobed placentas, velamentous insertion)

Other complications of pregnancy, pre-existing conditions and concomitant disease,
such as:
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 pre-eclampsia[11]
 previous (high risk) fetus
 HIV infection of the mother
 Sexually transmitted diseases, such as genital herpes (which can be fatal to the
baby if the baby is born vaginally)
 previous classical (longitudinal) Caesarean section
 previous uterine rupture
 prior problems with the healing of the perineum (from previous childbirth
or Crohn's disease)
 Bicornuate uterus
 Rare cases of posthumous birth after the death of the mother
Postpartum care:
Puerperium
Puerperium refers to the first six weeks after delivery. At this time, the woman undergoes
psychologic and physiologic adaptations as she return to a non pregnant state.
Postpartum care should respond to the special needs of the mother and baby should include:
 Prevention and early detection and treatment of early complications and disease
 Provision of advice and services on breastfeeding, birth spacing, immunization and
maternal nutrition.

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Psychological Adaptation after delivery:
RUBIN`S POSTPARTUM PHASE
 Taking in Phase: The taking in phase usually occurs during the first 2 to 3 days postpartum.
During this time, the womans attention is focused on her own needs for sleep, rest and she
is dependent on others.
 Taking Hold Phase/ Transition Phase: The taking hold period extends from 3rd day to 2
weeks postpartum. The concern of the mother at this time is focused on her ability to control
body function and her ability to assume the mothering role. She prefers to do impatient by
her self.
 Letting Go Phase: the mother, at this point, realizes that the infant is a separate individual
and not a part of herself. She, then, experiences a feeling of loss. As the mother realizes
the individuality of the baby, she gives up fantasies about the child. The 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.
Your newborn may be your top priority — but postpartum care counts, too. From
vaginal soreness to urinary problems, here's what to expect as you recover from
a vaginal delivery.
Pregnancy changes your body in more ways than you might have guessed, and it
doesn't stop when the baby is born. After a vaginal delivery, taking good care of yourself
is an essential part of postpartum care. Here's what to expect.
Vaginal soreness
If you had an episiotomy or vaginal tear during delivery, the wound might hurt for a few
weeks. Extensive tears might take longer to heal. In the meantime, you can help
promote healing:
 Soothe the wound. Cool the wound with an ice pack, or place a chilled witch
hazel pad — available in most pharmacies — between a sanitary napkin and the
wound.

 Take the sting out of urination. Pour warm water over your vulva as you're
urinating. Press a clean pad firmly against the wound when you bear down for a
bowel movement.
 Keep the wound clean. Use a squirt bottle filled with water to rinse the tissue
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between the vaginal opening and anus (perineum) after using the toilet.
 Sit down carefully. If sitting is uncomfortable, sit on a pillow or padded ring.
While you're healing, expect the discomfort to progressively improve. Contact your
health care provider if the pain intensifies, the wound becomes hot, swollen and painful,
or you notice a pus-like discharge.
Vaginal discharge
You'll have a vaginal discharge (lochia) for a number of weeks after delivery. Expect a
bright red, heavy flow of blood for the first few days. If you've been sitting or lying down,
you might notice a small gush when you stand up. The discharge will gradually taper off,
changing from pink or brown to yellow or white. To reduce the risk of infection, use
sanitary napkins rather than tampons.
Don't be alarmed if you occasionally pass small blood clots. Contact your health care
provider if:
 You soak a sanitary pad within an hour while lying down
 The discharge has a foul odor
 You pass clots larger than a golf ball
 You have a fever of 100.4 F (38 C) or higher
Contractions
You might feel contractions, sometimes called afterpains, during the first few days after
delivery. These contractions — which often resemble menstrual cramps — help prevent
excessive bleeding by compressing the blood vessels in the uterus. For reasons that
aren't entirely clear, these contractions tend to be stronger with successive deliveries.

Your health care provider might recommend an over-the-counter pain reliever if
necessary.
Contact your health care provider if you have a fever or if your abdomen is tender to the
touch. These signs and symptoms could indicate a uterine infection.
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Urination Problems
Swelling or bruising of the tissues surrounding the bladder and urethra can lead to
difficulty urinating. Fearing the sting of urine on the tender perineal area can have the
same effect. Difficulty urinating usually resolves on its own. In the meantime, it might
help to pour water across your vulva while you're sitting on the toilet.
Contact your health care provider if you have any symptoms of a urinary tract infection.
For example:
 It hurts to urinate
 You don't think you're emptying your bladder fully
 You have an unusually frequent urge to urinate
Pregnancy and birth stretch the connective tissue at the base of the bladder and can
cause nerve and muscle damage to the bladder or urethra. You might leak urine when
you cough, strain or laugh. Fortunately, this problem usually improves within three
months. In the meantime, wear sanitary pads and do Kegel exercises to help tone your
pelvic floor muscles.
To do Kegels, tighten your pelvic muscles as if you're stopping your stream of urine. Try
it for five seconds at a time, four or five times in a row. Work up to keeping the muscles
contracted for 10 seconds at a time, relaxing for 10 seconds between contractions. Aim
for at least three sets of 10 repetitions a day.
Hemorrhoids and Bowel Movements
If you notice pain during bowel movements and feel swelling near your anus, you might
have hemorrhoids — stretched and swollen veins in the anus or lower rectum. To ease

any discomfort while the hemorrhoids heal, soak in a warm tub and apply chilled witch
hazel pads to the affected area. Your health care provider might recommend a topical
hemorrhoid medication as well.
If you find yourself avoiding bowel movements out of fear of hurting your perineum or
aggravating the pain of hemorrhoids or your episiotomy wound, take steps to keep your
stools soft and regular. Eat foods high in fiber — including fruits, vegetables and whole
grains — and drink plenty of water. It's also helpful to remain as physically active as
possible. Ask your health care provider about a stool softener or fiber laxative, if
needed.
Another potential problem for new moms is the inability to control bowel movements
(fecal incontinence) — especially if you had an unusually long labor. Frequent Kegel
exercises can help. If you have persistent trouble controlling bowel movements, consult
your health care provider.
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Sore breasts and leaking milk
Several days after delivery, your breasts might become heavy, swollen and tender. This
is known as engorgement. To ease the discomfort, nurse your baby or use a breast
pump to express milk. You might also want to apply cold washcloths or ice packs to
your breasts. Over-the-counter pain relievers might help, too. To help prevent nipple
pain, make sure that your baby latches on to your breast correctly. If you're unsure or
every feeding is painful, ask a lactation consultation for help.
If your breasts leak between feedings, wear nursing pads inside your bra to help keep
your shirt dry. Change pads after each feeding and whenever they get wet.
If you're not breast-feeding your baby, wear a firm, supportive bra. Compressing your
breasts will help stop milk production. In the meantime, don't pump your breasts or
express the milk. This only tells your breasts to produce more milk.
Hair loss and skin changes

During pregnancy, elevated hormone levels put normal hair loss on hold. The result is
often an extra-lush head of hair — but now it's payback time. After delivery, your body
sheds the excess hair all at once. Within six months, your hair will most likely be back to
normal. In the meantime, shampoo only when necessary, and find a hairstyle that's
easy to maintain. Avoid curling irons and harsh chemicals.
Stretch marks won't disappear after delivery, but eventually they'll fade from reddish
purple to silver or white. Expect any skin that darkened during pregnancy — such as the
line down your abdomen (linea nigra) — to slowly fade as well.
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Mood changes
Childbirth triggers a jumble of powerful emotions. Mood swings, irritability, sadness and
anxiety are common. Many new moms experience a mild depression, sometimes called
the baby blues. The baby blues typically subside within a week or two. In the meantime,
take good care of yourself. Share your feelings, and ask your partner, loved ones or
friends for help. If your depression deepens or you feel hopeless and sad most of the
time, contact your health care provider. Prompt treatment is important.
Weight loss
After you give birth, you'll probably feel flabby and out of shape. You might even look
like you're still pregnant. Don't worry. This is perfectly normal. Most women lose more
than 10 pounds during birth, including the weight of the baby, placenta and amniotic
fluid. In the days after delivery, you'll lose additional weight from leftover fluids. After
that, a healthy diet and regular exercise can help you gradually return to your pre-pregnancy
weight.
The postpartum checkup
About six weeks after delivery, your health care provider will check your vagina, cervix
and uterus to make sure you're healing well. He or she might do a breast exam and
check your weight and blood pressure, too. This is a great time to talk about birth
control, breast-feeding and how you're adjusting to life with a new baby. You might also
ask about Kegel exercises to help tone your pelvic floor muscles.

Above all, share any concerns you might have about your physical or emotional health.
Chances are, what you're feeling is entirely normal. Look to your health care provider for
assurance as you enter this new phase of life.
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Stages of Breast Milk
Breast milk is widely considered to be the best food for newborn babies. Mothers' milk
production starts in the breast glands during pregnancy, and through each stage of a baby's
development, it transforms itself to meet the child's needs. During the first days of a baby's life,
the supply of milk is low but the nutrient content is high. As breastfeeding is established and the
baby grows and changes, the amount and composition of breast milk adapts.
Colostrum
Colostrum is the first stage of breast milk. The mother's body begins producing it even before
the baby is born. If your breasts leak while you're pregnant, they're leaking colostrum.
Colostrum is orange or yellow in color. It is thicker and stickier than later breast milk and is
produced in small quantities. The milk is high in antibodies, carbohydrates and protein and low
in fat. This stage of breast milk normally lasts for the first few days after birth.
Transitional Milk
Following after colostrum, breasts produce "transitional milk." As the name implies, this stage of
breast milk is a transition between the early colostrum stage and the later "mature milk" stage.
Transitional milk lasts for about two weeks. The volume of milk produced increases in line with
the capacity of a newborn baby's stomach. While the amount of antibodies in the milk is
reduced, antibodies are still produced in sufficient quantities to protect the baby from numerous
viruses and bacteria.
Mature Milk
The "mature milk" stage is the last stage of breast milk production and lasts until the mother
stops breastfeeding. This milk comes in about two to three weeks after breastfeeding was
begun. It is composed mainly of water, which keeps the baby hydrated, and also includes fats,
proteins, carbohydrates and antibodies. This milk is the perfect food for babies during the first
six months of life and gives them immunological advantages.

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Foremilk and Hindmilk
Once the mother's mature milk has come in, the supply should adjust itself along with the baby's
feeding requirements. Within a breastfeeding session, there are differences in the mature breast
milk. The first milk that the baby gets is called "foremilk." It is thinner and has lower fat content
than the "hindmilk." Experts recommend emptying one breast fully before switching the baby to
the other breast to ensure that she drinks the more filling, higher-fat and higher-calorie hindmilk.
Maternal Position during Breastfeed
In order for this process to work efficiently you must:
 hold the baby so that he/she is facing the nipple
 keep your fingers away from the area to be drawn into the baby's mouth, allowing the
baby to draw in the entire nipple and as much of the areola as possible
 press your fingers slightly towards your ribs to keep the nipple extended as much as
possible
 guide and insert the areola by centering the nipple in the baby's mouth and pointing it
toward the top back section of the baby's mouth
 hold the baby in close to your body
The baby must:
 face the mother's body
 open his/her mouth wide (like a big yawn)
 draw the nipple in to the upper back part of his mouth
 place his gums beyond the nipple, taking in as much of the areola as possible
 have his tongue out, over his lower gum, "cradling" the nipple and areola
Traditional or cradle position
This is the most convenient nursing position for many mothers and one you will use
often.

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 Sit upright in a comfortable chair. You may want to place a pillow
behind your back so that your back can remain straight. You can
also put a pillow on your lap to support the baby. Your feet may
rest on a low footstool to elevate your lap. You may prop your
arms with pillows or armrests.
 Hold the baby so that the baby's arm closest to your body can go
around your midriff and his head is cradled on your arm. Your hand can then grasp his
thigh or buttocks so that your arm supports his entire body.
 The baby's body should face you. The baby should not have to turn his/her head in
either direction to receive the breast. You should position your baby's face so that your
nipple is easily accessible to his mouth without the need for you to turn your body.
Lining your baby's nose up with the nipple will help position the nipple so that it is
pointed toward the back of the palate when the baby opens his/her mouth.
 With your free hand, you may want to support the breast by cupping the breast so that
your thumb and forefinger lie on opposite sides of the nipple and the rest of your hand
supports the breast from underneath. (You will be slightly compressing the breast in the
same direction as the baby's mouth). Be sure that your fingers are far enough back from
the nipple to avoid interfering with the baby's mouth. Slightly pressing the breast tissue
back toward your ribs helps the nipple to protrude.
 Guide your nipple so that it brushes the baby's lips, causing the baby to "root" or open
his/her mouth widely. (If he/she doesn't root, you can use your finger in his mouth to get
him/her ready to suck, then transfer him to the breast.) At first, this may take a few
minutes and may require patience.
 When the baby's mouth opens wide, quickly use your supporting arm to pull the baby
close to your body.
 Your nipple should be centered in the baby's mouth. When your baby grasps your
breast, his/her gums should surround the areola, bypassing the nipple itself, and his
tongue should extend over his lower gum.
 Pull the baby's legs in close to you, angling his/her body slightly to help keep his/her
nose free. Only if necessary, you can use your thumb to gently depress the breast near
the baby's nose, allowing breathing space.

 As the baby begins suckling, relax your shoulders, but continue to hold the baby in
close. Use pillows if they are helpful. If you feel any nipple discomfort after the first
minute, start again using the above steps. Check to be sure the baby has the nipple
pulled back into his/her mouth and that his/her gums surround the areola. Don't allow
the baby to slip away from you and suck or chew the tip of the nipple. This will lead to
sore nipples.
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Cross-cradle hold
This position is similar to the traditional Cradle hold, but it allows more control over the
baby's head.
 Sit upright in a comfortable chair. You may want to place a pillow
behind your back so that your back can remain straight. You can
also put a pillow on your lap to support the baby. Your feet may
rest on a low footstool to elevate your lap. You may prop your
arms with pillows or armrests.
 Hold the baby so that the baby's arm closest to your body can go
around your midriff. One hand can then hold his head, with your arm along his back,
while your other hand can hold your breast.
 The baby's body should face you. The baby should not have to turn his/her head in
either direction to receive the breast. You should position your baby's face so that your
nipple is easily accessible to his mouth without the need for you to turn your body.
Lining your baby's nose up with the nipple will help position the nipple so that it is
pointed toward the back of the palate when the baby opens his/her mouth.
 Hold the breast so that your thumb and forefinger lie on opposite sides of the nipple and
the rest of your hand supports the breast from underneath. (You will be slightly
compressing the breast in the same direction as the baby's mouth). Be sure that your
fingers are far enough back from the nipple to avoid interfering with the baby's mouth.
Slightly pressing the breast tissue back toward your ribs helps the nipple to protrude.
 Guide your nipple so that it brushes the baby's lips, causing the baby to "root" or open
his/her mouth widely. (If he/she doesn't root, you can use your finger in his mouth to get

him/her ready to suck, then transfer him to the breast.) At first, this may take a few
minutes and may require patience.
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 When the baby's mouth opens wide, quickly bring the baby firmly to the breast.
 Your nipple should be centered in the baby's mouth. When your baby grasps your
breast, his/her gums should surround the areola, bypassing the nipple itself, and his
tongue should extend over his lower gum.
 Bring the baby's legs in close to you, angling his/her body slightly to help keep his/her
nose free. Only if necessary, you can use your thumb to gently depress the breast near
the baby's nose, allowing breathing space.
 As the baby begins suckling, relax your shoulders, but continue to hold the baby in
close. Use pillows if they are helpful. If you feel any nipple discomfort after the first
minute, start again using the above steps. Check to be sure the baby has the nipple
pulled back into his/her mouth and that his/her gums surround the areola. Don't allow
the baby to slip away from you and suck or chew the tip of the nipple. This will lead to
sore nipples.
Football (or clutch) hold
This position is especially helpful for mothers who have had Cesarean deliveries or who
have any abdominal discomfort. It is also helpful when baby is especially active, if the
baby is small or pre-mature, or if the baby is having difficulty
grasping the areola.
 Sit in a comfortable position in a large chair or on a bed. Place
pillows next to you up to the level of your breast and behind you to
move your body forward from the back of the chair.
 The baby should be lying on his back supported by your arm and
pillows. He/She should be at the level of the breast.
 Put your arm over and around the baby and hold him close to your body. The baby's
feet should be extended behind your back and his/her face should be toward you. Use
your forearm to keep the baby's body next to you and to support his/her shoulders. Use
your hand to support his/her head and neck.

 With your free hand, cup the breast with your thumb on top and forefingers supporting
the breast. Be sure that all of your fingers are far enough back on the breast from the
nipple so that the baby can grasp as much of the areola as possible.
 Use your nipple to tickle the baby's upper lip to cause him/her to take root or open
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his/her mouth widely. At first, this may take a few minutes and may require patience.
 When the baby's mouth opens widely, bring the baby quickly and firmly to the breast.
Your nipple should be centered in the baby's mouth pointed slightly towards his/her
upper back palate, with his tongue over his bottom gum. Be sure that the baby's gums
surround the areola, bypassing the nipple itself.
 As the baby begins sucking, relax your body as much as possible, but continue to hold
the baby in close. Use pillows if helpful. Be sure the baby continues to hold the areola. If
you feel any nipple discomfort, after the first minute, start again using the above steps.
Check to be sure the baby has the nipple pulled back into his/her mouth and that his/her
gums surround the areola. Don't allow the baby to slip away from you and suck the tip of
the nipple.
Sidelying down
Until the baby learns to suckle easily, this technique may be somewhat awkward. With
practice, however it is an enjoyable way to feed your baby as you receive much needed
rest. Both of you may even end up dozing comfortably.
 Lie on your side on a flat surface positioning pillows around your
head and shoulders for support. Your "nursing" breast should be
resting against the bed surface so that the nipple is pointing
toward the baby. Through out the feeding, there may be a
tendency to roll to your back thereby causing the baby to pull the
tip of the nipple in an awkward position. To prevent this, place
pillows behind you to keep your body on its side. Some mothers prefer to begin nursing
by raising their head upon an elbow and then lowering it to rest on a pillow once the
baby begins suckling.
 Lay the baby on his/her side, positioning his/her face directly in front of the nipple you
are offering. A rolled baby blanket or pillow will prevent the baby from rolling back.

 The baby's ears should be in direct line with his/her shoulders. Positioned so, the baby
will not need to turn his/her head. Pull the baby's legs in close to you, angling his/her
body slightly to keep his nose free.
 Cup your breast with your thumb and forefingers above and below the nipple being
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careful to keep all fingers far back from the nipple.
 Guide the nipple to brush the baby's upper lip. This will cause him/her to root.
 When the baby's mouth opens wide, bring the baby firmly to the breast. Your nipple
should be centered in the baby's mouth pointed slightly towards his/her upper back
palate. The baby's gums should be surrounding the areola, and the baby's tongue
should be over the bottom gum.
 As the baby begins suckling, relax your body being careful to remain on your side with
the baby held in close to you. Use pillows if helpful. Start again if there is any nipple
discomfort after the first minute.
You may need many trials to perfect the skill of proper positioning. Remember your
baby is learning too! If your ever feel your baby is latched on improperly—his/her mouth
is open only slightly, he/she seems to be chewing rather than suckling, there is a
"clicking" sound in the back of his/her throat, or your nipple hurts while he/she is
sucking—break the suction gently by inserting your clean little finger into the side of the
baby's mouth and lift him/her away from your breast. Take several deep, relaxing
breaths and begin again. Having the baby properly attached to the breast is one of the
most important steps in a successful nursing experience.
Keep in mind that breastfeeding is a learned experience for both you and your baby.
First attempts may be awkward, but with practice and a positive attitude, nursing will
soon become second nature for both of you.
The information in this brochure was prepared by Nursing Mothers Counsel Inc. and
has been approved by NMC Medical Advisory Board.
Taking your baby off the breast and burping

Taking your baby off the breast
Be sure to break the suction by slipping your little finger in the corner of your baby’s
mouth between the gums. Do not remove your baby from your breast until the suction is
released, or you may develop sore nipples. The suction is quite strong, and it may
require some effort to release your baby’s grip.
Burping your baby
Not every breastfed baby needs to burp with every feeding. Generally, breastfed babies
do not swallow as much air as bottle fed babies do. If your baby has been crying before
the feeding, and is pulling on and off the breast, try burping then try breastfeeding
again. Some babies do not burp right away, and you may need to try several positions.
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Helpful positions for burping your baby include:
 Propped up with baby’s tummy against your shoulder
 Lying tummy-down across your lap
 Sitting up, leaning forward with your hand on the left side of the baby’s
body supporting the baby’s stomach and neck
Benefits of Breastfeeding
Benefits of Breastfeeding to the infant include the following:
 Breast milk enhances maturation of the gastrointestinal (GI) tract and contains
immune factors that contribute to a lower incidence of gastroenteritis, lymphoma,
childhood obesity, Crohn’s disease, and Celiac disease.
 Breastfed infants receive specific antibodies and cell mediated immunologic factors
that help protect against otitis media, respiratory illnesses such as respiratory
syncytial virus and pneumonia, urinary tract infections, bacteremia, and bacterial
meningitis.

 There is a lower incidence of certain allergies among breastfed infants from families
at high risk. Allergic manifestations occur at a greater rate and are more severe in
formula-fed infants.
 Breastfed infants are less likely to die from sudden infant death syndrome (SIDS).
 Breast milk may have a protective effect against childhood lymphoma and insulin-dependent
82
diabetes.
 Breast milk may enhance cognitive development.
 Breastfeeding appears to have an analgesic effect for infants undergoing painful
procedures such as venipuncture.
Maternal benefits include the following:
 Women who have breastfed have a decreased risk of ovarian, uterine, and breast
cancer.
 Breastfeeding promotes uterine involution and is associated with a decreased risk of
postpartum hemorrhage.
 Mothers who are breastfeeding tend to return to their pregnancy weight more
quickly.
 Breastfeeding may provide some protection against the development of
osteoporosis.
 Breastfeeding provides a unique bonding experience and increases maternal role
attainment.
Newborn screening
Newborn screening is a public health program designed to screen infants shortly
after birth for a list of conditions that are treatable, but not clinically evident in the

newborn period. Some of the conditions included in newborn screening programs are
only detectable after irreversible damage has been done, in some cases sudden death
is the first manifestation of the disease. Screening programs are often run by state or
national governing bodies with the goal of screening all infants born in the jurisdiction.
The number of diseases screened for is set by each jurisdiction, and can vary greatly.
Most newborn screening tests are done by measuring metabolites and enzyme activity
in whole blood samples collected on specialized filter paper, however many areas are
starting to screen infants for hearing loss using automated auditory brainstem response
and congenital heart defects using pulse oximetry. Infants who screen positive undergo
further testing to determine if they are truly affected with a disease or if the test result
was a false positive. Follow-up testing is typically coordinated between geneticists and
the infant's pediatrician or primary care physician.
83
Newborn screening (DOH)
Republic Act 9288
Newborn screening (NBS) is a public health program aimed at the early
identification of infants who are affected by certain genetic/metabolic/infectious
conditions. Early identification and timely intervention can lead to significant reduction of
morbidity, mortality, and associated disabilities in affected infants. NBS in the
Philippines started in June 1996 and was integrated into the public health delivery
system with the enactment of the Newborn Screening Act of 2004 (Republic Act 9288).
From 1996 to December 2010, the program has saved 45 283 patients. Five
conditions are currently screened: Congenital Hypothyroidism, Congenital Adrenal
Hyperplasia, Phenylketonuria, Galactosemia, and Glucose-6-Phosphate
Dehydrogenase Deficiency.
Current Status of NBS Implementation in the Philippines
Newborn Screening Legislation

NBS was integrated into the public health delivery system with the enactment of
Republic Act 9288 or Newborn Screening Act of 2004 as it institutionalized the
‘National NBS System’, which shall ensure the following: [a] that every baby born in the
Philippines is offered NBS; [b] the establishment and integration of a sustainable NBS
System within the public health delivery system; [c] that all health practitioners are
aware of the benefits of NBS and of their responsibilities in offering it; and [d] that all
parents are aware of NBS and their responsibility in protecting their child from any of the
disorders. The highlights of the law and its implementing rules and regulations are:
1. DOH is the lead agency tasked with implementing this law;
2. Any health practitioner who delivers or assists in the delivery of a newborn in the
Philippines shall prior to delivery, inform parents or legal guardians of the newborns
the availability, nature and benefits of NBS;
3. Health facilities shall integrate NBS in its delivery of health services;
4. Creation of the Newborn Screening Reference Center at the National Institutes of
Health and establishment and accreditation of NSCs equipped with a NBS
laboratory and recall/follow up program;
5. Provision of NBS services as a requirement for licensing and accreditation, the
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DOH and the Philippine Health Insurance Corporation (PHIC)
6. Inclusion of cost of NBS in insurance benefits
Currently, there are four Newborn Screening Centers (NSCs) in the country: NSC-National
Institutes of Health in Manila; NSC- Visayas in Iloilo City; NSC-Mindanao in
Davao City; and NSC-Central Luzon in Angeles City. The four NSCs provide laboratory
and follow up services for more than 3000+ health facilities.
DOH, its partners and major stakeholders remain aggressive in identifying strategies
to intensify awareness in the communities and increase coverage among home
deliveries. Among the recent efforts to increase the newborn screening coverage are
appointment of full-time Regional NBS Coordinators; opening more G6PD Confirmatory

Laboratories; partnership with midwives organizations; and production of information
materials targeting different groups of health workers and professionals.
85
Newborn Screening Statistics
As of December 2010, there are 2,389,959 babies that have undergone NBS and
based on these data, the incidences of the following disorders are: CH (1: 3,324); CAH
(1: 9,446); PKU (1: 149,372); Gal (1: 108,635) and G6PD deficiency (1: 52). The
program has saved the following numbers of newborns from complications and/or
death: 719 from CH, 253 from CAH, 22 from Gal, 16 from PKU and 44 273 from G6PD
deficiency.

Maternal and Child Nursing Lecture

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